1. health and fitness
2. disease

Primary Clinical
Care Manual
PD3507 - Emergency
Participation Manual
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Site
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Date Completed
Please select ...
Aboriginal
Administration
Allied
Dental
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Nursing
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Other
Student
Health
Officer
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or Torres Strait Islan
PD3507 Emergency 1
Version1 (2014)
Contents
PD3507 Introduction3
PD3507 - Part 2: Pre-Course Survey5
PD3507-1 Emergency Presentations Part 16
PD3507-1 Learning Activity10
PD3507-2 Emergency Presentations Part 211
PD3507-2 Learning Activity17
PD3507-3 Emergency Presentations Part 318
PD3507-3 Learning Activity23
PD3507 Theory to Practice Activity 24
PD3507 Quiz 28
PD3507- 1 Learning Activity32
PD3507- 2 Learning Activity32
PD3507- 3 Learning Activity33
PD3507 Theory to Practice Activity Feedback34
PD3507 Quiz Feedback38
PD3507 Emergency 2
Version1 (2014)
PD3507 Introduction
Session Overview
The PCCM provides comprehensive information emergency management. This session provides
further information on the use of the PCCM as a guide for the management of a range of emergencies.
Learners will need to have a hard copy of the PCCM, a printed copy of the downloadable PCCM or
access to the electronic version of the PCCM to be able to complete this session.
Learning Objectives
On completion of this session participants will be able to use the PCCM as a guide for the management of a range of emergency presentations including:
• Cardiovascular
• Neurological
• Trauma and injuries
• Fractures dislocations and sprains
• Acute wounds
• Burns
• Environmental
• Gastrointestinal
• Genitourinary
• Poisoning and drugs
• Toxinology (bites and stings)
Modules
Module 1 provides information on using the PCCM as a guide in the management of:
• Cardiovascular emergencies including chest pain, acute pulmonary oedema, cardiac arrhythmias, electrocution, acute hypertensive crisis and acute arterial occlusion
• Neurological emergencies including sub-arachnoid haemorrhage (SAH) and transient ischaemic attacks (TIA) / stroke
• Trauma and injuries including primary and secondary survey and preparation for evacuation or hospitalisation
• Fractures, dislocations and joints
PD3507 Emergency 3
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Module 2 provides information on using the PCCM to guide the management of:
• Acute wounds including primary and delayed primary closure, secondary intention and
debridement
• Burns including superficial, partial and full thickness
• Environmental emergencies in particular decompression illness (DCI), hypothermia, and
hyperthermia including health exhaustion and heat stroke.
• Gastrointestinal emergencies including nose bleeds, acute abdominal pain, epigastric pain,
upper gastrointestinal bleeding, rectal bleeding and bowel obstruction
Module 3 provides information on using the PCCM to guide the management of:
• Genitourinary emergencies including renal colic, acute retention of urine and testicular / scrotal pain
• Poisoning and drug emergencies including risk assessment and
• Toxinology (bites and stings) from snakes, spiders, marine stingers and other marine life.
Pre-Session Survey
Before you commence, we ask you to complete a quick survey to identify current knowledge base. This
will provide a baseline you can refer to once you have completed this topic.
Quiz
Once you have completed the modules in this topic, you are asked to complete an interactive quiz
which is graded. You can review your results and complete the quiz as many times as you like until
you feel you have mastered the topic.
Post Session Survey
When you have completed this session, we ask you to complete another quick survey to determine if
we have met your learning needs.
Certificate
The final section is the completion of a personalised certificate which provides evidence of your
training. Included on this is the average time the session takes which can be used for professional
development points.
PD3507 Emergency 4
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PD3507 - Part 2: Pre-Course Survey
Strongly Disagree
Disagree
Neutral
Agree
Please indicate the degree to which you agree to the following,
by ticking the box most relevant.
Strongly Agree
Before you commence this session we ask you to take a few moments to complete the pre-session
survey for this topic. This will give us some indication what your learning needs might be.
I am confident in my ability to use the Primary Clinical Care
Manual to manage patient emergencies
I am confident in my ability to use the Primary Clinical Care
Manual to manage general presentations
I am confident in my ability to use the Primary Clinical Care
Manual to manage presentations for mental health and
substance abuse
I am confident in my ability to use the Primary Clinical Care
Manual to manage sexual and reproductive health
I am confident in my ability to use the Primary Clinical Care
Manual to complete and history and physical examination on a
child or infant
I am confident in my ability to use the Primary Clinical Care
Manual to manage paediatric presentations
PD3507 Emergency 5
Version1 (2014)
PD3507-1 Emergency Presentations Part 1
Learning Objectives
On completion of this module learners will be able to use the PCCM to guide the management of:
• Cardiovascular emergencies
• Neurological emergencies
• Trauma and injuries
• Fractures, dislocations and sprains
Important Information
On completion of this module learners will be able to use the PCCM to guide the management of:
• Cardiovascular emergencies
• Neurological emergencies
• Trauma and injuries
• Fractures, dislocations and sprains
This module provides only basic, introductory information on emergency presentations.
It includes information on:
• Common causes for the presentation
• Signs and symptoms patients may present with
• Factors to consider when managing presentations
• Learners will be directed to the PCCM for information on management
General Principles
Management of all emergencies includes:
• DR ABCD resuscitation if required
• Accurate and swift clinical assessment
• Appropriate immediate and longer term management
• Follow up, which in most cases includes consultation and or referral to a Medical Officer and specialist.
The PCCM provides further information on specific presentations
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Cardiovascular
Cardiovascular emergencies include:
• Chest Pain as a result of acute coronary syndrome, unstable angina, or myocardial infarction
• Acute Pulmonary Oedema which includes left ventricular failure and heart failure
• Cardiac arrhythmias which can occur secondary to a number of injuries or illnesses
• Electrocution which may cause cardiac arrhythmias or cardiac arrest
• Acute hypertensive crisis which may be the result of a cardiac event, poisoning, pre-eclamsia or an overwhelming infection
• Acute arterial occlusion which is caused by the blockage of an artery cutting off blood supply to a limb
Cardiovascular emergencies are life-threatening disorders that must be diagnosed quickly to avoid
delay in treatment and to minimize morbidity and mortality.
Patients may present with collapse, chest pain, breathlessness, arrhythmia and hyper or hypotension
It is important to be able to identify the myriad of signs and symptoms that indicate an emergency
cardio-vascular event and respond appropriately.
Neurological
Neurological emergencies include:
• Subarachnoid haemorrhage
• Transient Ischaemic Attack / stroke
• Patients may present with sudden onset of localised symptoms including
• Severe headache
• Weakness – usually unilateral
• Difficulties with speech, sight, mobility balance, dizziness, swallowing
• Less common symptoms include
• Confusion
• Sudden onset vertigo
• Nausea or vomiting
• Stupor or coma
• Difficulty swallowing
• Collapse
Any awake patient who complains of the most severe headache they have ever had must be regarded
as having a subarachnoid haemorrhage.
It is usually due to an aneurysm on an intra-cerebral artery. It is important to suspect SAH as a
subsequent recurrent bleed will be associated with a poor outcome.
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A stroke occurs when the arteries to the brain become blocked (ischaemic stroke / cerebral infarction)
or rupture (haemorrhagic stroke), resulting in disrupted blood supply and death of brain tissue.
A transient ischaemic attack (TIA) is sometimes termed a minor stroke or ‘mini‘ stroke. When the signs
of stroke present but go away within 24 hours the term TIA is used.
Trauma and Injuries
The management of the seriously injured patient should have three main parts:
1. primary survey of patient and resuscitation
2. secondary survey (more detailed)
3. preparation for evacuation / hospitalisation
• Ideally one or more assistants are needed
• Protect yourself e.g. from body fluids, traffic or the perpetrators of a crime
• Prevent deterioration caused by hypoxia and hypotension and rapidly treat life threatening complications such as airway obstruction and tension pneumothorax
• Keep all trauma patients warm
The Primary Survey and resuscitation includes:
• Airway and cervical spine protection
• Breathing, give oxygen
• Circulation, stop external bleeding with pressure
• Disability of the central nervous system which is conscious state
• Expose and examine – identify life-threatening injury and prevent hypothermia
The Secondary Survey includes:
• Full set of vital signs – monitor blood pressure, heart and respiratory rate, oxygen saturation and conscious state.
• Give pain relief to patient and comfort to family, friends
• History – obtain a full history from patient, witnesses and perform a head to toe assessment
Section 4 – Management – in the Trauma and Injuries section of the PCCM provides three useful
reference lists to help determine if a patient presenting following trauma requires retrieval and transfer
to higher level care.
The Criteria for Early Notification of Trauma for Interfacility Transfer provides tabulated information on
vital signs.
The Injuries and mechanism of Injury lists provide further information on possible requirements for
transfer.
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If a patient meets ANY of the criteria in EITHER OR vital signs, injuries or mechanism of injury, the
retrieval service needs to be consulted immediately and transfer organised as a matter of urgency.
Fractures
• Fractures (buckle or break in the bone) - often occur following direct or indirect injury
• e.g. twisting, violence to bones. Clinically fractures are either:
- simple, where the skin is intact, or
- compound where there is a break in the overlying skin
Dislocation is a complete disruption of one bone relative to another at a joint
- Often results from injuries away from the affected joint e.g. elbow dislocation after falling on
an outstretched hand
Sprain is a partial disruption of a ligament or capsule of a joint
•
•
Remember with pelvic or long bone fractures there can be significant blood loss into tissues. Patients
should always be examined for other injuries.
Check pulses and sensation below limb fractures, as the blood or nerve supply of the limb may be
damaged by the fracture.
Repeatedly monitor circulation.
The aim of management is adequate splinting and immobilisation to avoid long term disability.
Dislocations and sprains
Realign / reduce dislocation as soon as possible as the limb will become compromised e.g. for fracture around elbow.
Consult MO. Minor dislocations may be realigned locally.
Management for mild and moderate sprains:
• R Rest the injured part for 48 hours, depending on disability
• I Ice pack for 20 minutes every 2 - 4 hours when awake for the first 48 hours then cease
• C Compression bandage e.g. crepe bandage
• E Elevate to hip level to minimise swelling (ankle sprain)
• Give Analgesia e.g. paracetamol
• Review in 48 hours and then in 7 days
• Strap / bandage to support an immobilise
Management of severe sprain: as above
The Medical Officer may advise temporary splint e.g. plaster of paris until review
Consult the Medical Officer / Physiotherapist if available
•
•
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PD3507-1 Learning Activity
1.
Which of the following may be signs of a neurological emergency
Correct
Choice
Chest pain
Confusion
Severe headache
Breathlessness
Arrhythmia
PD3507 Emergency 10
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PD3507-2 Emergency Presentations Part 2
Learning Objectives
To be able to use the PCCM to guide the management of:
• Acute wounds
• Burns
• Environmental emergencies
• Ear Nose and Throat emergencies
• Gastrointestinal emergencies
Acute Wounds
The aim of proper wound care is to achieve healing without infection, scarring and deformity
Wounds are produced by two basic injuries:
• sharp (cutting) injuries, which produce straight edged wounds that usually heal well or
• blunt (crush / blow) injuries, which produce jagged irregular wounds, that are more difficult to repair, tend to be dirtier and have a higher risk of infection
Primary closure is the cleaning and repair of wounds within 6-8 hours after injury. This usually leads to
the best outcome, with least scarring.
• Delayed primary closure is the delay of repair for a few days to allow for proper cleaning, usually seen in dirty or complex wounds
• Healing by secondary intention is leaving the wound to heal naturally, where the only intervention would be proper cleaning, appropriate dressings and/or antibiotics if indicated for infection
• There is no formal closure of the wound (i.e.with sutures). Scarring may be more extensive when this method is required
• Debridement is the removal of dead and dying tissue from in and around a wound, usually with a scalpel or scissors
The longer the delay before repair, the greater amount of dead tissue will be present (delayed primary
closure involves debridement before closure).
Any necrotic tissue in a wound will delay its healing
Examine all wounds for foreign bodies, bony injuries, damage to vessels, nerves and tendons, and for
injury to surrounding structures.
Do not remove any large penetrating objects. Consult Medical Officer.
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Clinicians should never:
• Use lignocaine with adrenaline in or near fingers, toes, ears, nose, penis, scrotum
• Shave / cut eyebrow when repairing wound
Burns
There are a number of levels of burns, all of which require specific intervention.
Epidermal or first degree burns are usually minor and heal quickly and without scarring.
Superficial partial thickness second degree burns are painful, take longer to heal and may scar.
Mid to deep partial thickness second degree burns are more serious, less painful with a high risk of
scarring.
The most serious burns, full thickness or 3rd degree are very serious, and if extensive enough, life
threatening.
Depth
Pathology
Colour
Circulation Sensation
Blisters
Healing
Epidermal
Erythema
Ist degree
Epidernis only
Red, warm to
touch
Normal,
increased
Present
None, or may
develop later.
Peeling
Few days
Superficial - mid
dermal
Superficial partial
thickness
2nd degree
Epidermis and
upper dermis.
Most adjoining
structures intact
Pink
Hyperaemic
Painful ++
Hypersensitive
Yes, within
hours
2-3 weeks.
Minimal
scarring
Mid-deep dermal
Mid-deep
partial thickness
2nd degree
Epidermis and
significant parts
of dermis.
Deeper
structures intact
Pale pink /
blotchy red
May be
sluggish
Decreased
sensation
Early, usually large and
rupture within
hours
More than
2-3 weeks.
High risk of
scarring
Full thickness
3rd degree
Epidermis,
dermis and cell
structure destroyed
White and / or
charred
Nil
Nil
No blistering.
Epidermis
destroyed
No healing,
granulation
and wound
contraction
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For patients presenting with burns, a Medical Officer needs to be consulted as early as possible for:
• Analgesia order for children
• Patient may require intubation - respiratory problems may occur due to breathing in steam, flames, smoke or toxic fumes, or burns to head and neck
• Burns which circle a limb or chest (circumferential) may impair circulation and breathing. Urgent treatment may be required. Skin may need to be incised to restore circulation and breathing.
This is called escharotomy and requires urgent consultation with the Burns Unit
Burns involving face / neck / genitals / hands / feet
Burns on infant / babies
Electrical burns as tissue damage may be deeper than it appears
Chemical burns
Any concerns / uncertainty with regard to patient or any burn meeting referral criteria
•
•
•
•
•
• Keep the patient with major burns warm with space blanket (especially children)
• Be careful not to cause hypothermia, especially in children
• Give analgesia as soon as possible (pain is a major presenting symptom in burns. However patients with full thickness burns may have no pain)
• Provide first aid as soon as possible. Use cool running tap water (never ice or iced water) to stop burning
• If chemical burn flush with copious amounts of water. If dry chemical first remove chemical prior to irrigation
• Cling wrap should be used for initial dressing for major burns
Tetanus Immunisation
Tetanus vaccination is part of the National Immunisation Program.
• Primary course should be given in childhood
• A booster dose is recommended at 50 years of age
Any deep dirty wound is a tetanus prone wound for example:
• compound fractures, deep penetrating wounds containing foreign bodies (especially wood), infected wounds
• extensive tissue damage such as contusions or burns
• any superficial wound contaminated with soil, dust or horse manure especially if topical disinfection is delayed more than four hours
• re-implantation of an avulsed tooth
If a person is unsure of their status, they require a booster if they have a Tetanus prone wound.
Whatever the immune status of an individual with a tetanus prone wound local disinfection and, where
appropriate, surgical treatment of wound must never be omitted.
The tetanus HMP should be used in accordance with the current edition NHMRC Australian
Immunisation Handbook.
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Environmental
The PCCM covers three main types of environmental emergencies:
• Decompression illness (DCI) is due to the changes in pressure while diving resulting in bubble formation in the blood or tissues
• Recompression (in a hyperbaric chamber) is the universally accepted standard for the treatment of DCI
• Hypothermia from prolonged exposure to cold or freezing temperatures
- hypothermia is when the body’s core temperature falls below 35 degrees Celsius
• Hyperthermia, heat stroke or heat exhaustion from prolonged exposure to high temperatures
• Heat Exhaustion is a heat-related disorder often known as exercise associated collapse (EAC) and is associated with dehydration.
- Body temperature does not rise above 40 degrees Celsius
Heat stroke occurs as a result of impaired thermoregulation (heat loss or heat gain) or exercise
- More serious than heat exhaustion – body temperature is 41 degrees Celsius or higher
•
Consider Decompression illness (DCI) until proven otherwise with all symptoms occurring up to 48
hours after SCUBA diving in an otherwise fit and healthy person.
Always keep patient flat - never head down - if decompression illness (DCI) suspected.
Give 100 % O2 and continue until patient reaches hyperbaric chamber or ordered by Medical Officer
to remove.
If patient presents with Hypothermia:
• Do not remove wet clothing if there is no dry blanket or other suitable cover
• Do not place the patient in a warm bath
•
•
•
- Infants and elderly people are at greatest risk of hypothermia
- Immediate management is required for heat stroke. True heat stroke is a medical emergency and multi-organ failure is common
Do not induce shivering, as this will result in heat gain
IV fluids should be used with caution in heat stroke as pulmonary oedema can develop
- If patients present with heat exhaustion
Rehydrate and treat symptoms
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Ear, Nose and Throat
The most common reasons for epistaxis is upper respiratory infection, with mucosal congestion and
vasodilatation and trauma (nose picking).
Most cases occur in children under 10 years.
Usually spontaneous in children, occurring from the anterior part of the nose
In adults, occurs more posteriorly and may be associated with high blood pressure or a bleeding
condition.
If a person is very hypertensive consider dropping BP to decrease bleeding.
Immediate management is required if nose bleed is profuse or is not stopped.
It can lead to hypotension / shock, especially in the elderly.
Gastrointestinal
It is not necessary for the clinician to make a definitive diagnosis for presentations of acute abdominal
pain.
It is more important to recognise cases which are significant, and to be able to present the history
and findings in an ordered manner to the Medical Officer.
Consider ectopic pregnancy in all women of child bearing age (12 - 52 years) who present with
abdominal pain and / or vaginal bleeding.
Alcohol can cause epigastric and / or right and / or left upper quadrant pain secondary to.
Gastritis, acute pancreatitis or alcoholic hepatitis, gastric or duodenal ulcer, small bowel obstruction
or biliary tract disease
Epigastric pain associated with alcohol usually occurs during or soon after heavy alcohol intake.
People often confuse dyspepsia (indigestion) with gastritis (inflammation of the gastric mucosa which
can only be diagnosed on endoscopy or biopsy).
Epigastric pain from gastritis / gastro-oesophageal reflux disease (GORD) isn’t necessarily associated
with alcohol. GORD can occur in children or adults.
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There are many causes of upper gastrointestinal bleeding which can range from small bleed to very
large loss of blood.
Most common are gastric or duodenal ulcer, oesophageal varices / erosion.
A patient who vomits blood, which was swallowed from a nose bleed may look like an upper gastrointestinal bleed.
Use of Non Steroidal Anti Inflammatory Drugs can predispose to bleeding
Major bleeds, particularly from Oesophageal varices may be life threatening.
Immediate resuscitation may be indicated.
The characteristic of rectal bleeding is determined by the location of disease /condition leading to blood
loss.
The most common cause for rectal bleeding, apart from haemorrhoids (piles) is upper gastrointestinal
bleeding e.g. gastric (stomach) or duodenal ulcer.
Do not attribute rectal bleeding to haemorrhoids unless more serious causes have been excluded.
The most serious cause for rectal bleeding is underlying colonic/rectal cancer.
People between 50 and 75 years should be screened for colorectal cancer every 2 years.
Bowel obstruction can occur in the small or large intestine, it can be partial or complete.
The three most common causes of small bowel obstruction are post-operative adhesions, hernias and
cancers.
The most common causes of large bowel / colon obstruction are cancer, twisting of the bowel
(volvulus), narrowing of the opening due to diverticulitis.
Patients are assessed based on the symptoms and history and managed as they would be for acute
abdominal pain.
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PD3507-2 Learning Activity
1.
Which of the following presentations requires immediate consultation with a medical officer.
Correct
Choice
Analgesia orders for children
Minor wounds requiring primary closure
Decompression Illness
Dyspepsia
Superficial burn to the upper arm
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PD3507-3 Emergency Presentations Part 3
Learning Objectives
On completion of this module learners will be able to use the PCCM to guide the management of:
• Emergencies of the genitourinary system
• Poisoning and drug emergencies.
• Toxinology (bites and stings) emergencies
Genitourinary
Renal colic is the pain caused by kidney stones passing through the ureter from the kidney to the
bladder.
Consult Medical Officer if fever present as an infected obstructed kidney is a urological emergency.
Strain all urine for stones (either through a piece of stocking or tea strainer, or urinate into container and
look for stone(s) before discarding.
Pain relief needs to be administered as soon as possible, as the pain can be excruciating.
Acute retention of the urine is most common in middle aged or elderly men.
It is usually preceded by a history of hesitancy and dribbling due to prostatic enlargement.
It can also occur secondary to delay in passing urine, UTI, medication, spinal injury or severe pain
associated with primary genital herpes.
It is important to provide early and effective pain relief as acute retention of urine can be painful and
distressing.
The two most common conditions which cause acute scrotal pain and swelling - torsion of the testis and
acute epididymo-orchitis (see table on next page).
Testicular torsion is an emergency requiring urgent surgery (within 4-6 hours) to save testes - consult
Medical Officer immediately.
Acute epididymo-orchitis which is usually secondary to a Sexually Transmitted Infection (Chlamydia or
Gonorrhoea).
Other less common causes of acute scrotal pain include mumps, strangulated inguinal hernia and
traumatic haematoma.
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This table in the PCCM will assist with deciding between torsion of the testis and acute epididymo-orchitis
Torsion
Epididymo-orchitis
Age
Any.
Most common.
10-25 years old
Young, sexually active adults
Older men with prostatic
problems
Onset
Usually sudden, but can be
gradual
Very severe
Absent or slight, less than 37.5C
Abdominal pain, vomiting
Gradual
Pain
Fever
Symptoms
Examination
Elevation
Swollen, red and tender. Affected testis may sit higher than
other and be lying transversely
No change or worse pain
Moderate
Significant
Abdominal pain, urethral discharge/ dysuria
Swollen, red and tender
Provides relief of pain
Poisoning / Overdose
Consult Medical Officer first if a substance is known to be toxic and a toxic quantity is known or
suspected to have been taken before the Poisons Information Centre (PIC).
Use universal precautions in all poisoning cases where toxins unknown.
Do not undertake any gastrointestinal decontamination until a full risk assessment has been completed
Consider poisoning in any patient who is confused, drowsy, unconscious or fitting.
Remember that someone who is conscious and talking after taking a poison could still be in the early
stages of severe poisoning.
All patients with intentional poisonings require a 12 lead ECG and a paracetamol level.
A recommended source of up to date electronic information on toxicology and toxinology can be found
in the therapeutic guidelines section of each state’s website of clinical information.
In cases of severe or complex poisoning where specific expert medical advice is required the PIC can
refer health practitioners to a Clinical Toxicologist.
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The Risk assessment associated with poisoning overdose includes:
• Agent taken
• Name of product, its ingredients/components, manufacturer
• Look for container if possible
• Ask relatives or witnesses
• Overdoses of drugs often involve more than one substance
• Inquire specifically if alcohol has been taken in all instances as it may greatly affect the toxicity of other exposures
• Also inquire specifically about paracetamol and any other over-the counter products
Route of exposure Oral, topical, eye, inhaled, injected
Dose
Exactly how much was taken; this may require manually counting out the amount remaining in the container from the amount initially thought to be there
It is important to always consider the worst case scenario
Exact Time of exposure if possible
Intent of exposure was it accidental or deliberate
Has any treatment been attempted e.g. Has substance been diluted, skin been washed, eyes irrigated
etc.
Patient factors Does the patient have any pre-existing illness, heart disease, patient , weight, BGL, etc.
Clinical course
What symptoms has the patient noticed since exposure to poison/medication
This can then be correlated with the agent, dose and time since ingestion to strengthen the risk
assessment
•
•
•
•
Clinical status of patient Blood pressure, HR, respiratory rate, temperature, O2 saturation, conscious
state.
Risk Assessment
Agent/s taken
Route
Dose
Time
Name of product, ingredients, components, manufacturer
Oral, topical, eye, inhaled, injected
Exact amount
Exact time if possible
Intent
Treatment
Patient
Clinical course
Patient State
Accidental or deliberate
Diluted, skin washed, eyes irrigated
Pre-existing illness, weight, blood glucose level
Symptoms since exposure
Routine observations plus oxygen saturation and conscious state
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Toxinology
The PCCM includes information on the management of a number of bites and stings including:
• Snake bites including sea snakes
• Spider bites
•
•
- General
- Funnel Web
- Red Back
Scorpion stings and centipede bites
Marine envenomation
Aim of management of all bites and stings is to prevent lymphatic spread
• Snake bites
- All require pressure immobilisation bandage
• Spider bites
- General – localised treatment
- Funnel Web – pressure immobilisation
- Red Back - DO NOT apply pressure immobilisation bandage, apply localised treatment
Antivenom or polyvalent can be given following assessment, on identification of the agent or following
an order by an authorised practitioner.
Scorpion stings and centipede bites are treated locally and not with pressure immobilisation.
Ticks should be removed as soon as possible and the symptoms treated accordingly.
Marine envenomation – Jelly fish
• Box jellyfish are very venomous. Stings are treated with vinegar and Antivenom – pressure immobilisation is not used
• Irukandji are also very venomous. Stings are treated with vinegar. Patients can go on to suffer from Irukandji Syndrome 15 to 40 minutes after sting
- Systemic symptoms which can be life threatening include agitation, sweating, vomiting,
severe pain and severe cardiac symptoms
Blue Bottle are mildly venomous. Sting sites are immersed in very hot water. Vinegar is not used.
Other jellyfish stings are usually mild and are treated by removing tentacles and relieving localised symptoms. Vinegar is not used.
•
•
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Envenomation from other marine creatures includes:
• Blue ringed octopus and cone shell which are very venomous. Stings may be life threatening. Managed by pressure immobilisation and emergency care
• Fish stings include stone fish, bullrout, stingray and cat fish. Managed by immersion in hot water and analgesia. No pressure immobilisation
• Sea urchin stings are managed using hot water immersion and localised treatment
• Sponge stings are managed by washing site and treating localised symptoms
• Ciguatera poisoning is caused by the ingestion of tropical fish which contain ciguatoxins
• The classic feature is temperature reversal, paradoxical or reverse temperature perception
• Management is based on the presenting symptoms.
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PD3507-3
1.
Learning Activity
Which of the following stings or bites are treated with pressure immobilisation bandaging?
Correct
Choice
Sea snake bites
Red-back spider bites
Funnel Web spider bites
Scorpion sting
Irukandji sting
Blue-ringed octopus sting
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PD3507 Theory to Practice Activity
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Jonathon is an 18 year old man who presents to clinic the afternoon after he sustained a tooth knuckle
injury in a fight at a party the night before. The wound is not bleeding but is red and painful.
1.
What immediate management is required?
Answer
2.
What clinical assessment needs to be conducted?
Answer
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Your examination has revealed a small puncture wound on the knuckles of Jonathon’s right hand. It is
red, swollen and painful and he is complaining of having problems clenching his fist.
3.
What is now required?
Answer
Jonathon’s injury is becoming infected and he is going to require oral antibiotics. He has no known
allergies. He can’t remember when he had his last Tetanus injection.
4.
What steps will you now take (within your scope of practice) to ensure Jonathon has safely administered and appropriate medication.
Answer
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Schedule
4
Amoxycillin / clavulanate
DTP
IHW / SM / R&IP / IPAP
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics must consult MO/NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Form
Strength
Tablet
875/125mg
Suspension
125 mg / 31.25 mg
per 5 mL or
400 mg / 57 mg
per 5 mL
Route of administration
Recommended
dosage
Duration
Adult
875/125mg bd
Oral
Child
22.5 + 3.2 mg / kg
/ dose to a max.
of
875 + 125 mg bd
5 days
Provide Consumer Medicine Information: take immediately before food.
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
[10]
Prevention of tetanus in inadequately immunised people with tetanus prone wound
Schedule
4
DTP
IHW / IPAP
Tetanus imunoglobulin
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics must consult MO/NP
Form
Ampoule
Strength
Route of administration
250 international
units
IM
Recommended
dosage
Duration
250 international
units
If more than
24 hours have
elapsed since
wound, give 500
international units
Stat
Provide Consumer Medicine Information
Management of associated emergency: See Anaphylaxis
[1]
PD3507 Emergency 26
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Schedule
2
Paracetamol
DTP
IHW / IPAP
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics may proceed
Form
Tablet
Strength
500 mg
Suspension
120 mg / per 5 mL
(24 mg / mL)
or
100 mg / mL drops
Suppository
125 mg
250 mg
500 mg
Route of administration
Oral
Oral
Rectal
Recommended
dosage
Adults & children >
12 years
1 - 2 tabs every 4
hours to max. 8 tabs
per day
Children 7 - 12 years
1/2 - 1 tab every 4
hours to a max. 4
times per day
Child
15 mg / kg / dose
every 4 hours if
necessary to a max.
of 4 times per day
Adult & children > 12
years
500 -1000 mg
Duration
Stat
Further doses
on MO / NP
orders
5 days
Children 7 - 12 years
250 - 500 mg
Stat
Child < 7 years
15 mg / kg / dose
Provide Consumer Medicine Information: not for administration to children under 1 month
Management of associated emergency: consult MO
[1] [2]
PD3507 Emergency 27
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PD3507 Quiz
1.
Tick
The main aim of management of all stings and bites is to provide pain relief
Choice
True
False
2.
What is the healing time for each type of burn?
Burn
Healing time
Mid-deep partial thickness
Erythema
Full thickness
Superficial partial thickness
Patients went for long periods without medication
PD3507 Emergency 28
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3.
Tick
Complete the table in relation to primary and secondary survey of presentations for trauma and injuries
Choice
A
B
C
D
E
F
G
H
PD3507 Emergency 29
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4.
Match the management of acute wounds with its definition.
Tick
Definition
Management
1
Immediate cleaning and repairing
Primary closure
2
Debridement
Removal of necrotic tissue
3
Secondary Intention
No intervention
4
Delayed primary closure
Delay of repair to allow cleaning
5.
Tick
Which of the following may cause testicular pain?
Choice
Torsion of the testes
Urinary tract infection
Renal colic
Acute retention of urine
Mumps
PD3507 Emergency 30
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6.
No.
Match the injury with its definition
Injury
Definition
1
Buckle in the bone
2
Disruption of bone relative to another
3
Partial disruption of a joint capsule
PD3507 Emergency 31
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PD3507- 1 Learning Activity
1.
Tick
Which of the following may be signs of a neurological emergency?
Choice
Chest pain
Confusion
Severe headache
Breathlessness
Arrhythmia
PD3507- 2 Learning Activity
2.
Tick
Which of the following presentations requires immediate consultation with a medical officer?
Choice
Analgesia orders for children
Minor wounds requiring primary closure
Decompression Illness
Dyspepsia
Superficial burn to the upper arm
PD3507 Emergency 32
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PD3507- 3 Learning Activity
3.
Tick
Which of the following stings or bites are treated with pressure immobilisation bandaging?
Choice
Sea snake bites
Red-back spider bites
Funnel Web spider bites
Scorpion sting
Irukandji sting
Blue-ringed octopus sting
PD3507 Emergency 33
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PD3507 Theory to Practice Activity Feedback
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Jonathon is an 18 year old man who presents to clinic the afternoon after he sustained a tooth knuckle
injury in a fight at a party the night before. The wound is not bleeding but is red and painful.
Answer
Nil as wound is not bleeding
2.
What clinical assessment needs to be conducted?
Answer
Take history including circumstances of injury:
How and when did the injury happen?
Type of injury / wound and time until presentation
Where did the injury occur?
Has it been contaminated with dirt, oil, water and other environmental hazards
When was the last tetanus vaccination?
Perform standard clinical observations
Perform physical examination:
Site of injury
Check for foreign body:
How long and how deep is the wound?
Is it still bleeding?
Is there visible damage or division of structures e.g. tendons, nerves, bone?
Is there any skin or tissue loss?
Inspect the local structures and surrounding area.
Check colour, warmth and pulses below the wound
Check sensation around and below the wound (do this before putting in any anaesthetic)
Assess the tendons of the hand through range of movement of any underlying tendons:
extensors: straighten the fingers against resistance
flexors: squeeze fingers
thumb: raise it to the ceiling (palm up), and also make an ‘O’ with the little finger, both against
resistance
Is there bony tenderness to suggest an underlying fracture?
Is there increasing swelling to suggest bleeding into the tissues?
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
PD3507 Emergency 34
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Your examination has revealed a small puncture wound on the knuckles of Jonathon’s right hand. It is
red, swollen and painful and he is complaining of having problems clenching his fist.
3.
What is now required?
Answer
• This is a high risk wound as Jonathon has presented more than 8 hours after the injury
occurred.
• Consult Medical Officer
• The wound needs to be thoroughly cleaned. See Acute wounds
• Debride dead tissue and irrigate copiously
• Do not suture. Allow to heal by secondary intention
• Larger wounds may need delayed primary closure.
• Review daily and dress with non-adherent dressing e.g. melolin
• If not allergic treat with Amoxycillin / Clavulanate
Jonathon’s injury is becoming infected and he is going to require oral antibiotics. He has no known
allergies. He can’t remember when he had his last Tetanus injection.
4.
What steps will you now take (within your scope of practice) to ensure Jonathon has safely
administered and appropriate medication?
Answer
The answer to this question depends on your scope of practice and the Health Management
protocols you work under. The list below provides brief information.
Paracetamol can be given by Authorised Indigenous Health Workers (IHW) and Isolated Practice
Area Paramedics (IPAP)
Antibiotics
•
IHW and IPAP must consult the Medical Officer (MO) or Nurse Practitioner (NP)
•
Non-endorsed Registered Nurses must consult the MO or NP
•
Scheduled Medicines Rural and Isolated Practice Registered Nurse (SM R&IP) may proceed
Tetanus immunoglobulin
•
•
IHW and IPAP must consult MO / NP
Non-endorsed Registered Nurses must consult MO / NP
The following tables provide information on the Health Management Protocols for Amoxycillin /
clavulanate , Tetanus immunoglobulin and simple analgesia.
PD3507 Emergency 35
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Schedule
4
Amoxycillin / clavulanate
DTP
IHW / SM / R&IP / IPAP
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics must consult MO/NP
Scheduled Medicines Rural & Isolated Practice Registered Nurses may proceed
Form
Strength
Tablet
875/125mg
Suspension
125 mg / 31.25 mg
per 5 mL or
400 mg / 57 mg
per 5 mL
Route of administration
Recommended
dosage
Duration
Adult
875/125mg bd
Oral
Child
22.5 + 3.2 mg / kg
/ dose to a max.
of
875 + 125 mg bd
5 days
Provide Consumer Medicine Information: take immediately before food.
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
[10]
Prevention of tetanus in inadequately immunised people with tetanus prone wound
Schedule
4
DTP
IHW / IPAP
Tetanus imunoglobulin
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics must consult MO/NP
Form
Ampoule
Strength
Route of administration
250 international
units
IM
Recommended
dosage
Duration
250 international
units
If more than
24 hours have
elapsed since
wound, give 500
international units
Stat
Provide Consumer Medicine Information
Management of associated emergency: See Anaphylaxis
[1]
PD3507 Emergency 36
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Schedule
2
Paracetamol
DTP
IHW / IPAP
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics may proceed
Form
Tablet
Strength
500 mg
Suspension
120 mg / per 5 mL
(24 mg / mL)
or
100 mg / mL drops
Suppository
125 mg
250 mg
500 mg
Route of administration
Oral
Oral
Rectal
Recommended
dosage
Adults & children >
12 years
1 - 2 tabs every 4
hours to max. 8 tabs
per day
Children 7 - 12 years
1/2 - 1 tab every 4
hours to a max. 4
times per day
Child
15 mg / kg / dose
every 4 hours if
necessary to a max.
of 4 times per day
Adult & children > 12
years
500 -1000 mg
Duration
Stat
Further doses
on MO / NP
orders
5 days
Children 7 - 12 years
250 - 500 mg
Stat
Child < 7 years
15 mg / kg / dose
Provide Consumer Medicine Information: not for administration to children under 1 month
Management of associated emergency: consult MO
[1] [2]
PD3507 Emergency 37
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PD3507 Quiz Feedback
1.
Tick
The main aim of management of all stings and bites is to provide pain relief
Choice
True
False
2.
What is the healing time for each type of burn?
Burn
Healing time
Mid-deep partial thickness
More than 2 to 3 weeks
Erythema
A few days
Full thickness
Doesn’t heal
Superficial partial thickness
2 to 3 weeks
PD3507 Emergency 38
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3.
Complete the table in relation to primary and secondary survey of presentations for trauma and injuries
Tick
Choice
A
Airway and cervical spine protection
B
Breathing
C
Circulation
D
Disability – level of consciousness
E
Expose and examine
F
Take full set of vital signs
G
Give pain relief
H
Take history
PD3507 Emergency 39
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4.
Match the management of acute wounds with its definition.
Tick
Definition
1
Immediate cleaning and repairing
1
Primary closure
2
Debridement
2
Removal of necrotic tissue
3
Secondary Intention
3
No intervention
4
Delayed primary closure
4
Delay of repair to allow cleaning
5.
Tick
Management
Which of the following may cause testicular pain?
Choice
Torsion of the testes
Urinary tract infection
Renal colic
Acute retention of urine
Mumps
PD3507 Emergency 40
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6.
Match the injury with its definition
No.
Injury
Definition
1
Fracture
Buckle in the bone
2
Dislocation
Disruption of bone relative to another
3
Sprain
Partial disruption of a joint capsule
PD3507 Emergency 41
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Primary Clinical
Care Manual
PD3508 - General Presentations
Participation Manual
Name
Community
Site
Please select ...
Position
Date Completed
PD3508 General Presentations Aboriginal
Administration
Allied
Dental
Medical
Nursing
Midwife
Other
Student
Health
Officer
Officer
and /Officer
or Torres Strait Islan
1
Version1 (2014)
Contents
PD3508 Introduction3
PDPD3508-1 General presentations5
PD3508-1 Learning Activity9
PD3508-2 General Presentations Part 210
PD3508-2 Learning Activity15
PD3508 Theory to Practice Activity16
PD3508 Quiz 19
PD3508-1 Learning Activity Feedback22
PD3508- 2 Learning Activity Feedback23
PD3508 Theory to Practice Activity Feedback24
PD3508 Quiz Feedback27
PD3508 General Presentations 2
Version1 (2014)
PD3508 Introduction
Session Overview
The PCCM provides comprehensive information the management of general, non-emergency health
conditions. This session provides further information on the use of the PCCM as a guide for the management of these presentations.
Learners will need to have a hard copy of the PCCM, a printed copy of the downloadable PCCM or
access to the electronic version of the PCCM to be able to complete this session.
Learning Objectives
On completion of this session participants will be able to use the PCCM as a guide for the management
of a range of presentations including:
Allergic reactions
Respiratory problems
Problems of the nervous system
Mouth and dental problems
Eye problems
Problems of the urinary tract
Skin problems
Foot infection in the person with diabetes
Chronic wounds
Communicable diseases
Chronic diseases
•
•
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•
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•
•
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•
Modules
Module 1 provides information on using the PCCM as a guide in the management of:
• Mild and moderate allergic reactions
• Non-life threatening respiratory problems
• Problems of the nervous system in particular headaches
• Mouth and dental problems
• Serious and non-serious problems of the eyes
• Problems of the urinary tract.
Module 2 provides information on using the PCCM to guide the management of:
• Skin infections including bacterial and fungal disease
• Foot infection in a person with Diabetes
• Chronic wounds
• Communicable diseases
• Chronic diseases
PD3508 General Presentations 3
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Learning Activities
The learning activity is included in each module needs to be completed before moving to the next module.
Theory to Practice Activity
The theory to practice activity included at the end of the modules needs to be completed before moving
to the quiz.
Quiz
Once you have completed the modules in this session, you are asked to complete an interactive quiz
which is graded.
PD3508 General Presentations 4
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PDPD3508-1 General presentations
Learning Objectives
• On completion of this modules learners will be able to use the PCCM as a guide for managing
• Allergic reactions
• Respiratory problems
• Problems of the nervous system
• Mouth and dental problems
• Eye problems
• Problems of the urinary tract
Important Information
This module provides only basic, introductory information on general presentations.
It includes information on:
• Common causes for the presentation
• Signs and symptoms patients may present with
• Important factors to consider
• Learners will be directed to the PCCM for information on management
Allergic Reactions
Mild allergic reactions involve the skin and subcutaneous tissues. Moderate / severe allergic reactions feature respiratory, cardiovascular, or gastrointestinal involvement.
Acute urticaria can last from a few minutes to 24 hours. If it lasts longer than 6 weeks it is considered
chronic urticaria.
People with diagnosed allergies, e.g. nuts, bees and / or medication, should avoid trigger agents and
have a readily accessible action plan and medical alert device.
The management of patients presenting with an allergic reaction depends of the systems involved
and the severity.
Respiratory Problems
Respiratory problems covered in the PCCM include:
• Upper Respiratory Tract Infection (URTI)
•
•
•
Common cold; Influenza; Sore throat
Tonsillitis; Bronchitis; Pharyngitis
Acute Bacterial Sinusitis
Pneumonia
Tuberculosis
PD3508 General Presentations 5
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The vast majority of Upper Respiratory Tract Infections (URTI) are caused by viruses and do not
require antibiotics.
A viral upper respiratory tract infection can be complicated by secondary bacterial infection requiring
antibiotics e.g. acute otitis media, sinusitis, bronchitis, pneumonia.
Other complications include exacerbation of asthma / chronic obstructive pulmonary disease (COPD)
Influenza is an acute respiratory illness caused by influenza viruses of which there are many different
types. Epidemics commonly occur over the winter months.
Recent years have seen the emergence of new influenza strains.
Consult locally developed guidelines for appropriate precautions to limit onward transmission of the
virus as well as individual patient management.
This may include collection of specimens and commencing anti-viral treatment in high risk groups
Influenza is probably over-diagnosed. Systemic symptoms such as fever, extreme lethargy, sore muscles and joints and headache differentiate it somewhat from a ‘common cold’.
Patients at risk may develop pneumonia secondary to influenza and should be offered vaccination
against influenza. See Immunisation program.
Clinicians need to be alert to the relationship between group A streptococcal infections and acute
rheumatic fever / acute post streptococcal glomerulonephritis.
These conditions are especially common in Aboriginal and Torres Strait Islander communities.
Indications for antibiotic treatment include:
• Patients aged 2 - 25 years with sore throat in communities with high incidence of acute rheumatic fever
• Follicular tonsillitis with fever and local lymphadenitis,
• Existing rheumatic heart disease,
• Quinsy
Nervous System
Acute and Chronic Headache can be classified into two broad categories - primary and secondary
primary headaches include migraine, cluster or tension headache
secondary headaches are triggered by an underlying disorder –
such as infection, injury or tumour, subarachnoid haemorrhage - and can be considered as a side effect of the main illness
•
•
Suspect subarachnoid haemorrhage (SAH) in any patient who presents with a headache of sudden
onset described as the most severe headache they have ever had.
Consult MO immediately. See Subarachnoid haemorrhage
PD3508 General Presentations 6
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Mouth and Dental
Patients with mouth and dental problems may present with:
• Trauma to teeth
• Toothache
• Periodontal disease
• Dental abscess – refer to MO if facial swelling or difficulty swallowing / breathing
• Post-extraction haemorrhage
• Dry socket – alveolar osteitis
• Oral thrush / Candidiasis
Mouth and dental problems can be very painful, the two main interventions for presentations are for
analgesia and antibiotics.
Non Steroidal Anti Inflammatory Drugs are particularly effective for bone pain. The most commonly
used NSAID for dental, oral and facial pain is ibuprofen.
An ibuprofen dose of 200 - 400 mgs 3 - 4 times daily is required to reduce inflammatory response
Severe pain usually requires the additional use of another analgesic such as paracetamol.
Use of ibuprofen or other NSAID is not recommended for dental pain relief in patients with kidney
disease unless in consultation with the patient’s MO.
Amoxycillin and Clindamycin are the most commonly used antibiotics. Metronidazole for more severe
infections - see PCCM for more details.
Eye
Patient’s presenting with the following serious eye problems need urgent referral to a Medical Officer:
• Chemical burns
• Blunt eye injury
• Penetrating eye injury
• Sudden loss of vision
• Orbital / Periorbital cellulitis
• Corneal ulceration
• Episcleritis and scleritis
• Acute iritis
• Acute Glaucoma
PD3508 General Presentations 7
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Less serious presentations with eye problems include:
• Foreign body / corneal abrasion
• Flash burn
• Conjunctivitis
• Bacterial
• Viral
• Allergic
• Trachoma
Determining the cause of eye disorder through systematic and thorough history and examination of
the eye is critical in presentation.
Failure to complete a thorough examination may lead to loss of sight. A visual acuity of 6/6 does not
exclude a serious eye condition
Urinary Tract
• UTI is more common in females as the urethra is short
• UTI is rare in males <50 years of age
•
After the age of 50 years men may have predisposing factors such as prostatitis and urethral obstruction due to prostatic hypertrophy.
Dysuria in younger males is usually caused by a STI
E. coli causes approximately 80% of acute UTI
The incidence of UTI is increased if there is:
• any obstruction to the flow of urine (tumour, stone, stricture, prostatic hypertrophy)
• abnormal renal anatomy
• catheterisation and
• in people who have diabetes
Any woman presenting with low abdominal or suprapubic pain without dysuria or frequency should be
assessed for pelvic inflammatory disease (PID).
See Urinary tract infection in pregnancy if patient is pregnant
PD3508 General Presentations 8
Version1 (2014)
PD3508-1 Learning Activity
1.
Which of the following injuries to the eye require urgent Medical Officer review
Correct
Choice
Blunt eye injury
Viral conjunctivitis
Trachoma
Sudden loss of vision
Acute Iritis
PD3508 General Presentations 9
Version1 (2014)
PD3508-2 General Presentations Part 2
Learning Objectives
• Learners will be able to use the PCCM as a guide for managing
• Skin problems
• Foot infection – person with Diabetes
• Chronic wounds
• Communicable diseases
• Chronic disease
Skin
It is important to ensure a comprehensive history and physical assessment is completed on patients
presenting with problems of the skin.
This includes:
• Obtaining a complete history including past episodes, exacerbating and relieving factors, other people affected and associated symptoms
• Determining a part history of Acute Post Streptococcal Glomerulonephritis (APSGN) and Acute Rheumatic Fever (ARF) and Acute Rheumatic Heart Disease (ARHD)
• Examining the skin including skin folds, moist areas, nails and hair and mucous membranes.
Patients may present with:
• Bacterial skin infections
Majority of infections will be Staphylococcus aureus. Less common are Streptococcus
pyogenes
It is important to be vigilant for group A Streptococcal infections.
Complications such as APSGN and ARF can result from Strep infections
Impetigo
Highly infectious particularly in children
Complicates pre-existing skin conditions such as scabies, eczema, tinea, insect bites and abrasions
Folliculitis
Infection of the hair follicle
Furunculosis (boil)
Deep inflammatory nodule that develops around the hair follicle
Common in axillae, inguinal area or buttocks
Carbuncles (abscess)
More extensive and deeper lesion with multiple heads
Lesions should not be squeezed as it may result in the spread of the infection
Lesions of the hands, face or breast should not be incised
•
•
•
•
PD3508 General Presentations 10
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• Cellulitis presents with spreading, tender erythema. It is associated with fever and systemic
toxicity, as opposed to impetigo which is a superficial skin infection
Erysipelas is a type of cellulitis with marked epidermal involvement with a clear line of
demarcation between the involved and uninvolved tissue. It is more common among infants, young children and older adults
Consider osteomyelitis and septic arthritis if a skin infection is taking a long time to resolve or occurs over a joint.
All infections are usually treated by antibiotic therapy and simple analgesia
•
Skin Conditions
Patients may also present with:
• Fungal skin infections which include
Tinea or ringworm can infect any part of a person’s skin, hair and nails.
It is caused by a fungus parasite, and has a typical appearance which is described as annular (forming a ring) or arcuate (bow shape).
Candidiasis is a yeast infection which is associated with some chronic diseases, lifestyle, medications or poor hygiene.
Tinea versicolor or pityriasis verscolor
Skin scrapings help with diagnosis and conditions are treated with topical anti-fungal agents
Leprosy often causes unexplained peripheral lesion which fails to respond to conventional treatment. All cases are referred to a Public Health Unit
Skin parasites include scabies and head lice
Highly contagious
All close contacts need to be treated
Secondary infections can occur and may require antibiotic therapy
Nappy rash
Usually irritant dermatitis which becomes colonised with Candida albicans (thrush).
May also have a secondary bacterial infection
•
•
•
Skin conditions are generally treated with topical creams, antifungal agents and antibiotics if required.
Foot infection Person with Diabetes
Foot infections in patients with diabetes are a serious complication that frequently lead to amputation.
Precipitating causes of foot ulceration and infection include: friction in ill fitting shoes, untreated or
self treated callus, foot injuries, burns, corn plaster, nail infections, heel friction when immobile and
foot deformities.
Consult Medical Officer or specialist diabetic foot service for any patient who has diabetes and has a
foot lesion / infection.
Early treatment with appropriate antibiotics and wound care may prevent the need for the patient with
diabetes to be evacuated, hospitalised and undergo an amputation.
Reducing pressure or improving vascularisation is required to heal a diabetic foot ulcer.
PD3508 General Presentations 11
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The patient with diabetes who has a foot lesion / infection is at risk of having underlying osteomyelitis
Clinical diagnosis is difficult.
If the ulcer is > 2 x 2 cm or bone is palpable, then osteomyelitis is likely. Further non invasive testing
is not necessary to initiate treatment.
Consult Medical Officer or specialist Diabetic Foot Service immediately if a patient with diabetes has
suspected osteomyelitis in the foot.
Chronic Wounds
Patients with chronic wounds may present with an acute wound that is not healing or an ulcer
Chronic wounds are common in patients with diabetes or other chronic disease.
The PCCM provides extensive information on assessment, types of wounds, wound management
and dressing products.
Wound care management is based on the principles of moisture balance.
• except where arterial disease has not been investigated or dry diabetic ulcer is present,
• inappropriate hydration of wound can lead to infection and amputation
Do not remove or moisten dry, adherent, intact skin without erythema or fluctuance eschar (possibility
of liquid mass / collection of pus) on the heels.
This serves as the body’s natural biological cover.
Measure all wounds - use plastic bag, acetate tracing and / or photograph as baseline.
Consult a specialist Diabetic Foot Service for all diabetic foot lesions.
Diabetic foot wounds should not be left for more than 3 days without checking / redressing
Communicable Diseases
Patients may present with:
Acute Hepatitis A
Transmission is by the faecal-oral route and can occur sexually, especially in men having sex with other men.
May occur through eating food contaminated by infected food handlers
Incubation period is between 2 weeks and 6 weeks (average 28 - 30 days).
Hepatitis A is self limiting (duration around 6 months) and never becomes chronic
The virus is excreted in the stools for two weeks before illness is apparent and continues for up •
•
•
•
•
PD3508 General Presentations 12
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to one week after onset of jaundice
Two cases constitute an outbreak
Prevented through vaccination and good hygiene practices
Acute Hepatitis B
If HepBsAg is persistently positive it should be rechecked in 6 months to confirm chronicity of carriage.
There is a high incidence of hepatitis B in Aboriginal and Torres Strait Islander communities and some migrant populations in Australia
Transmission occurs by three major routes:
percutaneous (IV, IM, SC or intradermal) and permucosal exposure
sexual transmission
perinatal transmission from mother to child at birth
Prevention and management includes vaccination and avoiding risk factors
Acute Hepatitis C
Acute hepatitis C becomes a chronic disease when Hep C RNA remains detectable after 6 months from the onset of the acute infection
Transmission is largely from infected blood or blood products
2 or more cases is considered an outbreak
Screen all patients who have tested positive for a STI for hepatitis B and C
In any patient with antibodies to hepatitis C, a hepatitis C PCR test (and liver function tests) must be performed to determine whether or not the infection is still present
razors, toothbrushes, nail clippers or similar items should not be shared if Hepatitis C is suspected
•
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•
•
•
Ross River fever and Barmah forest virus are two similar viral illnesses transmitted by mosquitoes and
characterised by fever, rash and joint pains.
• They can occur in epidemics associated with proliferation of mosquitoes
• The incubation period is between 3 - 11 days
• Ross river fever causes significant arthralgia for several months in a number of patients, most usually recover in 4 - 7 months
• Dengue viruses include serotypes DEN 1, 2, 3 and 4, the same viruses that are responsible for dengue haemorrhagic fever
• Clinical features depend on the age of the patient
• Infants and young children may have an undifferentiated febrile disease often with a maculopapular rash
• Older children and adults may have either a mild febrile syndrome or the classic disease
• In Australia the dengue virus is transmitted by the Aedes aegypti mosquito. This mosquito is a highly domesticated urban mosquito living and breeding in and around households throughout the tropics and subtropics
Dengue haemorrhagic fever (DHF) is a less common but serious and often rapidly fatal form of the disease; it occurs mostly in those previously exposed to dengue fever and who have become sensitised. DHF is more common in children
One or more confirmed cases of locally acquired dengue is considered an outbreak
•
•
PD3508 General Presentations 13
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Chronic Diseases
Chronic diseases that may require ongoing management include:
• Acute Rheumatic Fever and Rheumatic heart disease – ongoing secondary prophylaxis
• Chronic Asthma in adults and children
Asthma in children differs from asthma in adults in clinically important aspects, which include the patterns of asthma, natural history and anatomical factors.
The pattern and severity of asthma in childhood vary widely
Promote the avoidance of trigger factors along with drug management for prevention and treatment with a goal of no regular wheeze or cough
Chronic obstructive pulmonary disease
•
See breathlessness section of PCCM for management
Other chronic diseases included in the PCCM are:
Hypertension which is managed through monitoring and medication
Chronic kidney disease
Consider essential screening of ‘at risk’ population groups as kidney disease and failure are often asymptomatic
Treat all patients with Type 1 or Type 2 diabetes mellitus complicated by microalbuminuria or overt nephropathy
with an ACE inhibitor (ACEI), independent of BP and GFR
Chronic heart disease – monitoring and medication
Diabetes Mellitus – monitoring and medication
•
•
•
•
PD3508 General Presentations 14
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PD3508-2 Learning Activity
1.
Which of the following statements are correct?
Correct
Choice
Scabs should be removed from wounds to allow wound to dry out and heal faster
Tinea is a bacterial infection
Carbuncles and abscesses are the same thing
Nappy rash can become infected
Hepatitis C does not become chronic
PD3508 General Presentations 15
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PD3508 Theory to Practice Activity
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Bessie is a 65 year old woman who presents to your clinic with an ulcer on her left medial malleolus.
She has had varicose veins for many years which have been surgically managed in the past.
1.
Using the essential guidelines for assessment of lower limb ulcers in the chronic wounds section
of the PCCM complete the following table.
What type of ulcer bed would you expect?
What type of exudate would you expect?
What type of exudate would you expect?
What is the capillary return likely to be?
What will the surrounding skin look like?
What do you expect the vascular status to be?
2.
What clinical assessment needs to be conducted?
Answer
PD3508 General Presentations 16
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Your examination has revealed a moderately exudating ulcer with shallow irregular margins. The exudate is malodorous, the surrounding tissue red, swollen, hot and painful. Bessie has palpable pulses
and normal capillary refill. She claims she is not diabetic. Her observations showed a low grade temperature, normal respiratory and heart rates and a blood glucose level of 5.4 mmol/l.
3.
What is the most likely diagnosis and what management will it require?
Answer
4.
What type of wound dressing should be used and what wound management plan would be put
in place for Bessie?
Answer
PD3508 General Presentations 17
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5.
What long term management might Bessie require?
Answer
PD3508 General Presentations 18
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PD3508 Quiz
1.
Tick
Mild allergic reactions usually involve the skin and subcutaneous tissue only.
Choice
True
False
2.
Match the disease with its correct statement by entering the number in the appropriate column
Disease
Statement
1
Hepatitis A
Spread by faecal oral route
2
Dengue
Can become chronic
3
Ross River Fever
Mosquito borne infection
4
Hepatitis B
Vaccine preventable disease
5
Hepatitis C
Arthralgia present for up to 7 months
PD3508 General Presentations 19
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3.
Which of the following groups should have antibiotic treatment for Upper Respiratory Tract
Infections?
Tick
Choice
Patients with existing rheumatic heart disease
Children aged between 2 and 5 in low risk communities
Patients with follicular tonsillitis and lymphadenitis
Patients with Quinsy
Patients with influenza
4.
Which of the following skin conditions may be treated with topical anti-fungal creams or
ointments.
Tick
Management
Tinea
Nappy rash
Impetigo
Scabies
Boils
PD3508 General Presentations 20
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5.
Match the infecting agent with the condition it may cause by entering the appropriate number in
the empty column.
No.
Condition
1
Furunculosis
Candida albicans
2
APSGN
E. Coli Group
3
Urinary tract infection
A streptococcal
4
Bacterial skin infections
Streptococcus pyogenes
5
Nappy Rash
Staphylococcus aureus
PD3508 General Presentations No.
21
Agent
Version1 (2014)
PD3508-1 Learning Activity Feedback
1.
Which of the following injuries to the eye require urgent Medical Officer review
Correct Choice
Blunt eye injury
Viral conjunctivitis
Trachoma
✔
Sudden loss of vision
Acute Iritis
PD3508 General Presentations 22
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PD3508- 2 Learning Activity Feedback
2.
Which of the following presentations requires immediate consultation with a medical officer?
Correct
Choice
Scabs should be removed from wounds to allow wound to dry out and heal faster
Tinea is a bacterial infection
Carbuncles and abscesses are the same thing
Nappy rash can become infected
Hepatitis C does not become chronic
PD3508 General Presentations 23
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PD3508 Theory to Practice Activity Feedback
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Bessie is a 65 year old woman who presents to your clinic with an ulcer on her left medial malleolus.
She has had varicose veins for many years which have been surgically managed in the past.
1.
Using the essential guidelines for assessment of lower limb ulcers in the chronic wounds section
of the PCCM complete the following table
What type of ulcer bed would you expect?
Fibrinous material at the ulcer bed
What type of exudate would you expect?
Heavy
What will the ulcer look like?
Shallow irregular margins. Can vary from small
to nearly encircling the leg. Margins with either
be flat or have slight steep elevations
Normal
What is the capillary return likely to be?
What will the surrounding skin look like?
What do you expect the vascular status to be?
PD3508 General Presentations Pigmented, oedematous, atrophy blanch and
indurated.
Pulses present and palpable
24
Version1 (2014)
2.
What clinical assessment needs to be conducted?
Answer
• Obtain patient history including:
• orisk factors; smoking, hypertension, ischaemic heart disease (IHD),cerebrovascular disease
(CVD), hyperlipidaemia, obesity and alcohol use
• duration, progression of ulcer
• measures used to treat / manage
• Perform standard clinical observations + BGL
• Perform physical examination:
• Inspect and palpate lower limb oedema and pulses.
(See Essential guidelines for assessment of leg ulcers)
• assess ulcer and document details of size, location,
• record presence of exudate and odour
Your examination has revealed a moderately exudating ulcer with shallow irregular margins. The exudate is malodorous, the surrounding tissue red, swollen, hot and painful. Bessie has palpable pulses
and normal capillary refill. She claims she is not diabetic. Her observations showed a low grade temperature, normal respiratory and heart rates and a blood glucose level of 5.4 mmol/l.
3.
What is the most likely diagnosis and what management will it require?
Answer
• Based on the history and observations, Bessie most likely has a venous ulcer that has become
infected.
• She will require wound dressings, a wound management plan and antibiotic treatment in
consultation with the Medical Officer. • The wound should also be monitored to ensure it heals.
PD3508 General Presentations 25
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4.
What type of wound dressing should be used and what wound management plan would be put
in place for Bessie?
Answer
• An alginate dressing is the most appropriate
• Alginate products are indicated for leg ulcers, pressure sores, cavity wounds and donor sites;
also good as an initial treatment for bleeding wounds as they possess haemostatic properties
• Examples include Kaltostat® and Algisite M® available as sheets, ropes or ribbons for packing
cavity
• Carboflex® and Kaltocarb® could also be considered as they include activated charcoal to
absorb odour
• Change dressings when exudate has fully converted to a gel
5.
What long term management might Bessie require?
Answer
• If the ulcer heals, Bessie should be advised to monitor the area and return immediately if there
is any sign it is recurring.
• Bessie has already had surgical intervention for varicose veins, so consideration should be
given to referring her to a vascular surgeon for assessment of arterial and venous disease.
PD3508 General Presentations 26
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PD3508 Quiz Feedback
1.
Tick
Mild allergic reactions usually involve the skin and subcutaneous tissue only.
Choice
True
False
2.
Match the disease with its correct statement, by entering the appropriate number in the column
No.
Disease
No.
Statement
1
Hepatitis A
4
Vaccine preventable disease
2
Dengue
3
Arthralgia present for up to 7 months
3
Ross River Fever
2
Mosquito borne infection
4
Hepatitis B
1
Spread by faecal oral route
5
Hepatitis C
5
Can become chronic
PD3508 General Presentations 27
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3.
Which of the following groups should have antibiotic treatment for Upper Respiratory Tract
Infections
Tick
Choice
Patients with existing rheumatic heart disease
Children aged between 2 and 5 in low risk communities
Patients with follicular tonsillitis and lymphadenitis
Patients with Quinsy
Patients with influenza
4.
Which of the following skin conditions may be treated with topical anti-fungal creams or
ointments.
Tick
Management
Tinea
Nappy rash
Impetigo
Scabies
Boils
PD3508 General Presentations 28
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5.
Match the infecting agent with the condition it may cause by entering the appropriate number in
the empty column.
Condition
Agent
1
Furunculosis
5
Candida albicans
2
APSGN
3
E. Coli Group
3
Urinary tract infection
2
A streptococcal
4
Bacterial skin infections
4
Streptococcus pyogenes
5
Nappy Rash
1
Staphylococcus aureus
PD3508 General Presentations 29
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Primary Clinical
Care Manual
PD3509 - Mental Health and
Substance Use
Participation Manual
Name
Community
Site
Position
Date Completed
PD3509 Mental Health and Substance Use
Please select ...
Aboriginal
Administration
Allied
Dental
Medical
Nursing
Midwife
Other
Student
Health
Officer
Officer
and /Officer
or Torres Strait Islan
1
Version1 (2014)
Contents
PD3509 Introduction3
PDPD3509-1 Mental Health and Substance Use Assessment5
PD3509-1 Learning Activity13
PD3509-2 Mental Health and Substance Use Part 114
PD3509-2 Learning Activity18
PD3509-2 Mental Health and Substance Use Part 219
PD3509-3 Learning Activity23
PD3509 Theory to Practice Activity 24
PD3509 Quiz29
PD3509-1 Learning Activity Feedback32
PD3509-2 Learning Activity Feedback32
PD3509-3 Learning Activity Feedback33
PD3509 Theory to Practice Activity Feedback34
PD3509 Quiz Feedback37
PD3509 Mental Health and Substance Use 2
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PD3509 Introduction
Session Overview
The PCCM provides comprehensive information the management of patients presenting with mental
health problems. It is important for clinicians to be able to effectively manage the presentation but to
also be aware of the need to involve mental health specialists, Medical Officers, families and the community in the ongoing care and management of people with poor mental health. Health professionals
must at all times be aware of the need to ensure safety of the patient, their family, the community and
themselves when dealing with these patients.
Learners will need to have a hard copy of the PCCM, a printed copy of the downloadable PCCM or
access to the electronic version of the PCCM to be able to complete this session.
Learning Objectives
On completion of this session participants will be able to use the PCCM as a guide for the management
of a range of presentations for mental health issues including:
• Conducting a comprehensive mental health assessment
• Identifying risks associated with suicide, violence and other vulnerabilities
• Behavioural emergencies
• Delirium, dementia and psychosis
• Mood, anxiety and eating disorders
• Sleep problems
• Misuse of alcohol, tobacco and other drugs
Modules
Module 1 provides information on using the PCCM as a guide for conducting a mental health assessment including a mental state examination and identifying risk factors for poor mental health outcomes
Module 2 provides information on using the PCCM to guide the management of:
• Suicide behaviour or risk
• Behavioural emergencies
• Delirium
• Dementia
• Psychosis
• Mood disorders
PD3509 Mental Health and Substance Use 3
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Module 3 provides information on using the PCCM to guide the management of:
• Anxiety disorders
• Eating disorders
• Sleep problems
• Alcohol misuse
• Smoking
• Other drugs and substances
Learning Activities
The learning activity is included in each module needs to be completed before moving to the next module.
Theory to Practice Activity
The theory to practice activity included at the end of the modules needs to be completed before moving
to the quiz.
Quiz
Once you have completed the modules in this session, you are asked to complete an interactive quiz
which is graded.
PD3509 Mental Health and Substance Use 4
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PD3509-1 Mental Health and Substance Use Assessment
Learning Objectives
On completion of this module learners will be able to:
• Use the PCCM to assist in the management of clients presenting with mental health problems
including:
- Conducting a comprehensive mental health assessment
Identifying
- Risk of suicide
- Risk of violence
- Risks associated with vulnerability
•
The mental health and substance misuse section of the PCCM provides information to support
management of patients presenting with mental health issues.
It is important to conduct a comprehensive assessment using the same principles as a person
presenting with a physical problems.
It is also important to be aware of cultural influences the presence of and managing potential violence
and ensuring safety.
Primary health staff need to also be able to conduce a mental state examination including:
• determining suicide risk,
• the risk of violence or harming someone and
• the risk associated with vulnerability
Assessment Summary
A Mental health assessment includes:
• General health assessment and physical examination. See Patient history and physical
examination of the patient - adult / child
• Include in history taking mental health history - past episodes, admissions, medications, suicide
and / or self harm attempts and drug and alcohol screening
- Include family and carers to support history
Mental state examination (MSE) / risk assessment
Follow the Health Management Protocol (HMP) / clinical care guideline
Consult Medical Officer at any time
•
•
•
PD3509 Mental Health and Substance Use 5
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Principles
General principles of mental health presentations include:
• Following the same procedure as a person presenting with a physical problem and include a
mental health history, performing a MSE and the individual level of risk
• Considering the culture of the person you are assessing
• Always ensuring the safety of yourself, the patient and others
• The need for all mental health assessments to include a mental health management plan, clearly
identifying the immediate interventions that reflect the assessment findings
Cultural Considerations
Cultural considerations (Aboriginal and Torres Strait Islander peoples) which may impact on a mental
health presentations include:
• Cultural factors may have a significant bearing on the patient’s state of mind e.g. sorcery, having
been “sung” or “boned”, puri puri,
• Transgressions of cultural law and subsequent fear of punishment may present as anxiety,
depression or psychosis
• Eccentric behaviour is often tolerated in Aboriginal and Torres Strait Islander peoples
communities
• People with mental illness often will present later when more obvious signs become apparent or
the family reports a change in usual behaviour
• Co morbidity with substance use disorders is common
• History from family members and advice from Aboriginal and Torres Strait Islander Health
Workers is extremely important
• Consider involvement of interpreters (including telephone) and or Mental Health or Transcultural
Mental Health Workers for culturally and linguistically diverse populations
Safety
When dealing with patients with mental illness clinicians need to be aware of the following:
• Promotion of the safety of the patient, health professionals and others through a safe
environment is essential
• The safety others for whom the patient has care responsibilities e.g. children, elderly needs to
also be considered
• A safe environment for assessment, interview and discussion is important
• The patient may be experiencing extreme fear from internal threats, providing reassurance will assist
PD3509 Mental Health and Substance Use 6
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Clinicians need to:
• Remain calm, quiet and non-threatening
• Clearly explain who they are and what they are doing
• Identify any children (0-18 years) for whom the patient has care responsibilities
• Consider the impact of the person’s mental illness on their ability to safely care for children, if
applicable
• Involve the family and significant others, including Aboriginal and Torres Strait Islander Health
Workers in assessment and management
• Be supportive and listen to the person
• Determine if they will have an ongoing relationship with the person
• Work in pairs if possible
Managing Anger
It is important for practitioners to understand and be able to manage anger.
An agreed service procedure should be in place when working with potentially aggressive people
which would include:
• identification of a safe place
• directions for de-escalation
• consideration of police support. This should be an early intervention if the person is armed
• ability to leave the situation and call for help
• if trapped, look for furniture or objects to use as a shield
• strategies to deal with the person’s concerns
In the event a person presents angry and aggressive it is best to:
• observe the person over a period of time from a safe distance
• do not turn your back, touch or point at the person
• remain calm, even if you are not, and respectful
• stay neutral. Patients may be angry with the system but they may personalise their anger and
aggression towards the individual staff member
• don’t confuse the person with the problem
• remember the person may well be frightened
• consider body language and adopt non-threatening posture
• no prolonged, direct eye contact
• hands by your side with empty palms facing out
• speak softly and calmly
PD3509 Mental Health and Substance Use 7
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De-escalation strategy allows the clinician to:
• listen, let the person talk, avoid interruption and do not challenge
• empathise and indicate you understand the person’s experience - paraphrase
• acknowledge degree of distress, anger
• process plan. Plan strategies with the patient for agreed outcome
• remove potential weapons
• reduce stimulation from light, sound and activity
Mental Health History
When conducting a mental health history it is important to establish the patients’ behaviour and
personality prior to the current presentation. Focus on:
• Obtaining as much detail as possible.
•
- A clear account of what has transpired in the patient’s recent history will assist in diagnosis.
- A review of past clinical records, manual and electronic, should also be undertaken
Obtaining supporting history from family and carers including
- How the patient related to health care professionals in the past
- Suicide attempts
- Family history of psychiatric disorders
- Forensic history
- Personal history
- Trauma/abuse
- Mood - their pre-morbid personality? rather than behaviour
- History of violence? (May not have been charged therefore not in forensic system)
- Absconding may be a problem so clinicians need to be aware of the risk
Mental State Examination
It is not often possible to organise immediate assessment with a Mental Health Specialist.
For this reason primary care workers should be able to carry out mental state examinations (MSE)
assessments to:
• Determine the severity and nature of an individual’s problems and the risk of danger to self or
others.
• Allow all health staff to use the same terminology when discussing diagnosis and management
PD3509 Mental Health and Substance Use 8
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A MSE should be used for persons with initial mental health presentation and for those experiencing
a relapse of their illness
• Severity of symptoms may not be apparent unless identified in a structured way
• Included with the MSE and the mental health history is the risk screen that identifies level of risk
for suicide, self harm, vulnerability and violence
• Documenting and acting on findings in a timely manner is essential
Appearance
Describe the individual’s physical presentation including clothing, grooming, hygiene and cultural
appropriateness
Behaviour
Describe the individual’s behavioural style, including agitation, aggression, retardation, and any
inappropriate or unusual behaviour
Speech
Describe the rate, rhythm and volume of speech, and whether it is spontaneous
Mood and affect
Ask the individual to describe their mood
Affect is the outward appearance of their emotional state.
Comment on the quality, variability, range, intensity and appropriateness of affect
Perception
Hallucinations can occur in any of the five senses
Any type of hallucination can occur in psychosis,
Non-auditory hallucinations increases the chance that the person has a medical problem, such
as alcohol withdrawal or seizures
Explore whether the person believes the hallucinations are real
For auditory hallucinations ask what the voices are saying and determine if the person is
receiving commands to harm themselves or others.
Make note if the person has responded to the voices
Thought form
Thought form refers to how thoughts are connected.
If a person exhibits thought disorder, ideas may be connected in a strange or illogical fashion.
It is useful to record some quotes of the person’s speech
Individuals may; be incoherent, use certain words because they rhyme, use certain words
because they have secret meanings, different to what the words actually mean
Thought content
Anxieties, obsessions, preoccupations and delusions are described in this section.
It is useful to explore what the person thinks of their ideas; they may understand that their
concerns are excessive
Thoughts are described as delusional if a person is certain that their ideas are reasonable
despite convincing evidence to the contrary
Beliefs may be out of keeping with cultural and religious background
Delusions are commonly grandiose, persecutory or bizarre
Examples of common bizarre delusions include believing that the television is talking to them,
that others can hear their thoughts, or that their mind and body are being controlled
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
PD3509 Mental Health and Substance Use 9
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Judgement
Assess the individual’s capacity for reasoned and responsible decision making, in particular
regarding safety issues (including the safety of children for whom the person has care
responsibilities)
Insight
Comment on the individual’s insight into his or her own symptoms, diagnosis, and need for
treatment
Cognition Describe:
Orientation to time, person and place
Memory, attention and ability to concentrate - determine if the person can repeat three words,
and then recall them after a few minutes
Ability to follow instructions
•
•
•
•
•
If there are concerns the individual is delirious, it is helpful to observe them write a sentence, or draw
a clock face including the numbers and hands.
Be mindful that ‘general knowledge’ can vary greatly depending on cultural background
PD3509 Mental Health and Substance Use 10
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The MSE involves making observations and asking questions under the following headings - see
following tables.
The Suicide risk assessment rating matrix included in the PCCM is a guide only and does not replace
clinical judgement.
Suicide Risk
Risk Level
Previous Attempts
Preparations &
Plans
Ideation / Desire
Notable Risk
Factors
LOW
A
None
None or limited
B
One or more
None
A
None
None or limited
B
None
C
One or more
Mild intensity and No significant crisis
short duration
None
MEDIUM
Moderate intensity Two or more risk
or longer duration
factors
Evidence of more None
No risk factors.
detailed planning
Risk increases with
additional factors
One or more symptoms
from
any
category but not
meeting criteria for
HIGH RISK
HIGH
A
None
B
One or more
Evidence of detailed At least one additional risk factor of
and feasible plans
significance, risk increased with increasing
number of significant factors or psychotic
symptoms
Evidence of detailed None required, risk increase with additional
and feasible plans
significant factors
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Other Risk Factors
The Other Risk Factors table included in the PCCM provides information on other risk factors for poor
mental health.
OTHER RISK FACTORS
Violence (including Static Factors
Sexual Violence)
< 25 years of age, male, history of violence / sexual offence, criminal history, conduct
disorder, history of substance abuse, history of abuse / trauma
Dynamic Factors
Impulsivity, anger, intoxication / withdrawal / cognitions supporting violence, recent
threats or other aggressive actions / thoughts, carries weapon, access to firearm.
Psychotic symptoms
Vulnerability
At risk of being sexually abused by others, at risk of domestic / family violence. At risk
of being financially abusive to others, at risk of self-neglect, cognitive impairment /
intellectual disability
Child protection risk Does the client have custody or care responsibilities for children (full or periodic?)
screen
The overall risk summary provides important information about the overall risk a patient with mental
health problems.
It is a summary of the suicide and other risk factors tables.
OVERALL RISK SUMMARY
Tick according to response
LOW
MEDIUM
HIGH
Suicide Risk
Other self-harm
Aggression risk
Vulnerability risk
Dependent children
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PD3509-1 Learning Activity
1.
Which of the following strategies should NOT be used if a patient becomes very angry
Correct
Choice
Touch the patient to calm them down
Remain calm
Agree with the patient’s issue
Adopt a non-threatening posture
Maintain eye contact at all times
PD3509 Mental Health and Substance Use 13
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PD3509-2 Mental Health and Substance Use Part 1
Learning Objectives
On completion of this module learners will be able to use the PCCM to assist with management of
patients presenting with mental illness including:
• Suicide risk behaviour
• Behavioural emergencies
• Delirium
• Dementia
• Psychosis
• Mood disorders
Suicidal Behaviour or Risk
Deliberate self harm is not always associated with suicide and can be used to deal with severe distress.
Consult MO urgently if suicide risk is considered to be high.
In the case of actual self harm that has or will cause serious physical harm, contact emergency
services immediately.
Ensure safety of patient and those involved with patient, including family, carers and staff, including the
immediate safety needs of children.
Clinicians should involve the family or support people in the care of the suicidal person wherever possible.
Behavioural Emergencies
Acute confusion can be caused by many physical conditions and may mimic mental illness.
Causes include drugs, hypoxia, metabolic conditions, cerebral conditions, infections, constipation and
urinary retention in the elderly.
Alcohol use and physical illness or injury should be suspected and excluded in all patients with mental
health presentations before making a diagnosis of mental illness
Medical Officers are encouraged to speak to Psychiatrist at referring facility as soon as possible in all
psychiatric emergencies. This has been found to lead to smoother management of the patient’s needs.
Patient should not be left alone if there are any concerns.
PD3509 Mental Health and Substance Use 14
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Support people including:
Health Workers, Mental Health Workers in Aboriginal and Torres Strait Islander communities,
Interpreters and or Transcultural Mental Health Workers for cultural and linguistically diverse (CALD)
populations should be utilised where possible.
The safety of any children for whom the patient has care responsibilities should always be considered.
Delirium, Dementia and Psychosis
This table assists to distinguish between delirium, dementia and psychosis which will be covered in the
next few pages.
DELIRIUM
DEMENTIA
PSYCHOSIS
Onset
Rapid
Slow
Rapid
Pattern
Fluctuating
Fluctuating - Stable
Stable
Oriented
No
Yes
No
Attention
Disordered
Normal
Delusional
Cognition
Disordered
Impaired
Selectively impaired
Speech
Incoherent
Perseveration
Rapid pressured
http://www.ozemedicine.com/wiki/doku.php?id=n_mental_state
Delirium
Delirium is characterised by:
• a disturbance of consciousness with a reduced ability to focus, sustain, or shift attention
• a change in cognition (e.g. memory deficit or disorientation) or the development of a perceptual
disturbance
• the disturbance develops over a short period of time and tends to fluctuate during the course of
the day
Delirium is often a symptom of an acute physical problem that needs to be managed urgently.
The Medical Officer needs to be consulted as delirium is a medical emergency and needs investigation
for medical cause.
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Dementia
Dementia has a much slower onset than delirium.
Consult with and involve the patient’s family, carers, GP and health support services.
Utilise non-pharmacological strategies as a first-line measure to manage the symptoms of dementia,
including environmental, behavioural and social strategies.
Safety remains the major priority for immediate & longer term management of the patient with dementia.
Psychotic Disorders
Psychosis is a general term used to describe mental health problems in which a person has lost some
contact with reality.
It may be characterised by distortion of thinking, perception and mood.
The person’s ability to make sense of their thinking, perception and mood is seriously affected.
The Medical Officer should be consulted and provided with details of symptoms and signs of psychosis
elicited from the history and examination of the patient.
Appropriate support people in the community should be involved in the care of the patient with psychosis.
Mood Disorders
Mood refers to a prolonged emotional state that influences an individual’s whole personality and life
functioning.
It pertains to a person’s prevailing and pervading emotion and is synonymous with the terms affect,
feeling state, and emotion.
Mood disorders may include depression, mania and perinatal depression.
A Medical Officer should be consulted and provided with details of the presenting symptoms.
Appropriate community and family support should also be included.
PD3509 Mental Health and Substance Use 16
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Depression
Depression is the most common mental health disorder, and is often encountered in the primary care
setting. It can be difficult to detect and ranges from mild to severe.
Some groups are at higher risk of depression e.g. those who are psychotic, have recently experienced
loss or stress.
Women in the perinatal period, the chronically ill, and people with physical disorders are also commonly
affected.
Mania
A manic episode is classified as:
• Mild (3 - 4 manic symptoms). May include
- Elevated, expansive or irritable mood
- Inflated self esteem
- Decreased need for sleep
- Pressured speech and racing thoughts
Moderate (extreme increase in activity or impairment in judgement) including
- Increased goals, plans and activities
- Poor judgement, impulsive, risk taking
Severe without psychotic features requiring continual supervision to protect the person from
harm to self or others,
Severe with psychotic features
•
•
•
Admission to appropriately equipped and staffed facility should be considered for a person who presents with mania
They may require admission under the Mental Health Act 2000.
PD3509 Mental Health and Substance Use 17
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PD3509-2 Learning Activity
1.
Complete the following comparative table
DELIRIUM
Onset
Slow
Pattern
Fluctuating
Oriented
No
Attention
Disordered
Cognition
Speech
DEMENTIA
PD3509 Mental Health and Substance Use 18
Rapid
Stable
Yes
Delusional
Impaired
Incoherent
PSYCHOSIS
Selectively impaired
Perseveration
Version1 (2014)
PD3509-2 Mental Health and Substance Use Part 2
Learning Objectives
On completion of this module learners will be able to use the PCCM to assist in the management of
Anxiety disorders
Eating disorders
Sleep problems
Alcohol dependency
Smoking
Other drugs / substances
Anxiety Disorders
Anxiety is a normal reaction to threat. Anxiety disorders are characterised by irrational anxiety when a
threat does not exist or has passed.
Behaviour designed to avoid the onset of anxiety is often an important aspect of the clinical presentation.
Anxiety disorders may be as common as depression in the perinatal period.
Psychological therapies may not only help with recovery but may also help to prevent recurrence of
anxiety.
Cognitive Behaviour Therapy (CBT) is one of the most evidence based treatments for depression and
anxiety disorders.
CBT teaches people to think realistically about common difficulties, helping them to change their thought
patterns and the way they react to certain situations.
Patients should avoid drugs and alcohol, as substances can exacerbate anxiety disorders.
Anxiety disorders may include:
• Panic disorder – sudden onset for no obvious precipitating reason
• Generalised anxiety disorder (at least six months duration) – anxiety that is generalised and
prolonged
• Post traumatic stress disorder (PTSD) – in response a traumatic event – patients continue to
experience the event
• Obsessive compulsive disorder – recurrent obsessional thoughts which cause anxiety or distress
• Social phobia – a fear of scrutiny by other people leading to avoidance of social situations
• Specific phobia – excessive or unreasonable fear of an object or situation
PD3509 Mental Health and Substance Use 19
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Explain to the patient how the body’s arousal reaction produces tremor, hyperventilation, tachycardia,
muscle tension etc.,
Also ensure they understand that worrying about such symptoms can create a vicious cycle.
Eating Disorders
Eating disorders include anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified
Anorexia has the highest long-term mortality rate of any mental disorder.
Eating disorders are most commonly diagnosed in adolescent females.
They however are also found in both males and females across age spectrum from children to older
persons.
Eating disorders commonly co-occur with other mental health problems such as depression and anxiety.
Sufferers commonly deny eating disorder behaviours.
A medical officer should be consulted as soon as possible if Body Mass Index (BMI) < 14 or if patient
is medically compromised.
Patients should also be referred to a Medical Officer for ongoing monitoring of weight and BMI,
nutritional intake, BP, pulse and electrolytes.
Psychiatrist or local Mental Health Service should be consulted for treatment of mental health problems
and monitoring of suicide risk.
Sleep Problems
Sleep problems are one of the most common complaints in both the general health and mental health
settings.
Patients with insomnia often have dysfunctional beliefs and attitudes about sleep.
It is important to reassure them that most people with insomnia get more sleep than they perceive.
Temporary sleep problems are common at times of stressful life events, acute physical illnesses, or
changes in schedule.
Sleep requirements vary widely and usually decrease with age.
PD3509 Mental Health and Substance Use 20
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Alcohol Intoxication
Patients misusing alcohol may present with:
Acute alcohol intoxication
• Can significantly complicate the provision of appropriate care, it should not compromise it.
• Intoxicated individuals are more likely to present late, to have underlying contributing factors and
to have these contributing factors missed on assessment
• The underlying factors may include head injury, hypoglycaemia, hypothermia, epilepsy, hypotension or organic brain disease
• An individual who presents to a facility whilst intoxicated or withdrawing from alcohol should be
extended the same level of care as any other patient
• Persons presenting intoxicated from alcohol may subsequently develop a withdrawal state.
• This is expected if there is a history of dependence. However those with no such history are
likely to recover uneventfully
Alcohol withdrawal
Treat any alcohol dependent patient presenting in a state of established withdrawal as a potential
medical emergency.
Delirium tremens (DT) is a medical emergency with a significant mortality rate if not treated appropriately.
If eye signs are consistent with Wernicke’s encephalopathy (paralysis of the nerves that move the eye),
this is a vitamin emergency. Medical Officer will order thiamine.
Conduct a rapid assessment including past and recent history, particularly relating to past withdrawals,
delirium tremens, seizures and other medical conditions.
The course of withdrawal depends on:
• the severity of dependence
• illnesses such as physical and mental health disorders
• psychological factors i.e. the physical environment, fears and expectations
PD3509 Mental Health and Substance Use 21
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Smoking
Assess smoking status in every patient over 10 years of age
All patients who smoke, regardless of the amount they smoke, should be:
• Asked about their interest in quitting
• Assessed whether they are nicotine dependent and if so provide appropriate pharmacotherapy
• Advised to stop smoking
• Offered referral to a proactive telephone call-back cessation service such as ‘Quitline’ or
Alcohol, Tobacco and Other Drugs service if available
Other Drugs / Substances
Patients may present with:
• Overdose
• Asking for help to quit
• Under the influence
• Altered level of consciousness
• Drug induced psychosis
• It is important to determine the substance being abused
• Management will depend on presentation
• Patient should be referred for follow up care as appropriate
PD3509 Mental Health and Substance Use 22
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PD3509-3 Learning Activity
1.
Match the anxiety disorder with its defining statement by adding the appropriate number in the column.
No.
Disorder
No.
Statement
Panic disorder
1
Excessive or unreasonable fear of an object
Generalised anxiety
2
Fear of scrutiny by other people
Post-traumatic stress
3
Re-experiencing trauma with flashbacks
Obsessive compulsive
4
Ongoing apprehension for 6 months or more
Social phobia
5
Excessive hand washing to reduce anxiety
Specific phobia
6
Sudden onset of anxiety for no obvious reason
PD3509 Mental Health and Substance Use 23
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PD3509 Theory to Practice Activity
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Jessica is a twenty-two year old female who has been brought to your clinic by her friend Julie with a
heavily bleeding laceration above her right eye. She has poor coordination, blurred vision and slurred
speech. Jessica is very agitated and is alternating between yelling obscenities at Julie and crying
inconsolably. Julie says they had been at a party and Jessica had been pushed to the ground by an
intoxicated male.
1.
What immediate management is required?
Answer
2.
What clinical assessment needs to be conducted?
Answer
PD3509 Mental Health and Substance Use 24
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Julie tells you that she thinks Jessica had at least 4 cans of a Vodka pre-mix drink in the last three
hours, but it is unusual for Jessica to get this drunk this quickly.
3.
What action would you take in view of Jessica’s apparent intoxication?
Answer
PD3509 Mental Health and Substance Use 25
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After 4 hours, Jessica has stabilised and you have been able to conduct a comprehensive physical examination which reveals that Jessica has grazes to her knees and elbows and has a cut above her left
eye which was bleeding profusely. All injuries appear clean with no foreign bodies evident. The blood
flow from the head wound has decreased significantly.
4.
What action would you take to manage Jessica’s injuries?
Answer
5.
What steps will you now take (within your scope of practice) to ensure Jessica has safely
administered and appropriate medication.
(NB Jessica’s tetanus immunisation status is current)
Answer
PD3509 Mental Health and Substance Use 26
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Schedule
2
Paracetamol
DTP
IHW / IPAP
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics may proceed
Form
Tablet
Strength
500 mg
Suspension
120 mg / per 5 mL
(24 mg / mL)
or
100 mg / mL drops
Suppository
125 mg
250 mg
500 mg
Route of administration
Oral
Oral
Rectal
Recommended
dosage
Adults & children >
12 years
1 - 2 tabs every 4
hours to max. 8 tabs
per day
Children 7 - 12 years
1/2 - 1 tab every 4
hours to a max. 4
times per day
Child
15 mg / kg / dose
every 4 hours if
necessary to a max.
of 4 times per day
Adult & children > 12
years
500 -1000 mg
Duration
Stat
Further doses
on MO / NP
orders
5 days
Children 7 - 12 years
250 - 500 mg
Stat
Child < 7 years
15 mg / kg / dose
Provide Consumer Medicine Information: not for administration to children under 1 month
Management of associated emergency: consult MO
[1] [2]
PD3509 Mental Health and Substance Use 27
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Schedule
4
Lignocaine
DTP
IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers & Isolated Practice Area Paramedics must consult MO/NP
Scheduled medicines Rural & Remote Isolated Practice Registered Nurses may proceed
Form
Ampoule
Strength
Route of administration
1%
50 mg / 5 mL
Recommended
dosage
Adult
3 mg / kg
to total max.
infiltration of 200mg
Subcutaneous
Child
3mg / kg / dose
to max. 5mg / kg /
dose
Duration
Stat
Do not repeat
the total max.
dose at
intervals of
< 1.5 hours
Provide Consumer Medicine Information
Management of associated emergency: Resuscitation equipment available. Consult MO
[2] [3]
PD3509 Mental Health and Substance Use 28
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PD3509 Quiz
1.
Tick
Deliberate self-harm is usually an attempt at suicide
Choice
True
False
2.
Tick
Which of the following are true statements in regards to a mental health examination (MSE)?
Choice
Can only be done by a mental health specialist
Is conducted every time a person with diagnosed mental illness presents to the clinic
Helps determine the severity and nature of a person’s problem
Determines if a client is at risk of danger to themselves or others
Involves making observations and asking questions under specific criteria
PD3509 Mental Health and Substance Use 29
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3.
Tick
Which of the following statements are false in regards to delirium?
Choice
Has a slow and gradual onset
People with delirium often have incoherent speech
Is often associated with delusional ideations
Is a medical emergency
is often an symptom of an acute illness
4.
Tick
Which of the following statements impacts on the course of withdrawal
Choice
How much alcohol has recently been consumed
The severity of the dependence
Associated physical illness
Associated psychological factors
The type of alcohol consumed
PD3509 Mental Health and Substance Use 30
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5.
Match the classification of a manic episode with its definition
No.
Tick
No.
1
Mild
Extreme increase in activity or impairment
2
Moderate
Severe with associated psychosis
3
Moderate - Severe
Elevated mood, inflated self-esteem and
decreased need for sleep.
4
Severe
Severe with no psychosis but possible selfharm
PD3509 Mental Health and Substance Use 31
Choice
Version1 (2014)
PD3509-1 Learning Activity Feedback
1.
Which of the following strategies should NOT be used if a patient becomes very angry
Correct
✔
Choice
Touch the patient to calm them down
Remain calm
✔
Agree with the patient’s issue
Adopt a non-threatening posture
✔
Maintain eye contact at all times
PD3509-2 Learning Activity Feedback
1.
Complete the following comparative table
DELIRIUM
DEMENTIA
PSYCHOSIS
Onset
RAPID
Slow
Pattern
Fluctuating
FLUCTUATING-STABLE Stable
Oriented
No
Yes
NO
Attention
Disordered
NORMAL
Delusional
Cognition
DISORDERED
Impaired
Selectively impaired
Speech
Incoherent
Perseveration
RAPID PRESSURE
PD3509 Mental Health and Substance Use 32
Rapid
Version1 (2014)
PD3509-3 Learning Activity Feedback
1.
Match the anxiety disorder with its defining statement by adding the appropriate number in the column.
No.
Disorder
No.
Statement
6
Panic disorder
1
Excessive or unreasonable fear of an object
4
Generalised anxiety
2
Fear of scrutiny by other people
3
Post-traumatic stress
3
Re-experiencing trauma with flashbacks
5
Obsessive compulsive
4
Ongoing apprehension for 6 months or more
2
Social phobia
5
Excessive hand washing to reduce anxiety
1
Specific phobia
6
Sudden onset of anxiety for no obvious reason
PD3509 Mental Health and Substance Use 33
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PD3509 Theory to Practice Activity Feedback
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Jessica is a twenty-two year old female who has been brought to your clinic by her friend Julie with a
heavily bleeding laceration above her right eye. She has poor coordination, blurred vision and slurred
speech. Jessica is very agitated and is alternating between yelling obscenities at Julie and crying
inconsolably. Julie says they had been at a party and Jessica had been pushed to the ground by an
intoxicated male.
1.
What immediate management is required?
Answer
Ensure own safety and that of other patients, staff, Julie and Jessica
2.
What clinical assessment needs to be conducted?
Answer
• Conduct a rapid assessment
• Obtain a full history from Jessica if she will respond, if not ask Julie
•
- About past similar episodes:
- The amount, type and duration of alcohol and any other drug intake
Perform standard clinical observations +
- O2 saturation
-BGL
- Conscious state. See Glasgow Coma Scale / AVPU
- Head to body assessment looking for other injuries
PD3509 Mental Health and Substance Use 34
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Julie tells you that she thinks Jessica had at least 4 cans of a Vodka pre-mix drink in the last three
hours, but it is unusual for Jessica to get this drunk this quickly.
3.
What action would you take in view of Jessica’s apparent intoxication?
Answer
Keep Jessica in the clinic until she stabilises
• Consider the possibility of Jessica ingesting drugs other than alcohol (deliberate or not). (See
poisoning and drug emergencies – recreational drugs)
• Monitor heart rate, blood pressure, temperature and vomiting
• Monitor level of consciousness and manage accordingly (see altered levels of consciousness)
• Stem blood flow from her head laceration and monitor levels of sobriety until she settles
• Continue management when she is more coherent and cooperative
After 4 hours, Jessica has stabilised and you have been able to conduct a comprehensive physical
examination which reveals that Jessica has grazes to her knees and elbows and has a cut above her
left eye which was bleeding profusely. All injuries appear clean with no foreign bodies evident.
The blood flow from the head wound has decreased significantly.
4.
What action would you take to manage Jessica’s injuries?
Answer
• When able clean, manage and dress Jessica’s wounds
• Physical examination
•
•
(see acute wounds) which includes
- Depth and size of the wound
- Clean or jagged edges
- Foreign bodies
- Determining if there is bone involvement
Measuring and managing blood loss
Determining most appropriate process for healing – in this case
- healing by secondary intention for the grazes and
- primary closure for the injury above the eye - (see PCCM for information on suturing or
using skin glue)
NB Only suture the wound if you are confident of getting a good result, as cosmetic outcome is very
important. The suturing should happen within 6 - 8 hours of injury
PD3509 Mental Health and Substance Use 35
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5.
What steps will you now take (within your scope of practice) to ensure Jessica has safely
administered and appropriate medication.
(NB Jessica’s tetanus immunisation status is current)
Answer
The answer to this question depends on your scope of practice and the Health Management
protocols you work under. The list below provides brief information.
Paracetamol can be given by Authorised Indigenous Health Workers (IHW) and Isolated Practice
Area Paramedics (IPAP)
Local anaesthesia if suturing wound
• IHW and IPAP must consult the Medical Officer (MO) or Nurse Practitioner (NP)
• Non-endorsed Registered Nurses must consult the MO or NP
• Scheduled Medicines Rural and Isolated Practice Registered Nurse (SM R&IP) may proceed.
• See tables over page for more information.
PD3509 Mental Health and Substance Use 36
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PD3509 Quiz Feedback
1.
Deliberate self-harm is usually an attempt at suicide
Tick
Choice
True
✔
2.
False
Which of the following are true statements in regards to a mental health examination (MSE)?
Tick
Choice
Can only be done by a mental health specialist
Is conducted every time a person with diagnosed mental illness presents to the clinic
✔
✔
✔
Helps determine the severity and nature of a person’s problem
Determines if a client is at risk of danger to themselves or others
Involves making observations and asking questions under specific criteria
PD3509 Mental Health and Substance Use 37
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3.
Tick
✔
Which of the following statements are false in regards to delirium?
Choice
Has a slow and gradual onset
People with delirium often have incoherent speech
✔
Is often associated with delusional ideations
Is a medical emergency
is often an symptom of an acute illness
4.
Tick
Which of the following statements impacts on the course of withdrawal
Choice
How much alcohol has recently been consumed
✔
✔
✔
The severity of the dependence
Associated physical illness
Associated psychological factors
The type of alcohol consumed
PD3509 Mental Health and Substance Use 38
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5.
Match the classification of a manic episode with its definition
No.
Tick
No.
Choice
1
Mild
3
Extreme increase in activity or impairment
2
Moderate
1
Severe with associated psychosis
3
Moderate - Severe
4
Elevated mood, inflated self-esteem and
decreased need for sleep.
4
Severe
2
Severe with no psychosis but possible selfharm
PD3509 Mental Health and Substance Use 39
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Primary Clinical
Care Manual
PD3510 - Sexual and
Reproductive Health
Participation Manual
Name
Community
Site
Position
Date Completed
PD3510 Sexual and Reproductive Health
Please select ...
Aboriginal
Administration
Allied
Dental
Medical
Nursing
Midwife
Other
Student
Health
Officer
Officer
and /Officer
or Torres Strait Islan
1
Version1 (2014)
Contents
PD3510 Introduction3
PDPD3510-1 Women and Antenatal Health5
PD3510-1 Learning Activity12
PD3510-2 Labour and Birth13
PD3510-2 Learning Activity20
PD3510-3 Sexual Health21
PD3510-3 Learning Activity26
PD3510 Theory to Practice Activity27
PD3510 Quiz35
PD3510-1 Learning Activity Feedback37
PD3510-2 Learning Activity Feedback38
PD3510-3 Learning Activity Feedback39
PD3510 Theory to Practice Activity40
PD3510 Quiz Feedback45
PD3510 Sexual and Reproductive Health
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PD3510 Introduction
Sexual and reproductive health are important population health initiatives that work to ensure sexually
active men and women remain healthy through the provision of regular screening and education and
health promotion programs. This in turn impacts on the health of a woman during pregnancy which
affects the health of the foetus and the neonate. The birth of a healthy infant provides a strong basis
for a healthy child and decreases the risk of developing chronic disease in childhood and adult hood.
Session Overview
The PCCM provides information on managing presentations for:
• Sexual health problems
• Healthy and health risks in pregnancy
• Pre-term labour
• Normal labour and birth and
• Ante and post natal complications
Learning Objectives
On completion of this session learners will
• Be able to use the PCCM to assist in
• Conducting well women health checks
• Providing Antenatal care
• Managing diabetes and hypertension in pregnancy
• Managing pre-eclampsia
• Provide care in ectopic pregnancy and miscarriage
• Manage antepartum haemorrhage
• Manage infections in pregnancy
• Managing pre-term labour
• Managing umbilical cord presentation or prolapse
• Managing normal labour and birth
• Appropriately administering Rh D immunoglobulin
• Managing Post-partum haemorrhage
• Providing post pregnancy care
• Managing rape / sexual assault
• Understand the general principles of screening for and managing sexually transmitted infections
(STI)
• Discuss the various STIs, their most likely presentation and management
• Understand the link between PID and STI
PD3510 Sexual and Reproductive Health
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Modules
Module 1 provides information on women’s health and antenatal care
Module two discusses the management of pregnancy and birthing presentations and module three
discusses the screening and management of sexually transmitted infections.
Learning Activities
The learning activity included in each module needs to be completed before moving to the next module.
A theory to practice learning activity is also included and is required on conclusion of the two modules.
Quiz
Once you have finished the modules, you are asked to complete a graded interactive quiz.
PD3510 Sexual and Reproductive Health
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PDPD3510-1 Women and Antenatal Health
Learning Objectives
On completion of this module learners will be able to use the PCCM to assist in:
• Conducting well women health checks
• Antenatal care
• Diabetes and hypertension in pregnancy
• Pre-eclampsia
• Ectopic pregnancy and miscarriage
• Antepartum haemorrhage
• Infections in pregnancy
Health Check - Women
An annual health check-up for all Aboriginal and Torres Strait Islander women is recommended.
This should include a check for sexually transmitted infections in sexually active women, at the time of
the pelvic examination, as many infections have no symptoms.
All women aged between 50 and 74 years of age, should be encouraged to attend mammography
breast screening every two years.
Mammogram screening is not recommended for women at average risk under 40 years of age.
All women should be advised to be familiar with the normal look and feel of their breasts and to report
any new or unusual changes to their General Practitioner without delay.
Pap smear screening is recommended every two years for women who have ever had sex and have
an intact cervix starting from 18 years of age.
Human papillomavirus vaccination to eligible females as per latest edition of The Australian
Immunisations Handbook.
In North Queensland it is recommended that all sexually active women aged 15 – 39 are offered a test
for chlamydia, gonorrhoea, trichomonas (when swabs are being taken) and syphilis at least once each
year.
Men and women aged 40 - 49 should have syphilis serology annually.
PD3510 Sexual and Reproductive Health
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Using the PCCM
A joint statement by the Statewide Maternity and Neonatal Clinical Network, Royal Flying Doctor
Service (Queensland Section), Retrieval Services Queensland and the Rural and Remote Clinical
Support Unit, which produces the PCCM states:
The Primary Clinical Care Manual (PCCM) is the primary guide for the Scheduled Medicines Rural and
Isolated Practice Registered Nurse (SM R&IP).
and other Advanced Practice Nurses, Aboriginal and Torres Strait Islander Health Workers and Medical
Officers working outside the hospital system.
In most instances, the Queensland Maternity and Neonatal Clinical Guidelines relate to practice within
maternity units within hospitals.
The PCCM completely aligns with relevant Queensland Maternity and Neonatal Clinical Guidelines.
The PCCM is to be used where there are unplanned births.
Facilities where planned births occur are advised to refer to the Queensland Maternity and Neonatal
Clinical Guidelines.
In the event that a woman in preterm labour or threatened preterm labour or other urgent pregnancy
complications presents to a facility which does not have a maternity service, early contact should be
made with the appropriate Medical Officer.
Where the RFDS provides primary medical cover for a facility the RFDS Medical Officer on call is the
appropriate first point of medical contact.
The Medical Officer will ring Retrieval Services Queensland (RSQ) at the QEMS Coordination Centre
(QCC) if Interfacility transfer is necessary or if specialist advice is required.
RSQ will be able to coordinate specialist obstetric and or neonatal advice as required regarding
management and if needed, evacuation to an appropriate obstetric and or neonatal service.
PD3510 Sexual and Reproductive Health
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Antenatal Care
The first antenatal visit by Medical Officer or Midwife should ideally occur after the first missed period
preferably before 12 weeks gestation.
If a woman presents late, all antenatal care activities recommended for first antenatal visit plus
those which correspond to current gestation especially if greater than 32 weeks gestation should be
conducted.
A minimum of four antenatal visits should be offered and or provided to women with low risk pregnancies
with an aim of seven to nine visits in total.
Perinatal mental health needs to be an important consideration of antenatal care.
Diabetes in Pregnancy
Diabetes in pregnancy is either pre-existing (type 1 or type 2) or gestational diabetes mellitus (GDM)
Oral Glucose Tolerance Test (OGTT) is the diagnostic test for gestational diabetes.
Women with blood glucose levels above target on three consecutive days will most likely be
commenced on insulin therapy.
Their care must be conducted in consultation with an Obstetrician and Endocrinologist.
Basal bolus is the commonly used insulin regime to manage diabetes in pregnancy.
Insulin adjustment is carried out in response to patterns in blood glucose levels.
Women taking regular medications, including oral anti-hyperglycaemic agents, antihypertensive agents
and statins or fibrates, should promptly consult the Medical Officer or Pharmacist regarding the need
for, and safety of, use of these medications in pregnancy.
Hypertension in Pregnancy
Hypertension during pregnancy is associated with a significantly higher risk of adverse perinatal and /
or maternal outcomes.
The definition of hypertension in pregnancy is:
• Systolic blood pressure is ≥ 140 mmHg and or diastolic blood pressure is ≥ 90 mmHg taken at
rest, on at least 2 occasions 30 minutes apart
• The blood pressure should be confirmed by repeated readings over several hours
PD3510 Sexual and Reproductive Health
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Classification of hypertensive disorders of pregnancy
• Pre eclampsia - eclampsia is a complex multi system disease with significant risks to the health
of the mother and baby.
• Pre eclampsia can occur from 20 weeks and can progress very rapidly
• Gestational hypertension arises after 20 weeks with no features of pre eclampsia and resolves
within 3 months postpartum
• Chronic hypertension is essential, secondary, white coat or pre eclampsia superimposed on
chronic hypertension
Pregnant women with severe hypertension which is a systolic blood pressure of 160 mmHg or more,
and or diastolic blood pressure of 100 mmHg or more should be urgently investigated and or admitted
to hospital for investigation.
A Medical Officer should be consulted on all occasions if Blood Pressure is greater than 140 / 90 in
pregnancy.
The Primary Clinical Care Manual recommends the use of a lower definition of severe hypertension
(160/100) than the Queensland Maternity and Neonatal Clinical Guideline “Hypertensive disorders of
pregnancy”.
This is because of the greater difficulties encountered in admitting a rural and remote woman to an
appropriate maternity service.
Pre-eclampsia
A woman with severe pre-eclampsia may feel well and have no symptoms at all.
These women must be evacuated and or hospitalised under the care of an Obstetrician.
Those who required Nifedipine, Hydralazine or MgSO4 or have proteinuria require urgent evacuation
and or hospitalisation in an obstetrics facility.
Facilities where planned births occur are advised to refer to the Queensland Maternity and Neonatal
Guideline “Hypertensive disorders of pregnancy” for the management of pre-eclampsia.
PD3510 Sexual and Reproductive Health
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Chronic Hypertension
Essential Hypertension is a blood pressure ≥ 140 / 90
• With no apparent cause,
• In women prior to pregnancy or before 20 weeks gestation,
• In pregnancy and requiring anti-hypertensives
Where there is high prevalence of hypertension in the population essential hypertension may be
detected at antenatal visits.
Secondary hypertension may be due to chronic kidney disease, renal artery stenosis, diabetes,
endocrine disorders or co-arctation of the aorta.
Any woman with pre-existing hypertension who becomes pregnant should be cared for in consultation
with Physician and Obstetrician.
Angiotensin converting enzyme (ACEI) inhibitors (unless in postnatal), angiotensin ll receptor
antagonists and diuretics in pregnancy should be avoided.
Ectopic Pregnancy
Ectopic (tubal) pregnancy in all women who present with abdominal pain and or vaginal bleeding
should be considered.
A pregnancy test (blood or urine) should always be performed.
Positive pregnancy test (urine or blood) does not always mean a viable pregnancy.
A negative pregnancy test (urine) does not discount the possibility of pregnancy.
Risk factors associated with ectopic pregnancy include:
• History of sexually transmitted infections,
• Pelvic inflammatory disease,
• Intrauterine contraceptive device (IUCD) rare,
• Previous ectopic pregnancy,
• Tubal sterilisation
• In-vitro fertilisation (IVF)
Medical Officer should be consulted for all occasions of suspected ectopic pregnancy
PD3510 Sexual and Reproductive Health
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Miscarriage
Another likely cause is miscarriage or threatened miscarriage.
Miscarriages most commonly occur between 6 and 12 weeks.
When a miscarriage threatens, but the pregnancy proceeds, there is no greater risk of foetal abnormality
than in a pregnancy which was not complicated by bleeding.
Sexually transmitted infections may contribute to miscarriage.
Antepartum Haemorrhage (APH)
Antepartum haemorrhage is bleeding after 20 weeks gestation of more than 15 ml of blood.
There are a number of possible causes of antepartum haemorrhage. They include:
• Placental abruption
•
•
•
•
- part of the placenta has separated from the uterine wall
- bleeding may be partly or completely hidden behind the placenta (consider this when
assessing vaginal blood loss)
- uterus hard and tender
- pain (if posterior placenta, may have vague backache only)
- if labour occurs it is often rapid
Placenta previa
- placenta partially or completely overlies the cervical canal
Vasa previa
- results in foetal blood loss
- it is painless
- foetal distress occurs
- usually results in foetal death
Antepartum haemorrhage of unknown cause
- bleeding painless, usually bright red and may be recurrent
Other causes
- lower genital tract bleeding
Vaginal digital examination must not be performed
Heavy blood loss heavy requires immediate management.
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UTI in pregnancy
Acute cystitis
Lower abdominal pain and sometimes mild low back pain; low abdominal or suprapubic pain,
without dysuria or frequency, in early pregnancy could also be PID;
Any woman presenting with low abdominal pain should be assessed for PID.
Urinary frequency
Discomfort / burning on passing urine (dysuria)
Abnormal urinalysis (leucocytes / nitrites / protein / blood)
Pyelonephritis
Fever, rigors, nausea, vomiting
Loin pain
Abnormal urinalysis (leucocytes / nitrites / protein / blood)
Asymptomatic bacteriuria
Asymptomatic bacteriuria in pregnancy should be treated due to the increased risk of
pyelonephritis and preterm labour
Abnormal urinalysis (nitrites / protein / blood)
Pure growth >105 / L on urine culture
•
•
•
•
•
•
•
•
•
•
•
Group B streptococcus
Pregnant women with Group B streptococcal disease may present:
• In pre-term labour
• Rupture of membranes greater than 18 hours prior to birth
• Maternal fever – during labour or within 24 hours of giving birth
Staff working in isolated or rural areas may be required to give the first dose of antibiotic to affected
women to ensure adequate prophylaxis.
Antibiotics where possible should be given at least 4 hours prior to delivery, however if birth is within 2
hours, this is not a reason to withhold antibiotic treatment.
Facilities where planned births occur are advised to refer to the Queensland Maternity and Neonatal
Guideline on early onset group B streptococcal disease.
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PD3510-1 Learning Activity
1.
Which of the following are recommended as part of an annual women’s health check?
Correct
Choice
Syphilis screening
Mammogram in women from 30 years onwards
Pap smear screening – recency and or conduct smear test
Trichomonas screening
Pregnancy testing
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PD3510-2 Labour and Birth
Learning Objectives
On completion of this module learners will be able to use the PCCM to assist in the management of:
• Pre-term labour
• Umbilical cord presentation or prolapse
• Normal labour and birth
• Appropriate administration of Rh D immunoglobulin
• Post partum haemorrhage
• Post pregnancy care
Introduction
This section in the PCCM is intended for facilities that do not have planned birthing, and is congruent
with the Queensland Maternity and Neonatal Clinical Guideline on Assessment and management of
preterm labour.
It is not for use in planned birthing facilities.
Facilities where planned births occur are advised to refer to the Queensland Maternity and Neonatal
Clinical Guidelines.
For pregnancy and birth related emergencies, Where the RFDS provides primary medical cover for a
facility the RFDS medical officer on call is the appropriate first point of medical contact.
The medical officer will undertake assessment, management and transfer with specialist as necessary
(facilitated through Retrieval Services Queensland  1300 799127)
Pre-term Labour Rupture of Membranes
Rupture of the membranes is the rupture of amniotic membranes prior to the onset of labour.
Pre-labour rupture of membranes (PROM) is the rupture of membranes after 37 completed weeks of
gestation.
Preterm pre-labour rupture of membranes (PPROM) is rupture of membranes before 37 weeks of
gestation.
Vaginal digital examination must not be performed if not in labour due to the risk of infection.
A Medical Officer must be consulted immediately if a woman presents with rupture of the membranes.
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Suppression of preterm labour
Preterm labour is defined as regular uterine contractions (at least one every 10 minutes) at 34 weeks
or less gestation.
This period of gestation is chosen because at greater than 34 weeks the risks of suppression of
spontaneous labour outweigh the risks of prematurity.
May be caused by febrile illness such as UTI, intrauterine infection, or trauma.
The best neonatal outcomes are achieved if the baby can safely be transported in-utero to receiving
maternity facility.
Aim to postpone birth for at least 48 hours whilst steroids accelerate foetal lung maturation.
Suppression of labour is likely to be successful at less than 4 cm of cervical dilatation, but less likely if
dilatation is more than 6 cm.
Foetal fibronectin (fFN) testing carries a
• A negative results carries a 98% likelihood that birth will not occur within 72 hours of testing
• A positive result indicates an approximately 50% likelihood of birth occurring within 72 hours
Contraindications to suppression of labour include:
• Gestation more than 34 weeks,
• Advanced labour,
• Foetal death in-utero,
• Placental abruption,
• Maternal infection,
• Pre-eclampsia,
• Maternal hypotension: BP < 90 mmHg systolic,
• Lethal foetal anomalies,
• Suspected foetal compromise,
• PV bleeding from placenta previa
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Prevention of pre-term labour complications
Corticosteroids given to women in early pre-term labour help babies lungs to mature. This reduces the
number of:
• Neonatal deaths and
• Babies who suffer from
• Respiratory distress syndrome,
• Intracerebral haemorrhage
• Necrotising enterocolitis after birth
• Use of repeat courses of corticosteroids should not occur routinely
• Antenatal corticosteroid therapy should be given to women 24 to 34 weeks gestation who are at
risk of preterm birth within the next 7 days
Umbilical Cord Presentation / Prolapse
Umbilical cord presentation is when the umbilical cord is found, on digital vaginal examination, to be in
front of presenting part with intact membranes
This is of concern because of risk of cord prolapse if membranes rupture.
Umbilical cord prolapse is when the membranes have ruptured and cord comes out before the baby.
This is of concern because:
• presenting part will press on the cord cutting off the oxygen supply to the baby and it will die
• umbilical cord outside vagina will spasm, cutting off oxygen supply to the baby and it will die
Normal Labour and Birth
Plan for births to take place at an appropriately equipped and staffed facility.
Pregnant women from isolated areas should be advised to leave their communities at 36 weeks (or
earlier depending on woman’s individual needs) and travel to the appropriate town or city where they
attend the antenatal clinic as needed until birth.
Prepare for the event that some births will occur in facilities that do not undertake planned births.
Birth in an evacuation aircraft should be avoided if at all possible.
All births in rural and remote communities must, wherever possible, be attended by a midwife or
medical officer.
Only midwives or medical officer should perform vaginal examinations on women in labour.
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Registered Nurses and Health Workers should undertake a supportive role for the birthing woman and
facilitate the normal physiological birth process.
Rh D Immunoglobulin
Rh D immunoglobulin is indicated for the prevention of Rh D sensitisation in Rh D negative women.
Rh D immunoglobulin should be administered as soon as possible after the sensitising event, but
always within 72 hours.
Routine antenatal anti-D prophylaxis should be offered to all non-sensitised pregnant women who are
Rh D negative at 28 weeks and 34 weeks gestation.
Screening for antibodies with blood sample from mother at 28 weeks before the first routine prophylactic
injection is given is important.
Primary Postpartum Haemorrhage (PPH)
Primary postpartum haemorrhage occurs during the third stage of labour to within 24 hours of birth.
Immediate management is required for patients who have a large blood loss (≥ 500 mL) from genital
tract.
High risk women include those who are or have:
• grande mulitparity (P4 or more),
• over distended uterus,
• fibroids,
• anaemia,
• past history of PPH or APH,
• placenta praevia,
• Von Willebrand disease,
• prolonged or precipitate labour
• operative delivery,
• large baby,
• chorioamnionitis
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Secondary Postpartum Haemorrhage
Secondary PPH occurs between twenty four hours and six weeks postpartum.
It can be caused by:
• infection including sexually transmitted infections
• retained products of conception
• hormonal imbalance
• pregnancy related tumour (rare; gives false positive pregnancy test)
• incidental
• Immediate management required if blood loss is estimated above 500 mL
Episiotomy
Episiotomy is not performed as a routine procedure in a normal birth.
Episiotomy is used to hasten birth.
• In the situation of acute foetal distress,
• If the mother is in immediate life threatening danger,
• To achieve satisfactory progress with the birth when the perineum is responsible for lack of
progress
A Midwife and or Medical Officer will advise in case of breech delivery, foetal distress, or the perineum
remains white, rigid and thick as the baby’s head crowns.
Episiotomy should only be performed by a Midwife or Medical Officer if indicated
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Neonatal Resuscitation
Neonatal resuscitation equipment is required in all facilities in the event of unplanned delivery.
If time allows always prepare neonatal resuscitation equipment items prior to delivery in the order in
which they would be used (see flowchart).
The most important interventions in neonatal resuscitation are ensuring the airway is open and if the
infant is not breathing, provide effective positive pressure ventilation.
Effective ventilation is the key to successful neonatal resuscitation. Ventilation should be established
before considering and administering neonatal naloxone.
Neonatal naloxone is not a resuscitation drug.
Never administer neonatal naloxone to the infant of a mother with narcotic addiction (or on methadone
maintenance).
Sudden reversal of chronic narcotic action can cause severe life-threatening withdrawal symptoms,
including refractory seizures.
If a mother received narcotics within 4 hours of birth, her newborn may experience some degree of
respiratory depression due to transplacental drug effect.
Mastitis / Breast Abscess
Mastitis or breast abscess occurs as a result of inadequate drainage of the breast.
It is important to encourage regular removal of the breastmilk by feeding or expressing.
Breastfeeding (or expressing) must continue to reduce the risk of complications such as breast
abscess. It is safe for healthy infants to receive this milk.
Assist the mother to continue breastfeeding or expressing.
If the mother decides to cease breastfeeding, weaning should wait unit the condition is resolved to
reduce the risk of breast abscess.
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Contraception
Contraception if properly used, reduces the rate of fertility to between <1% (sterilisation, implants and
injectable progestogen) and 25% (coitus interruptus).
Even methods with higher failure rates can help with birth spacing.
Contraception is always initiated by medical officer or nurse practitioner.
Simultaneous use of condoms and other contraception methods for protection against HIV and other
STI when a risk of transmission exists, is recommended.
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PD3510-2 Learning Activity
1.
Which of the following are contraindications for the suppression of pre-term labour?
Correct
Choice
Gestation less than 34 weeks
Early labour
Intra-uterine foetal death
Suspected foetal compromise
Pre-eclampsia
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PD3510-3 Sexual Health
Learning Objectives
On completion of this module:
• Learners will understand the general principles of screening for and managing sexually
transmitted infections (STI)
• Discuss the various STIs, their most likely presentation and management
• Understand the link between PID and STI
• Use the PCCM to assist in the management of rape / sexual assault
General Principles
Chlamydia is the most common notifiable STI in Australia. Chlamydia and genital herpes are seen in
all areas.
Gonorrhoea and trichomonas are common in rural and remote regions, while genital warts are a frequent presentation in urban areas.
Excessively high rates of chlamydia and gonorrhoea persist in remote regions leading to:
• psycho-social distress,
• gynaecological problems,
• pregnancy loss,
• infertility
• and a population particularly vulnerable to an epidemic of HIV infection
There is currently a resurgence of syphilis in remote populations and a significant epidemic is continuing
among urban non-Aboriginal and Torres Strait Islander men who have sex with men.
STI Testing
In remote Aboriginal and Torres Strait Islander settings all sexually active men and women < 40 years
should have a test for chlamydia, gonorrhoea, syphilis and women only, trichomonas, at least once
each year.
Men and women aged 40 – 49 years should have syphilis serology annually.
Always explain the testing process and obtain informed consent before STI testing.
Symptomatic cases and contacts of individuals with a known STI must be treated at first presentation
(presumptive treatment). Do not wait for pathology results.
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STI testing in pre-pubertal asymptomatic children requires parental consent and should not be
performed unless specifically requested by the Medical Officer.
Gonorrhoea/chlamydia and Trichomonas
The most likely cause of a urethral discharge in a man is gonorrhoea and/or chlamydia.
Most women with gonorrhoea or chlamydia will have no symptoms or mild symptoms that go
unrecognised.
They may also have a vaginal discharge that originates from the cervix.
10 - 15 % of women with untreated gonorrhoea or chlamydia will develop an upper genital tract infection
Gonorrhoea and chlamydia may also cause pelvic inflammatory disease (PID) which usually presents
with low abdominal pain.
Gonorrhoea and chlamydia can damage the fallopian tubes increasing the risk of ectopic pregnancy
and infertility.
See How to do a STI check to determine the diagnosis and for management.
Treat for a STI if you are unsure.
The cause of the discharge is difficult to diagnose on clinical examination.
Lower Abdominal Pain / Female (PID)
PID must be considered in the presence of low abdominal pain in sexually active women in whom other
causes have been excluded.
Low abdominal pain due to Pelvic Inflammatory Disease may range from mild (with no other
symptoms) to severe (acute abdomen).
Diagnosis of PID is clinical; do not wait for pathology results. Response to treatment confirms the
diagnosis.
PID in early pregnancy may present as a threatened miscarriage (pain with or without bleeding).
While laboratory tests may help, negative results do not exclude PID.
Medical Officer needs to be consulted urgently if patient is ill with board-like rigidity of abdomen this is
a severe case.
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Vaginosis and Candidiasis
Women may present with vaginal discharge which originates from the vagina.
The cause of vaginal discharge can be difficult to diagnose on clinical examination.
It could be from an STI or candidiasis.
All women should be treated if STI is a likely cause.
See How to do a STI check to determine the diagnosis and for management.
Genital Sores / Ulcers
The diagnosis of genital sores can be difficult and is based on a combination of clinical symptoms
and signs, laboratory tests and response to treatment.
Herpes is the most common cause of genital ulcers.
Scabies and candidiasis may cause genital sores but other signs of these infections should be present.
There is currently a resurgence of syphilis in remote populations and a significant epidemic is continuing
among non-Aboriginal and Torres Strait Islander men who have sex with men.
Syphilis is a notifiable disease.
If syphilis or donovanosis are likely or cannot be excluded, give treatment to cover both infections.
Syphillis
Untreated syphilis can be transmitted to sexual partners up to two years after infection and to babies
during pregnancy (by blood), up to nine years after infection in mother.
Infection of babies in pregnancy can lead to miscarriage, neonatal death or congenital syphilis.
To interpret syphilis serology the current RPR result and previous RPR or syphilis serology results and
the treatment history is needed.
Treatment of syphilis in pregnancy or newborn contact Syphilis Register for immediate management
If the time between treatments exceeds 10 days contact the Syphilis Register. Client may need to
re-commence treatment.
Long term untreated syphilis results in major chronic disease and premature death.
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Genital Warts
Genital warts are usually caused by the human papilloma virus.
Some strains of HPV cause genital warts while others are associated with abnormal pap smears.
The diagnosis of genital warts is clinical. Syphilis must be excluded.
HPV vaccination in Australia should reduce the incidence of genital warts, of high grade squamous
intraepithelial lesions and ultimately of cervical cancer.
HIV infection
HIV can be transmitted by:
• exchange of body fluids through unprotected anal, vaginal (and very rarely through oral) sex;
• sharing blood through unsafe injecting practices (injecting drug use, tattooing, body piercing)
• from mother to baby during pregnancy, at delivery or through breastfeeding
The presence of other STIs significantly increases the risk of both acquiring and passing on HIV, if
exposed.
HIV post exposure prophylaxis (PEP) is available in selected cases in the event of occupational and
non-occupational exposure to HIV.
Antiviral medication can improve the quality and length of life, as well as significantly reducing transmission to babies during pregnancy (from 30 % to <1 %).
Any positive result on a pathology test must be discussed with a specialist MO before discussing with
a client.
HIV positive Aboriginal and Torres Strait Islander population more frequently report heterosexual
transmission. They include a higher proportion of women than non-Indigenous HIV positive Australians.
Rape / Sexual Assault
It is critical to document the precise history the client gives and the physical findings accurately, with
objectivity, specificity and clarity.
This includes a visual record on a body diagram and or photograph if possible (with consent).
Always perform thorough examination even if legal action is not pending as the patient may change
their decision at a later date.
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If evacuation is required for medical and or surgical treatment, forensic examination will be done after
patient has been stabilised in the referring facility.
For complainants under 14 years of age seek phone advice from a specialist Paediatrician before
proceeding.
If there is no appropriate health professional to provide the service the patient should be evacuated.
The patient may prefer to remain in the community to gain support from family, or may wish to leave
for safety.
In order for a health professional to examine a victim or survivor following sexual assault, it is preferable:
• to be the same gender as the complainant where possible
• be trained and experienced in normal genital examination including internal vaginal and anal
examination
• be familiar with injury documentation and forensic specimen collection
• to have a chaperone who is not a relative or support person of the complainant where possible
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PD3510-3 Learning Activity
1.
Match the anxiety disorder with its defining statement by adding the appropriate number in the column.
Correct Choice
PID only needs to be considered in women with diagnosed sexually transmitted infections
PID in early pregnancy may present as a threatened miscarriage
Treatment only commences once the diagnosis has been confirmed
Negative results exclude PID
PID always presents as severe pain and rigid abdomen
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PD3510 Theory to Practice Activity
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Please note: this case scenario has been adapted from the Cunningham Centre’s Rural and Isolated
Practice Nurse Endorsement Education Program.
Scenario Two – Adult female
Penny, a 24 year old woman presents to the clinic complaining of mild lower abdominal pain. The pain
has been present for three days.
Presenting Concerns:
Penny presents complaining of having a pain in her stomach which has been present for three days.
She states it is in the lower tummy only and it is dull/ mild – like a period pain.
She states she has never had it before and nothing makes it worse or really makes it better, except
Panadol.
On a scale of 1 – bearable pain and 10 agony, reports it is a 2/10. She reports No nausea, vomiting,
fever, dyspnoea, diarrhoea, weight loss and no urinary symptoms.
The only treatment she has tried is Panadol.
1.
What immediate management is required?
Answer
2.
What clinical assessment needs to be conducted?
Answer
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Your assessment and history reveals the following.
Past Medical History
• Nothing only this pain
• Surgical: Operation on broken arm when I was 12 years old
• No other hospital admissions
• No diabetes, hypertension, epilepsy, asthma, mental health problems
Family and Social History
• Mother is a diabetic – type 2
• No other significant health problems in family
• She works as child care worker
• Lives alone in a unit
• Does not have a boyfriend
• Does not smoke or drink alcohol, no illicit substance use
• Medications
• No medications
• Not taking contraceptive pill
• Allergies
• Nil known
• Immunisation Status
• Up to date
Physical Examination
• Standard observations
• Temp. 37
• Heart Rate. 80bpm
• Resp Rate. 17pm
• GCS 15
• BP 115/75
• Weight 61kg
• Height 167cm
• BMI 21 healthy weight range
• General Appearance
• Well nourished, looks well
• Normal posture
• Clean clothes
• Pink lips, tongue and fingers, skin colour normal
• Pink conjunctiva and nail beds
• Mobility normal
• No breathlessness, odours, agitation
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Hydration status
• NAD – eyes normal, mouth and tongue wet, normal skin turgor
Skin
• No rashes, bruises, petechiae, purpura, unexplained or unusual marks
• No redness, swelling, tenderness
• Nil lymph nodes palpable
Gastrointestinal/reproductive system
• Nil scars, abdominal distension, hernias, striae, masses
• Bowl sounds present, all quadrants
• Soft, firm
• Nil obvious masses
• Tender lower abdomen – hypogastric – slight guarding
• nil rigidity, nil rebound tenderness
• bowel habits normal – BO this morning
• LNMP three weeks ago, 28 day cycle
• Nil PV bleeding or abnormal vaginal discharge/lumps or sores
• No itching/soreness in perineum
• BHCG negative, nil previous pregnancies
Urine
• Clear amber colour, urinalysis – nil dysuria or frequency,
• Negative nitrites NOAD
leukocytes + ,
Sexual History
• Has not had an STI before
• Does not have any tattoos or body piercing
• No current boyfriend
• Had one casual male sexual partner 2 months ago, no other sexual partners in last 6 months
• Did not use a condom / no dyspareunia
• Refuses vaginal examination
• Last pap smear 3 years ago
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3.
What action would you now take?
Answer
4.
What steps will you now take (within your scope of practice) to ensure Penny has safely
administered and appropriate medication. Her pregnancy test has returned a negative result.
Answer
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Penny with require a complex antibiotic regime which includes stat doses as well as a 14 day course
of oral antibiotics. (See following tables).
Azithromycin
Schedule
4
Azithromycin
DTP / IHW / SM R&IP / IPAP / SRH
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO /NP
Scheduled Medicine Rural and Isolated Practice Registered Nurses and Sexual and Reproductive
Health Program Authorised Nurses may proceed
Form
Strength
Route of administration Recommended doasage Duration
Tablet
500 mg
Oral
Stat. must be
given under
observation
1g
Provide Consumer Medicine Information: may be taken with or without food.
Management of associated emergency: consult MO
[7]
And Ceftriaxone (she has indicated she has not allergies)
Schedule
4
Ceftriaxone
DTP / IHW / SM R&IP / IPAP / SRH
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO /NP
Scheduled Medicine Rural and Isolated Practice Registered Nurses and Sexual and Reproductive
Health Program Authorised Nurses may proceed
Form
Strength
Route of administration Recommended doasage Duration
Vial
1 g (dilute in 3.5 mL
1% lignocaine)
IM
= 4 mL solution
500 mg
Stat. must be
given under
observation
Provide Consumer Medicine Information
Management of associated emergency: consult MO See Anaphylaxis
[7]
These are given as a stat dose.
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They are then followed by 14 days of:
Metronidazole
Schedule
4
Metrodidazole
DTP / IHW / SM R&IP / IPAP / SRH
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO /NP
Scheduled Medicine Rural and Isolated Practice Registered Nurses and Sexual and Reproductive
Health Program Authorised Nurses may proceed
Form
Strength
Route of administration Recommended doasage Duration
200 mg
Oral
100 mg bd
14 Days
400 mg
Provide Consumer Medicine Information: Take with or immediately after food. Avoid alcohol while
taking and for 24 hrs after taking this drug
Tablet
Management of associated emergency: consult MO
[7]
and Doxycycline
Schedule
4
Doxycycline
DTP / IHW / SM R&IP / IPAP / SRH
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO /NP
Scheduled Medicine Rural and Isolated Practice Registered Nurses and Sexual and Reproductive
Health Program Authorised Nurses may proceed
Form
Strength
Route of administration Recommended doasage Duration
200 mg
Oral
100 mg bd
14 Days
500 mg
Provide Consumer Medicine Information: Take with food; do not take at same time as iron, calcium or
antacids; avoid exposure to sunlight - can cause photosensitivity
Tablet
Management of associated emergency: consult MO
[7]
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Penny may also require some simple analgesia
Schedule
2
Paracetamol
DTP / IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed
Form
Strength
Route of administration Recommended doasage
Tablet
500 mg
Suspension
120 mg / 5 mL
(24 mg / mL)
or
Oral
100 mg / mL
drops
Suppository
125 mg
250 mg
500 mg
Duration
Adults & children >12 yrs
1-2 tabs every 4 hours to Stat
max. 8 tabs / day
Further
doses on
Children 7-12 yrs
MO / NP
1/2 - 1 tab every 4 hours
orders
to a max. 4 times / day
Stat
Child
Further
15 mg / kg / dose
doses on
every 4 hours if necessary
MO / NP
to a max. of 4 times / day
orders
Adults & children >12 yrs
500 - 1000 mg
Oral
Children 7-12 yrs
250 - 500 mg
Rectal
Stat
Child < 7 yrs
15 mg / kg / dose
Provide Consumer Medicine Information: not for administration to children under 1 month
Management of associated emergency: consult MO
[1] [2]
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6.
What follow up and referral will Penny need?
Answer
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PD3510 Quiz
1.
Which sexually transmitted infection is most commonly caused by human papilloma virus?
Answer
2.
Tick
Which of the following statements are true?
Choice
Pre-term labour is regular uterine contractions at 37 weeks
Umbilical cord presentation is a life-threatening condition
Repeat courses of corticosteroids are recommended to prevent complications of pre-term
labour
The aim of suppression of pre-term labour is to postpone the birth to allow foetal lung development
RhD immunoglobulin is used in RhD positive women
3.
Match the condition with its definition by adding the appropriate number in the column.
Condition
1
Ante-partum haemorrhage
Occurs up to 6 weeks post birth
2
Primary Post-partum pregnancy
Bleeding after 20 weeks gestation
3
Secondary Post-partum pregnancy
Occurs during 3rd stage of labour
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No.
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4.
Tick
Which of the following conditions in pregnancy may lead to pre-term labour?
Choice
Urinary tract infections
Chronic hypertension
Pre-eclampsia
Diabetes
Pre-term rupture of the membranes
5.
Match the STI with its correct statement, by adding the appropriate number in the column
No.
Tick
1
Chlamydia
Can lead to foetal death in pregnant women
2
HIV
Tested annually in sexually active women
3
Syphilis
Most common notifiable STI
4
Trichomonas
Presence of other STIs increases risk of
contracting
5
Gonorrhoea
More common in rural and remote regions
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PD3510-1 Learning Activity Feedback
1.
Which of the following are recommended as part of an annual women’s health check?
Correct
✔
Choice
Syphilis screening
Mammogram in women from 30 years onwards
✔
✔
Pap smear screening – recency and or conduct smear test
Trichomonas screening
Pregnancy testing
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PD3510-2 Learning Activity Feedback
1.
Which of the following are contraindications for the suppression of pre-term labour?
Correct
Choice
Gestation less than 34 weeks
Early labour
✔
✔
✔
Intra-uterine foetal death
Suspected foetal compromise
Pre-eclampsia
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PD3510-3 Learning Activity Feedback
1.
Match the anxiety disorder with its defining statement by adding the appropriate number in the column.
Correct Choice
PID only needs to be considered in women with diagnosed sexually transmitted infections
✔
PID in early pregnancy may present as a threatened miscarriage
Treatment only commences once the diagnosis has been confirmed
Negative results exclude PID
PID always presents as severe pain and rigid abdomen
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PD3510 Theory to Practice Activity
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
Please note: this case scenario has been adapted from the Cunningham Centre’s Rural and Isolated
Practice Nurse Endorsement Education Program.
Scenario Two – Adult female
Penny, a 24 year old woman presents to the clinic complaining of mild lower abdominal pain. The pain
has been present for three days.
Presenting Concerns:
Penny presents complaining of having a pain in her stomach which has been present for three days.
She states it is in the lower tummy only and it is dull/ mild – like a period pain.
She states she has never had it before and nothing makes it worse or really makes it better, except
Panadol.
On a scale of 1 – bearable pain and 10 agony, reports it is a 2/10. She reports No nausea, vomiting,
fever, dyspnoea, diarrhoea, weight loss and no urinary symptoms.
The only treatment she has tried is Panadol.
1.
What immediate management is required?
Answer
Nil
2.
What clinical assessment needs to be conducted?
Answer
Conduct a full history and examination.
Take a full set of observations
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Your assessment and history reveals the following.
Past Medical History
• Nothing only this pain
• Surgical: Operation on broken arm when I was 12 years old
• No other hospital admissions
• No diabetes, hypertension, epilepsy, asthma, mental health problems
Family and Social History
• Mother is a diabetic – type 2
• No other significant health problems in family
• She works as child care worker
• Lives alone in a unit
• Does not have a boyfriend
• Does not smoke or drink alcohol, no illicit substance use
• Medications
• No medications
• Not taking contraceptive pill
• Allergies
• Nil known
• Immunisation Status
• Up to date
Physical Examination
• Standard observations
• Temp. 37
• Heart Rate. 80bpm
• Resp Rate. 17pm
• GCS 15
• BP 115/75
• Weight 61kg
• Height 167cm
• BMI 21 healthy weight range
• General Appearance
• Well nourished, looks well
• Normal posture
• Clean clothes
• Pink lips, tongue and fingers, skin colour normal
• Pink conjunctiva and nail beds
• Mobility normal
• No breathlessness, odours, agitation
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Hydration status
• NAD – eyes normal, mouth and tongue wet, normal skin turgor
Skin
• No rashes, bruises, petechiae, purpura, unexplained or unusual marks
• No redness, swelling, tenderness
• Nil lymph nodes palpable
Gastrointestinal/reproductive system
• Nil scars, abdominal distension, hernias, striae, masses
• Bowl sounds present, all quadrants
• Soft, firm
• Nil obvious masses
• Tender lower abdomen – hypogastric – slight guarding
• nil rigidity, nil rebound tenderness
• bowel habits normal – BO this morning
• LNMP three weeks ago, 28 day cycle
• Nil PV bleeding or abnormal vaginal discharge/lumps or sores
• No itching/soreness in perineum
• BHCG negative, nil previous pregnancies
Urine
• Clear amber colour, urinalysis – nil dysuria or frequency,
• Negative nitrites NOAD
leukocytes + ,
Sexual History
• Has not had an STI before
• Does not have any tattoos or body piercing
• No current boyfriend
• Had one casual male sexual partner 2 months ago, no other sexual partners in last 6 months
• Did not use a condom / no dyspareunia
• Refuses vaginal examination
• Last pap smear 3 years ago
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3.
What action would you now take?
Answer
The most likely reason for Penny’s pain is Pelvic Inflammatory Disease (PID). She will require
A pregnancy test
Testing for sexually transmitted infections
Medication as a presumptive treatment – medication for PID should be given to women < 25
years, or at any age if at risk of STI if:
- the woman complains of low abdominal pain or pain is present on moving the cervix or
adnexae during bimanual examination
- examination and no other cause can be identified
•
•
•
4.
What steps will you now take (within your scope of practice) to ensure Penny has safely
administered and appropriate medication. Her pregnancy test has returned a negative result.
Answer
The answer to this question depends on your scope of practice and the Health Management protocols you work under. The list below provides brief information.
Paracetamol can be given by Authorised Indigenous Health Workers (IHW) and Isolated Practice
Area Paramedics (IPAP)
Antibiotics
•
IHW and IPAP must consult the Medical Officer (MO) or Nurse Practitioner (NP)
•
Non-endorsed Registered Nurses must consult the MO or NP
•
Scheduled Medicines Rural and Isolated Practice Registered Nurse (SM R&IP) and Sexual
and Reproductive Health Program Authorised Registered Nurses may proceed.
•
See tables over page for more information.
Penny with require a complex antibiotic regime which includes stat doses as well as a 14 day course
of oral antibiotics.
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6.
What follow up and referral will Penny need?
Answer
Follow up
Follow up at 1 - 2 days
Education and counselling:
- explain pelvic infection and its complications
- give general information on the transmission and prevention of STI and HIV
- discuss safe sex practices and provide condoms
- encourage compliance with medication to guard against risk of complications
- complete contact tracing / partner notification
- stress the importance of follow up
Clinical assessment:
- if medication compliant, should be significant improvement within 48 hours
- if no improvement or if worse, consult MO (IV antibiotics may be required, alternatively PID
may not be the cause)
- if not already done, offer blood tests for syphilis, HIV and hepatitis C and for hepatitis B if not
immune. See Hepatitis and HIV infection
- advise to abstain from sex until client and partner(s) treatment is finished
Follow up within 2 weeks - check:
- Treatment adherence and symptom resolution. If pain not resolved consult MO
- Contacts have been tested and treated
- Test results have been given
- If treatment completed and symptoms resolved a test of cure is not needed
Follow up at 2 - 3 months
- A repeat self- collected swab or urine PCR test for gonorrhoea, chlamydia and trichomonas
should be offered to check if the client has been reinfected
- A follow up test for HIV should be offered to cover the ‘window period’. See HIV infection
•
•
•
•
Referral / consultation
Consult MO on all occasions of acute abdominal pain or abnormal vaginal bleeding
If pain recurs, reassess for PID. If reinfection is unlikely, referral may be needed for pelvic
ultrasound and laparoscopy to assess for ovarian masses, adhesions and endometriosis
•
•
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PD3510 Quiz Feedback
1.
Which sexually transmitted infection is most commonly caused by human papilloma virus?
Answer
Genital Warts
2.
Tick
Which of the following statements are true?
Choice
Pre-term labour is regular uterine contractions at 37 weeks
✔
Umbilical cord presentation is a life-threatening condition
Repeat courses of corticosteroids are recommended to prevent complications of pre-term
labour
✔
The aim of suppression of pre-term labour is to postpone the birth to allow foetal lung development
RhD immunoglobulin is used in RhD positive women
3.
Match the condition with its definition by adding the appropriate number in the column.
No.
Condition
No.
Definition
1
Ante-partum haemorrhage
3
Occurs up to 6 weeks post birth
2
Primary Post-partum pregnancy
1
Bleeding after 20 weeks gestation
3
Secondary Post-partum pregnancy
2
Occurs during 3rd stage of labour
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4.
Tick
✔
Which of the following conditions in pregnancy may lead to pre-term labour?
Choice
Urinary tract infections
Chronic hypertension
Pre-eclampsia
Diabetes
✔
5.
Pre-term rupture of the membranes
Match the STI with its correct statement, by adding the appropriate number in the column
No.
Tick
No.
Choice
1
Chlamydia
3
Can lead to foetal death in pregnant women
2
HIV
4
Tested annually in sexually active women
3
Syphilis
1
Most common notifiable STI
4
Trichomonas
2
Presence of other STIs increases risk of
contracting
5
Gonorrhoea
5
More common in rural and remote regions
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Primary Clinical
Care Manual
PD3511 - Paediatric Assessment
Participation Manual
Name
Community
Site
Please select ...
Position
Date Completed
PD3511 Paediatric Assessment
Aboriginal
Administration
Allied
Dental
Medical
Nursing
Midwife
Other
Student
Health
Officer
Officer
and /Officer
or Torres Strait Islan
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Contents
PD3511 Introduction3
PDPD3511 Paediatric Assessment - History4
PD3511-1 Learning Activity11
PD3511-2 Paediatric Assessment – Physical Examination12
PD3511-2 Learning Activity17
PD3511 Theory to Practice Activity18
PD3511 Quiz19
PD3511-1 Learning Activity Feedback22
PD3511-2 Learning Activity Feedback22
PD3511 Theory to Practice Activity Feedback23
PD3511 Quiz Feedback24
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PD3511 Introduction
When children present for acute conditions it is essential to gather an orderly collection of information
to establish their health status. This includes taking a comprehensive and accurate history, performing
standard clinical observations and performing an appropriate physical examination.
Session Overview
This session provides information on history gathering and general and system specific examinations
of children presenting for acute care. It includes an overview of the initial assessment including the
identification of specific factors that may indicate increased risk. It also introduces the Emergency
Department Child Early Warning Tool for Rural and Remote Settings (ED CEWT), which is used to
guide the management of children presenting to this setting.
Learning Objectives
On completion of this session learners will be able to
• Identify risk signs that indicate a child is very unwell
• Discuss risk factors that may impact on a child’s care and recovery
• Discuss strategies for determining pain in a child
• Use the PCCM to guide in the history taking for child presentations
• Discuss the general principles of conducting a physical examination in a child
• Use the PCCM as a guide to assist in conducting a physical examination of a child
• Discuss when how and when urinalysis should be conducted for child presentations
Modules
Module 1 introduces special considerations for child presentations and the process of taking a
comprehensive history. Module 2 discusses physical assessment of a child.
Learning Activities
The learning activity included in each module needs to be completed before moving to the next module.
A theory to practice learning activity is also included and is required on conclusion of the two modules.
Quiz
Once you have finished the modules, you are asked to complete a graded interactive quiz.
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PDPD3511 Paediatric Assessment - History
Learning Objectives
• On completion of this module learners will be able to:
• Identify risk signs that indicate a child is very unwell
• Discuss risk factors that may impact on a child’s care and recovery
• Discuss strategies for determining pain in a child
• Use the PCCM as a guide managing child presentations
Child Presentations
Small children, especially young babies, get sick very quickly.
Risk signs in children are:
• temperature > 38°C or < 35.5°C
• irritability
• high pitched cry or weak cry
• drowsiness
• decreased activity
• reduced feeding
• breathing fast / noisy, respiratory distress, apnoea
• persistent vomiting
• dehydration (< 4 wet nappies in 24 hours)
• sunken eyes
• cold extremities
• capillary refill > 2 seconds
• uses eyes (rather than head) to follow you
• abdominal distension
Other high risk children include those with:
• lots of diarrhoea (> 8 watery stools in 24 hours)
• congenital or chronic disease e.g. cardiac, gastrointestinal, neurological
• where social conditions are concerning
• where parents may have difficulty managing at home
• a history of repeated or prolonged separations from their primary caregiver(s)
• psychosocial risk factors including family violence, poverty, homelessness, parents with
intellectual disability or mental health problems.
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For child presentations it is important to:
• Consult Medical Officer immediately about any baby under 3 months of age who is febrile or
considered to be at risk of poor outcomes
• Always check the immunisation status of children at every opportunity
• Believe the child or parent or carer no matter the time of day or night or the circumstance
• Make sure the patient and their parent or carer feels he or she has been listened to and done the
right thing in bringing the child regardless of the concern
Pain assessment in a Child
In children 3 years and older, the faces pain scale uses drawings of faces in increasing distress from 0
score – no pain to a score of 10 – severe pain.
Children choose the face that best represents their level of pain.
Pain level in children is rated using face, numbers and behavioural observations.
Physiological changes e.g. altered HR, RR, BP are not good indicators to use in isolation
Non - verbal children are very vulnerable to having their pain under estimated
The Children’s Early Warning Tools (ED CEWT) for rural and remote facilities and for Primary Health
Care Centres has pain assessment tools which will assist with determining pain levels.
History taking
History taking should always be completed prior to a physical examination unless the child is very ill. It
• Provides the first step in forming impression
• Guides the physical examination
Requires good interview technique to:
• Generate information needed for diagnoses
• Provide a basis for physical examination and pathology
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Presentation
When a child presents for health care the clinician is required to obtain an orderly collection of information
to identify the patient’s health status.
The following is essential to achieve this:
• taking a patient history
• performing standard clinical observations and other vital signs
• perform physical examination
• using diagnostic and pathology services and
• collaboration with other members of the team
Not all children are at the same stage of development in areas of physical, cognitive and psychosocial
development.
It is a requirement that all clinicians document their findings in a clear and concise way.
History taking
The purpose of a full history is to ascertain the cause of the child’s illness.
A careful history will make the cause clear in the vast majority of cases
• The first priority is to assess whether the child is:
- seriously ill and needs immediate management or,
- is a non urgent presentation and there is time for a complete patient history and health education
• Obtaining a full history is done in conjunction with examining the patient
- in a sick child this entails a full assessment of all systems
- in a child who has a localised problem it is reasonable to examine the relevant system only.
However, always be guided by the history and be prepared to examine other systems as necessary.
This is particularly important when examining children who often present with generalised symptoms
and signs:
- ask open ended questions
- believe the carer
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Presenting Concern
When a child presents it is important to:
• Ask the child or carer what the problem is
• Ask about length of illness and exact details of symptoms and signs. For each symptom the
following details are important
Site - where is the pain / symptom? does it go anywhere else?
Onset - when did it start, gradual or sudden onset?
Character e.g. sharp, dull or burning
Radiation - does the pain radiate anywhere else?
Alleviating factors - what makes it better e.g. sitting up, medicines?
Timing - how long did it last, have they had it before?
Exacerbating factors - what makes it worse?
Severity - mild, moderate or severe pain. Pain score 0 - no discomfort to 10 - unbearable pain or
use facial diagrams
Associated Symptoms
Asking the child or carer about associated symptoms helps elicit more information that is relevant to
the presentation.
It is important to always ask about:
• Fever
• Pain
• Shortness of breath
• Rapid breathing
• Diarrhoea
• Weight loss
• Rash
Associated symptoms may include:
• Nausea
• Vomiting
• Photophobia
• Headache
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Other information
More information is required if the patient is a child - this may include asking the carer about:
Behaviour and activity which includes:
• Is the child drowsy or acting normally
• Is the baby feeding normally, including waking up for feeds or sleeping through
What is the child / babies appetite like:
• Be precise with quantities
• How many drinks or breast feeds
• Is the baby alert and awake
Fluid intake and output:
• Is the baby, child vomiting or having diarrhoea between feeds
• How long after a feed is the child vomiting or having diarrhoea
• How many wet and or dirty nappies has the baby / child had in the past 24 hours
• What is amount an type of bowel motions.
Treatment or Medications
Ask the carer what treatment or medications (if any) they have used to alleviate symptoms e.g.
• Have they tried analgesia
• What analgesia did they try
• How often have they taken it
• When did they last have it
• Did the treatment work
• How long did it work for
Past History
Past medical and surgical history:
• Was delivery normal and were there any immediate neonatal problems?
• Any problems with growth and development?
• Significant illnesses in the past? What and when?
• Hospital admissions? Why and when?
• Operations or injuries? What and when?
• Mother’s alcohol history during pregnancy?
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Family and social history:
• Health problems in the family - especially siblings and parents
• Who looks after the child, what is the social situation?
• Mental health problems in carers / child?
• Household smokers?
• Recent contacts or trips away
• If medicines are given, will they be taken?
Medications
• Regular medicines (prescribed, herbal, bush medicines, over the counter) generic name(s), dose,
frequency?
• Are they taken correctly?
• May need to ask about other medicine(s) in the home the child may have taken
• See Medication reconciliation and Medication history checklist for more details
Allergies
• Adverse medicine reactions:
• adverse reactions / allergies to medicines?
• attach “adverse medicine reaction” sticker to medication chart if required
• Allergens e.g. bee stings, tapes, sticking plaster, nuts:
• specific reaction e.g. skin reaction, bronchospasm
• is an EpiPen® / medicine used to treat the allergy?
Immunisations
• Check if up to date
• Documented evidence of immunisation status should be obtained, follow up with opportunistic
immunisation
Immunisations
• The NIPs is antigen based and vaccine combinations may vary from state to state
• Targeted approved immunisation programs may vary from state to state and have to be
endorsed by the Executive Director, Health Protection Directorate
• For further advice on immunisation - contact your local Public Health Unit
• Implementation of the Immunisation HMP must be in accordance with:
- current edition NHMRC Australian Immunisation Handbook
- National Immunisation Program schedule (NIPs)
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• Utilise all clinical encounters to assess vaccination status and when indicated, vaccinate children
• Administer all due and overdue immunisations at time of presentation, if client is assessed as fit
for vaccination.
• Plan and document catch-up immunisations if further vaccinations are required
•
• Vaccinate children and adults according to the current NIPs and / or recommendations as per
current edition NHMRC Australian Immunisation Handbook
Standard Clinical Observations
All children presenting for acute care should have standard clinical observations which include:
• Temperature, Heart Rate and
respiratory rate
If indicated:
• O2 saturation
• Blood Pressure
• is not usually needed
• ensure correct sized cuff - must be wider than 2/3 the length of upper arm
• blood glucose level (BGL)
• indications include altered level of consciousness / seriously ill children
• conscious level - GCS / AVPU
• capillary refill
• weight
See Standard clinical observations and other vital signs - child
See Glasgow coma scale / AVPU
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PD3511-1 Learning Activity
1.
Which of the following are signs that a child is very unwell?
Correct
Choice
Temperature above 37.5 degrees Celsius
Irritability
More than 6 wet nappies in 24 hours
High pitched cry
Warm extremities
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PD3511-2 Paediatric Assessment – Physical Examination
Learning Objectives
On completion of this module learners will be able to:
• Discuss the general principles of conducting a physical examination in a child
• Use the PCCM as a guide to assist in conducting a physical examination of a child
• Discuss when how and when urinalysis should be conducted for child presentations
General Principles
• A physical examination of a child may be best done with the child on the carer’s knee.
• If the child is irritable perform the examination opportunistically i.e. do what you can when you
can.
• Leave the most disruptive parts (ears and throat) until last
• In general, examination of a child is not a good screening test.
• Use the history to guide you to areas where you think you will find an abnormality
• In any sick child a thorough and complete examination is required.
• All clothing will need to be removed at some stage during the complete examination
• In a child who is not sick, examine the relevant system first and proceed to further examination
as guided by the history and your findings
General Appearance
A physical examination starts with assessing the general appearance of the child. Questions include:
• Does the child look well or sick?
• Alert or drowsy? Altered conscious state? See Glasgow coma scale / AVPU
• Muscle tone - normal or is the child floppy?
• Look / gaze - does the child fix the gaze on the face or is there a glassy eyed stare?
• Interactive or disinterested in interacting / playing?
• Increased work of breathing? e.g. retractions, nasal flaring, grunting, gasping, fast breathing,
wheeze
• Observe speech / cry - strong and vigorous or weak or hoarse?
• Look at the conjunctiva and the nail beds - are they pale?
• Look at the lips, tongue and fingers - are they blue?
• Is the child well nourished?
• Is there any neck stiffness - feel gently. Ask the older child to put their chin on their chest - if they
can they do not have neck stiffness
• Is the child able to be consoled by the care giver?
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Hydration
It is important to assess hydration which provides valuable information on the general recent state of
health’. Babies are very vulnerable to dehydration, especially if they are not eating solids.
• Check for recent weight loss
• Check if eyes are normal or sunken? If Tears are absent or present?
• Is the mouth and tongue wet or dry?
• Is skin turgor normal or reduced? Pinch skin: normal skin returns immediately on release
• Fontanelle – normal or depressed (bulging indicates pressure - if bulging consider meningitis)
Urinalysis
• Examine the urine of all sick children, all children with abdominal pain or urinary symptoms and
all children with unexplained symptoms or signs
• Look at the colour - is it normal, dark, blood stained?
• Does it smell normal?
• Perform urinalysis
• Perform a βhCG test if child bearing age and appropriate to presentation (with parental consent
if age appropriate)
Skin
Always check the whole body, particularly in a sick child for:
• Rash - non blanching, petechiae, purpura?
• Colour - unusually pale, mottled or cyanotic?
• Bruising, unexplained or unusual marks?
• Signs of infection - redness, swelling or tenderness?
• Inspect / palpate lymph nodes in the neck, axillae or groins for tenderness
• See Assessment and physical examination of skin, hair and nails for detailed assessment
Growth
Growth is a very important measurement for determining if a child is thriving or in poor health.
Child presentations should always have growth measurements conducted. This includes:
• Height
• Weight - if child is less than 2 years old weigh naked
• Head circumference if child is less than 2 years old
• Plot on growth charts appropriate for age and gender
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Cardiovascular System
The health of the cardiovascular system in a child is determined by:
• Skin colour - pink, white, grey mottling? Compare the trunk with the limbs
• Skin temperature - hot, warm, cool, cold, sweating? Compare the trunk with the limbs
• Palpating peripheral pulses - is rate fast, slow or normal - is the pulse volume weak or strong?
• Determining central perfusion by blanching the skin over the sternum with your thumb for 5
seconds.
• Time how long it takes for the colour to return
• Peripheral perfusion - ‘blanch’ the skin on a finger or toe for 5 seconds.
• Time how long it takes for the colour to return
• Assessing for evidence of oedema - particularly hands, feet and face?
• Clinicians who are skilled should also listen to heart sounds
Respiratory System
The respiratory system is assessed by:
• Inspecting anterior / posterior chest:
• Is there equal chest movement
• Is the child using accessory muscles of respiration?
- This includes retraction, recession - mild, moderate or severe? Nasal flaring? Head bobbing?
• Determining if the child talk continuously or only in words or sentences or unable to talk at all?
• Measuring respiratory rate over one minute, observe rhythm, depth and effort breathing
• Listening for extra respiratory noises - cough, ± sputum, wheeze, stridor, grunt, snore, hoarse
speech or cry
• Auscultating air entry in both lung fields - equal? Adequate, decreased or absent?
- Are there wheezes or crackles?
- Do they occur on inspiration or expiration?
Note that transmitted sounds from the upper respiratory tract are very common in children and may
mask other signs:
• Determining if the child is able to lie flat
• Measuring Oxygen saturation
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Gastrointestinal system
When assessing the gastrointestinal system in a child it is important to:
• Look for any scars or abdominal distension / hernias
• Auscultate bowel sounds are they present or absent?
• Palpate abdomen. Is it
•
•
•
- soft or firm?
- any obvious masses?
- tender to touch? Identify which abdominal quadrant and exact area
- any guarding / rigidity - even when the child is relaxed?
- any rebound tenderness - press down and take your hand away very quickly – is the pain
greater when you do this?
Question about change in bowel habits
Feel for a palpable bladder
Check the testes in boys - are they both in the scrotum?
- Is there any redness, swelling or tenderness?
Nervous System
• A detailed assessment of the nervous system in a child is both technically difficult and time
consuming.
• It is better to conduct a brief assessment which determines
- Conscious state - See Glasgow coma scale / AVPU
- Orientation to time, place and person if appropriate for the child’s age.
- Ask the child their name, age, location. Ask them to tell you the time, date and year
- Pupils: size, equality, shape, reactivity to light
Look for inequality between one side of the body and the other. Compare the tone and power of
each side of the face and the limbs
Test touch sensation using cotton wool
Test finger nose coordination. If possible, observe child walking, looking around and using hand
•
•
•
Musculoskeletal System
Assessing the musculoskeletal system in a child includes determining if there is:
• A full range of movement in limbs, joints and muscles
• Pain in limbs, joints or muscles
• Any redness, pain, swelling, heat over joint(s)?
• Normal or abnormal gait
Acute Rheumatic Fever (ARF) should always be considered if a child presents with joint pain
This is especially relevant in populations who are at high risk of developing (ARF)
See Acute rheumatic fever (ARF) and Bone and joint infections - child.
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Ears, Nose and Throat
Children who present with fevers and are generally unwell often have problems of the ears, nose and
throat.
• When examining ears it is important to
- look at the pinna and determine if there is redness or swelling
- look for any obvious swelling or redness of the ear canal, if there is, looking with an otoscope
will be painful
- check the internal structure with an otoscope - look at the ear canal for redness, swelling,
discharge?
- inspect eardrum to determine if it is normal? Is there redness, dullness, bulging or retraction,
fluid or air bubbles, perforations or discharge?
See Assessment of the ear for detailed assessment
Examination of the nose includes
- Feeling for facial swelling / inflammation
- Determining if here any discharge or obvious foreign body?
Assessment of the throat involves
- Looking at the lips, buccal mucosa, gums, palate, tongue, throat
- Determining if there is redness and or swelling
- Assessing the condition of the teeth
- Inspecting the tonsils to determine if there is redness, enlargement or pus
•
•
•
Eyes
• Always test the visual acuity of each eye. Use age appropriate Snellen chart at 6 metres in good
light
• Look at the eyes and surrounding structures - any redness, discharge or swelling?
• Look at the pupils - are they equal in size and regular in shape? Check pupillary reflex to light
• Check eye movements - ask the child to follow the movement of your finger
See Assessment of the eye for detailed assessment
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PD3511-2 Learning Activity
1.
Which of the following are signs of possible dehydration in a child?
Correct
Choice
Recent weight loss
Sunken eyes
Dry tongue
Bulging fontanelle
Normal skin turgor
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PD3511 Theory to Practice Activity
1.
Complete the following table (see the PCCM Paediatric Presentation Section) for information
Standard Clinical Observations and other vital signs - child
Approximate normal physiological ranges for a child
Normal Range
Parameter
<3 mths
Heart Rate
<1 yr
1-2 yrs
Other
vital signs
if indicated
> 12 yrs
25-35
35.0C <37.5C
Temp Rectal
Blood
Pressure
O2
saturation
(%)
Capillary
Refill
Consciousness
Blood
Glucose
>5-12 yrs
110 - 160
Respiratory
Rate
Standard
Clinical
Temp Axilla
Observations
Temp
Sublingual
2-5 yrs
35.5C 36.5 - 38.5C
Systolic
> 70
Glasgow coma scale
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AVPU Tool
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PD3511 Quiz
1.
Tick
Due and overdue immunisations should not be administered when a child presents for an
acute problem – they should be called back when the next immunisation clinic is conducted?
Choice
True
False
2.
Tick
Which of the following statements about child presentations are true?
Choice
Children should routinely have blood glucose levels checked
A 2 month old baby with a fever does not have to be reviewed by a Medical Officer
A sick child should have a full assessment of all systems
All children presenting for acute care should have a temperature check
Growth checks are of little value when assessing a child’s health
PD3511 Paediatric Assessment
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3.
Tick
Which of the following are deemed to be high risk presentations?
Choice
Children whose parents are intellectually disabled
Children who have been frequently separated from their primary carer
Children who have both parents working
Children with a low grade fever (less than 37.5 Celsius)
Children who come from large families
4.
Tick
Which of the following child presentations would require a urinalysis?
Choice
A child with an upper respiratory tract infection
A child who appears very unwell
A child with urinary symptoms
A child with abdominal pain
A child whose immunisations are overdue
PD3511 Paediatric Assessment
20
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5.
Tick
Which of the following assessments should be conducted on a child who presents with a low grade fever, runny nose and cough?
Choice
Eyes
Ear, nose and throat
Respiratory system
Cardiovascular system
Musculoskeletal system
PD3511 Paediatric Assessment
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PD3511-1 Learning Activity Feedback
1.
Which of the following are signs that a child is very unwell?
Correct
Choice
Temperature above 37.5 degrees Celsius
✔
Irritability
More than 6 wet nappies in 24 hours
✔
High pitched cry
Warm extremities
PD3511-2 Learning Activity Feedback
2.
Which of the following are signs of possible dehydration in a child?
Correct
✔
✔
✔
Choice
Recent weight loss
Sunken eyes
Dry tongue
Bulging fontanelle
Normal skin turgor
PD3511 Paediatric Assessment
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PD3511 Theory to Practice Activity Feedback
1.
Complete the following table (see the PCCM Paediatric Presentation Section) for information
Standard Clinical Observations and other vital signs - child
Approximate normal physiological ranges for a child
Normal Range
Parameter
<3 mths
1-2 yrs
2-5 yrs
5-12 yrs
>12 yrs
Heart Rate
110 - 160
100 - 150
95 -140
80 - 120
60 - 100
Respiratory
Rate
30 - 40
25-35
25 - 30
20 - 25
15 - 20
Systolic
> 80
Systolic
> 90
Standard
Clinical
Temp Axilla
Observations
Temp
Sublingual
Temp Rectal
Other
vital signs
if indicated
<1 yr
Blood
Pressure
O2
saturation
(%)
Capillary
Refill
Consciousness
Blood
Glucose
< 37.2 C
35.0 C - 37.8 C
<37.5 C
35.5C - 38.0 C
< 38.0 C
36.5 - 38.5 C
Systolic
> 60
Systolic
> 70
Systolic
> 75
Greater than 95%
Less than or equal to 2 seconds
Glasgow coma scale 15
AVPU Tool Alert
4 - 8 mmol (random capillary)
PD3511 Paediatric Assessment
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PD3511 Quiz Feedback
1.
Tick
Due and overdue immunisations should not be administered when a child presents for an
acute problem – they should be called back when the next immunisation clinic is conducted?
Choice
True
✔
2.
Tick
False
Which of the following statements about child presentations are true?
Choice
Children should routinely have blood glucose levels checked
A 2 month old baby with a fever does not have to be reviewed by a Medical Officer
✔
✔
A sick child should have a full assessment of all systems
All children presenting for acute care should have a temperature check
Growth checks are of little value when assessing a child’s health
PD3511 Paediatric Assessment
24
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3.
Which of the following are deemed to be high risk presentations?
Tick
Choice
Children whose parents are intellectually disabled
✔
Children who have been frequently separated from their primary carer
Children who have both parents working
Children with a low grade fever (less than 37.5 Celsius)
Children who come from large families
4.
Which of the following child presentations would require a urinalysis?
Tick
Choice
A child with an upper respiratory tract infection
✔
✔
✔
A child who appears very unwell
A child with urinary symptoms
A child with abdominal pain
A child whose immunisations are overdue
PD3511 Paediatric Assessment
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5.
Which of the following assessments should be conducted on a child who presents with a low grade fever, runny nose and cough?
Tick
Choice
Eyes
✔
✔
Ear, nose and throat
Respiratory system
Cardiovascular system
Musculoskeletal system
PD3511 Paediatric Assessment
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Primary Clinical
Care Manual
PD3512 - Paediatric Presentations
Participation Manual
Name
Community
Site
Please select ...
Position
Date Completed
PD3512 Paediatric Presentations
Aboriginal
Administration
Allied
Dental
Medical
Nursing
Midwife
Other
Student
Health
Officer
Officer
and /Officer
or Torres Strait Islan
1
Version1 (2014)
Contents
PD3512 Introduction
3
PD3512 Paediatric Presentations - Part 1
5
PD3512-1 Learning Activity
15
PD3512-2 Paediatric Presentations - Part 2
16
PD3512-2 Learning Activity
23
PD3512 Theory to Practice Activity
24
PD3512 Quiz
31
PD3512-1 Learning Activity Feedback
34
PD3512-2 Learning Activity Feedback
34
PD3512 Theory to Practice Activity Feedback
35
PD3512 Quiz Feedback
39
PD3512 Paediatric Presentations
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PD3512 Introduction
Children may present to a clinic with a common range of symptoms that may indicate a variety of
clinical conditions. The more common presentations are fever, cough, stridor, vomiting, abdominal pain
and diarrhoea. These symptoms could be indicative equally of simple infections or very severe illness.
A child’s health can deteriorate very quickly, so it is important to conduct a thorough history and
assessment. The PCCM provides comprehensive information on how to manage child presentations
and what follow up or review may be required.
Session Overview
This session introduces the child presentation flow charts in the PCCM which provide assistance with
decision making and discusses the management of a range of mild and potentially severe paediatric
illnesses.
Learning Objectives
On completion of this session learners will be able to use the PCCM to assist in assessing
•
•
•
General child presentations
The ear
Suspected abuse and neglect
And in the management of
•
•
•
•
•
•
•
•
A child with meningitis
A child with respiratory problems
A child with immune complications
Assessing a child’s ear
Ear problems
Problems of the gastrointestinal system
Urinary tract problems
Bone and joint infections
Modules
Module 1 introduces the decision support pathways for child presentations and discusses the
management of meningitis, respiratory problems and immune complications.
Module 2 provides information on assessment and management of ear infections, gastrointestinal
problems, problems of the urinary tract, bone and joint infections and suspected child abuse and neglect.
PD3512 Paediatric Presentations
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Learning Activities
The learning activity included in each module needs to be completed before moving to the next module.
A theory to practice learning activity is also included and is required on conclusion of the two modules.
Quiz
Once you have finished the modules, you are asked to complete a graded interactive quiz.
PD3512 Paediatric Presentations
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PD3512 Paediatric Presentations - History
Learning Objectives
On completion of this module learners will be able to use the PCCM to guide the management of:
•
•
•
•
General child presentations
A child with meningitis
A child with respiratory problems
- Upper Respiratory Tract Infection
- Bronchiolitis and Pneumonia
A child with immune complications
- Acute Post-Streptococcal Glomerulo Nephritis and Acute Rheumatic Fever
Child Presentations
The following pages show the decision support flow charts for child presentations and provide useful
information on the appropriate supporting section of the PCCM.
The flow charts can be used to direct clinical management of an acute presentation.
PD3512 Paediatric Presentations
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Child with fever
Fever is usually an indicator of infection. Two or more infections may co-exist, e.g. URTI plus
menigitis.
Babies less than 3 months of age contact MO immediately.
Consult MO for the child with a fever with no obvious source of infection or a fever that is
persistent despite measures taken.
Clinical assessment performed
Significant features of assessment unclear or you are unsure of cause?
Yes
Consult MO
No
Child unwell
Child unwell
Child unwell
Child unwell
May have
history of
URTI like
illness
Rapid onset
high fever
Dysuria,
frequency,
smelly
urine
Cough
Neck stiffness
or bulging
fontanelle
Stridor,
drooling,
unable to
eat,
drink or talk,
reluctant to
move neck
Headache,
photophobia
+/Rash
See
Meningitis
See
Epiglotis
Positive
urinalysis
Rapid
breathing,
chest
recession
Tachycardia
No other
significant
features
See
UTI
PD3512 Paediatric Presentations
Basically
well child
Basically
well child
Basically
well child
Basically
well child
Obvious
abscesses
or cellulitis
Vomiting
and
diarrhoea
URTI type
symptoms
may be
present
No other
significant
features
No other
significant
features
Bulging ear
drum on
examination
Sore throat,
ears, nasal
discharge,
cough,
lymphadenopathy
red inflamed
throat, tonsillar
enlargement
No other
significant
features
No other
significant
features
See
Acute
ottis
media
See
URTI
No other
significant
features
See
Pneumonia
See
Bacterial
skin
infections
6
See
Acute
gastroenteritis
Version1 (2014)
Child with cough
A cough in a child could be indicative of a number of different problems
If unsure of the cause the Medical Officer should be contacted immediately
For babies less than 3 months of age contact the Medical Officer immediately
Clinical assessment performed
Significant features of assessment unclear or you are unsure of cause?
Yes
Consult MO
No
Basically
well child
Barking
cough
Mild URTI
symptoms
Mild fever
Mild /
moderate
stridor
Child unwell
Rapid onset
high fever
Stridor,
drooling
Unable to
eat, drink
or talk
Reluctant to
move neck
No other
significant
features
Cough may
be absent
See
Croup
See
epiglottitis
Sudden onset
in
previously
well child
Basically
well child
Child
unwell
Sore throat, ears,
nasal discharge
Fever
Cough +/Stridor +/Wheeze +/-
Cervical
lymphadenopathy
Airway
compromised
Fever, red
inflamed ‘throat
Usually there
is a history of
ingesting or
choking on
something
Tonsillar enlargement
See
Acute upper
airway
obstruction /
choking
PD3512 Paediatric Presentations
Rapid
breathing
with chest
recession
Nocturnal
or exercise
induced cough
Paroxysmal
cough
whoop
Wheeze, rapid
breathing
Apnoea
No other
significant
features
No other
significant
features
Tachycardia
No other
significant
features
No other
significant
features
See
URTI
7
See
Pneumonia
See
Asthma
See
Whooping
couph /
pertussis
Version1 (2014)
Child with stridor
Stridor is a harsh vibrating sound originating from the large upper airways and occurring on
inspiration.
It occurs as a result of an upper airway obstruction and could be caused by:
croup which is a common cause of stridor,
inhaled foreign body,
epiglottitis – rare but important,
trauma,
angioneurotic oedema,
mass (tumour or abscess)
For babies less than 3 months of age contact the Medical Officer immediately
•
•
•
•
•
•
Obtain full history, including Hib immunisation status. Limit examination, Do not examine mouth or throat
Significant features of assessment unclear or you are unsure of cause?
Yes
Consult MO
In the meantime,
consider epiglottitis
No
Rapid onset
Slow onset
Weak or no cough
Temp > 38.5C
Septicaemia
Drooling saliva
Unable to eat or drink
Doesn’t talk
Any age
Reluctant to move neck
As the condition
deteriorates the stridor
may decrease
Croupy (barking) cough
Temp <38.5C
No systemic disturbance
Severe stridor less
common
Sudden onset in previously
well child
Gradual swelling of face,
neck and throat
Cough or wheeze may be
present
Usually there is a history
of exposure to allergen: an
injection of a drug or blood
product, ingestion of oral
drug / food or bites / stings
Usually there is a history
of ingesting or choking on
something e.g. peanut
Able to swallow
Will usually drink
Normal voice
< 4 years
More prominent at night
See
Croup / epiglottitis
See
Croup / epiglottitis
PD3512 Paediatric Presentations
See
Acute upper
airway
obstruction /
choking
8
See
Anaphylaxis
Version1 (2014)
Child with vomiting
Vomiting is a common and important symptom, which may indicate serious illness especially
in a very young child.
Vomiting could be the result of:
infection (pneumonia, urinary tract infection, meningitis, otitis media),
obstruction (pyloric stenosis, intussusception, appendicitis, hernia),
reflux oesophagitis,
raised intracranial pressure (trauma, abscess or tumour),
metabolic (diabetic ketoacidosis, poisoning)
For babies less than 3 months of age contact the Medical Officer immediately
•
•
•
•
•
Perform clinical assessment
Significant features of assessment unclear or you are unsure of cause?
Yes
Consult MO
No
Child unwell
Child unwell
Fever
Cough
Basically
well child
Dysuria
frequency
smelly urine
Diarrhoea
May have
history of
URTI like
illness
Headache,
photophobia
+/Neck
stiffness
+/Rash
See
Meningitis
Rapid
breathing
Chest
recession
Fever
Positive
urinalysis
No other
significant
features
No other
significant
features
Tachycardia
No other
significant
features
See
Pneumonia
2-6 weeks
old
3 mths - 3
yrs
Projectile
vomits,
hungry
following
feed
Abdominal
pain
intermittently
Weight
loss or
poor gain
Red currant
jelly stool
No other
significant
features
Well baby
Child unwell
Unweaned
Moderate or
severe
dehydration
Vomiting
and irritable
after feeds
No other
significant
features
High capillary
BGL
Ketones on
urinalysis
No other
significant
features
See
Acute
gastroenteritis
PD3512 Paediatric Presentations
See
UTI
See
Pyloric
stenosis
9
See
Intussusception
See
Gastro
esophageal
reflux
See
Diabetes
Version1 (2014)
Child with abdominal pain
Any history of significant trauma?
Yes
See criteria for Early Notification of
Trauma for Interfacility Transfer
Yes
Consult MO
Yes
Consider UTI
See Urinary tract infection - child
Yes
Consider pneumonia
See Pneumonia - child
Yes
Consider gastroenteritis
See Child with vomiting / fever/ chronic
diarrhoea
Yes
Consider constipation
See Constipation
No
Bile stained vomiting?
Bloody stool?
Localised tenderness?
Distension?
Guarding?
Rebound tenderness?
Palpable mass?
Inguinal-scrotal pain or swelling?
No
Positive urine dipstick for leukocytes,
nitrates or blood;
or bacteria on microscopy
No
Fever +/Tachypnoea
Recession
Cough
Chest pains
No
Diarrhoea +/- vomiting / fever
No
Firm stool palpable in lower abdomen?
No
Consult MO
PD3512 Paediatric Presentations
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Child with chronic diarrhoea
Diarrhoea every day for at least 10 days or recurrent episodes of loose stools over longer periods
requires investigation. Chronic diarrhoea could be caused by:
•
•
•
•
parasites (strongyloides, cryptosporidium, giardiasis),
malabsorption (lactose intolerance, coeliac disease),
inflammatory conditions (crohns disease, ulcerative colitis),
other infections e.g. Urinary Tract Infection, pneumonia
For babies less than 3 months of age contact the Medical Officer immediately
Clinical assessment performed
Significant features of assessment
unclear or you are unsure of cause
Yes
Consult MO
Yes
Treat if possible for
giardia or intestinal
worms. Consult MO
if other +ve result
Yes
See Lactose
Intolerance
No
Well hydrated, normal growth and
development, adequate diet
Obtain faeces sample for MC/S and
OCP
Is test positive?
No
Test for lactose intolerance
See Lactose intolerance
Is test positive?
No
Consider significant features
of assessment
Perianal itch
Sighting of worms in faeces
See Intestinal worms
PD3512 Paediatric Presentations
Foul smelling watery diarrhoea
Flatulence
Nausea
See Giardiasis
11
Bloody diarrhoea
Mucus in diarrhoea
Abdominal pain
Consult MO
Version1 (2014)
Meningitis
Bacterial Meningitis is a very serious condition with a mortality rate is around 5% to 10%.
Most children will make a full recovery, if appropriately treated.
Deafness is the most common long term complication.
Consult Medical Officer immediately if:
•
•
•
a sick looking child has no obvious source of infection, which would explain their symptoms - the
diagnosis is meningitis until proven otherwise
the child has been treated with antibiotics but is still not well (they may have partly treated
meningitis with masking of signs)
the child is unwell with prolonged Upper Respiratory Tract Infection symptoms
Restrict fluids to 50% of maintenance (10mg / kg) unless there are signs of shock - Medical Officer
needs to discuss as soon as possible with a Paediatrician.
Parents or carers may notice early, subtle changes in the child’s conscious state.
Their concerns should not be ignored.
Perform hearing test 3 months after discharge from hospital.
Respiratory problems
The vast majority of Upper Respiratory Tract Infections (URTI) are caused by viruses and do not
require antibiotics.
However a viral URTI can be complicated by secondary bacterial infection such as otitis media or
pneumonia, requiring antibiotics.
Other complications include exacerbation of asthma
The symptoms and signs of an upper respiratory tract infection (URTI) may be a precursor to
more serious illnesses such as meningitis
•
Clinicians must always be alert to the relationship between group A streptococcal sore throat and Acute
Rheumatic Fever or Acute Post Streptococcal Glomerulo Nephritis.
These complications are common and serious but potentially avoidable in Aboriginal and Torres Strait
Islander children.
PD3512 Paediatric Presentations
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Pertussis (whooping cough) is still common. It has an incubation period is on average 7 - 10 days.
Pertussis is a prolonged illness and can be complicated by apnoea in infants, pneumonia, hypoxic
brain injury, seizures or lead to chronic lung disease.
If adults and teenagers present with pertussis ask about young babies at home as pertussis is a
particularly severe disease in infants < 12 months of age.
It is important to explain that coughing may continue for 6 - 8 weeks after treatment and may recur with
the next URTI. The recurrence will not last long.
Croup usually follows 3 or 4 days of a mild URTI when the infection spreads to affect the upper airways;
it is usually mild and self limiting.
Epiglottitis (cellulitis of the epiglottis) is caused by Haemophilus influenza type B infection and is fatal if
untreated. It is rare since Hib vaccination was introduced.
Bronchiolitis is a viral infection of the chest affecting infants <12 months of age.
A child with bronchiolitis, is generally distressed without looking sick or toxic.
It can occur throughout the year in north Queensland (in southern Australia more common in winter spring).
The disease is more significant in babies < 4 months of age and those with underlying heart or lung
problems.
Pneumonia is a common complication of other URTIs, in particular bronchiolitis and chronic lung
disease e.g. related to prematurity.
A Medical Officer should be consulted immediately if a child presents with severe illness or is less than
3 months old.
Immune Complications
APSGN is common among Aboriginal and Torres Strait Islander children in northern Australia.
It is an inflammation of the kidneys as a result of immune complexes forming after a group A streptococcal
infection.
It causes blood to not filter properly and blood cells and protein leaking into urine.
It may also cause kidney damage which may lead to kidney failure in later life.
Early treatment of skin infections is essential for prevention of acute post-streptococcal glomerulonephritis
(APSGN)
PD3512 Paediatric Presentations
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ARF is an auto-immune response to bacterial infection with group A Streptococcus (GAS) in the throat
(and possibly the skin);
•
It affects the heart, joints, nervous system and skin
Aboriginal and Torres Strait Islander Australians living in rural or remote settings are known to be at
high risk.
Those living in urban settings, Maori and Pacific Islander people and, potentially immigrants from
developing countries also may be at high risk.
Acute Rheumatic Fever (ARF) is predominantly a disease of children aged between 5 and 14 years.
However, recurrent episodes may continue well into the fourth decade of life.
Patients with recurring ARF have a higher risk of developing Rheumatic Heart Disease.
RHD is a chronic condition resulting from scarring and deformity of the heart valves following ARF.
It is important to treat streptococcal throat and skin infections early In Aboriginal and Torres Strait
Islander communities.
Where there are high rates of acute rheumatic fever (ARF) and rheumatic heart disease (RHD).
Any case of arthritis with fever in a child should be considered as possible ARF or septic arthritis and
transferred to hospital for investigation and confirmation of diagnosis.
Regular penicillin prophylaxis is critical to prevent recurrences of ARF, which can lead to the
development or worsening of RHD.
PD3512 Paediatric Presentations
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PD3512-1 Learning Activity
1.
Which of the following presentations require immediate referral to a medical officer?
Correct
Choice
Temperature of 37.5C in a 12 month old baby
Fever in a baby less than 3 months old
Child with fever but no obvious source of infection
Child with migratory polyarthritis
Unwell child with prolonged upper respiratory tract infection
PD3512 Paediatric Presentations
15
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PD3512-2 Paediatric Presentations - Part 2
Learning Objectives
•
•
•
•
•
•
•
On completion of this module learners will be able to use the PCCM to guide
Ear assessments
Management of ear infections
Management of gastrointestinal problems
Management of urinary tract problems
Management of problems of the bones and joints
Assessment and management of suspected child abuse and neglect
Ear Assessment
•
•
•
•
•
•
•
•
•
•
•
Language and speech develop in the 0 - 5 year age group.
Assessment for possible middle ear disease, hearing impairment and speech and language
problems should be a routine part of the primary care of children aged 0 - 5 years
The PCCM provides concise information on assessment of the ear which includes
A complete patient history
Examination which incorporates the
Outer ear
Ear canal
Tympanic membrane (ear drum)
Assessing related systems including
Nose and throat
Chest
Ear Problems
The prevention of otitis media is important to reduce the incidence of hearing loss. Strategies for prevention include:
•
•
•
•
Encouraging family or care giver to present child for treatment early if there are features of otitis
media.
Informing family of risk if child is in a high risk group (includes Aboriginal and Torres Strait
Islander children)
- informing family and carers that onset of otitis media can occur within the first months of life.
Baby may have pain, irritability, fever or ear discharge
- there is an increased risk of acute otitis media during respiratory infections
- the family or care giver should be advised that ear pain may be absent and that
regular clinic attendance for ear examinations is recommended
personal hygiene - children’s hands and faces should be washed.
PD3512 Paediatric Presentations
16
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•
•
•
•
•
Transmission of bacteria causing otitis media is often from other children’s hands
breastfeeding for at least three months reduces the risk of otitis media and should be
encouraged
cigarette smoke exposure is a risk for otitis media in children. Adults should be encouraged to
quit smoking or smoke outside away from children
swimming should not be discouraged unless it is known to be associated with new infections in
that person
full immunisation; 23 valent pneumococcal vaccine (Pneumovax 23®) for children 4 - 5 years of
age who are at risk of pneumococcal infections
The most common infection of the ear is Otitis Media, which is a major cause of hearing impairment
in children.
The PCCM provides information on diagnosis, treatment and follow up care for children presenting with
Otitis Media including:
•
•
•
•
•
Acute otitis media (AOM)
- Presence of fluid behind the ear drum plus at least one of the following:
- Bulging ear drum, red ear drum, recent discharge of pus, fever, ear pain or irritability
Recurrent acute otitis media (rAOM)
- The occurrence of three or more episodes of acute otitis media in a six month period
Otitis media with effusion (OME, glue ear)
- Presence of fluid behind the ear drum without any symptoms or signs of acute otitis media
Acute otitis media with acute perforation (AOM with perforation less than 6 weeks)
- Discharge of pus through a perforation (hole) in the ear drum within the last six weeks
Chronic suppurative otitis media (CSOM discharging more than 6 weeks)
- Persistent discharge of pus through a perforation (hole) in the ear drum for at least six weeks
despite appropriate treatment for acute otitis media with perforation
Other potential problems of the ear covered in the PCCM include:
•
•
•
•
•
•
Ear discharge in the presence of grommets
Cholesteatoma – an abnormal skin growth in the middle ear
- Result of repeated infections
- Treated surgically
Mastoiditis – inflammation in the mastoid air cells
- Occurs after acute otitis media
- Requires urgent referral
Otitis Externa – swimmers ear or tropical ear
Traumatic rupture of the ear drum
- Usually the result of sudden increased pressure including
A blow to the hear or an explosion
Could also be caused by a penetrating injury or water forced into the ear
Foreign body – important to remove it safely without causing injury.
PD3512 Paediatric Presentations
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Gastrointestinal problems
If a child is less than 3 months or is very sick (see rapid assessment) the Medical Officer needs to be
contacted immediately following:
Other high risk children include those with:
•
•
•
excessive diarrhoea (> 8 watery stools in 24 hours)
congenital or chronic disease e.g. cardiac, gastrointestinal or neurological
concerning social conditions are concerning and or where the parents may have difficulty
managing at home
Other infections should always be considered as any infection can cause diarrhoea or vomiting.
It is important to accurately assess and treat potential dehydration in children.
The PCCM provides an flow chart on the management of a child assessed as being dehydrated.
Lactose intolerance is a common complication of acute diarrhoea and may cause chronic diarrhoea.
Other gastrointestinal problems covered in the PCCM include:
•
•
•
Giardiasis which is a type of gastroenteritis (gastro) caused by a tiny parasite, Giardia lambia
which lives in the bowel.
- Treated with antibiotic therapy – usually Tinidazole or Metronidazole
Intestinal worms which may include
- Thread worm which causes a perianal and or perineal itch
- Hookworm which can lead to anaemia if left untreated
- Strongyloides which can cause acute diarrhoea and subsequent dehydration and failure to
thrive
Treated using de-worming medicines
Children presenting with severe abdominal pain may be suffering from:
Constipation is the difficult passage of infrequent dry, hard stools that often cause pain and discomfort.
The most common cause is functional with no underlying cause
Constipation starts a vicious cycle - passing hard stool is painful, so the child avoids straining at
stool, the constipation gets worse and so on.
Part of the battle is forming a habit for the child to go to the toilet each day
Maintenance programs consisting of medication, toileting program, dietary advice and follow up
to prevent recurrence
Pyloric Stenosis – the narrowing of the duodenum as a result of enlargement of the pylorus muscle
Most common in babies between 2 and 6 weeks of age. Rarely occurs after 12 weeks of age
Baby may require rehydration – the Medical Officer needs to be consulted immediately
•
•
•
•
•
•
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Intussusception - The telescoping of the small bowel telescopes into itself
Suspect in a young child who looks unwell and has intermittent severe abdominal pain
In 15 % of cases the classic triad of abdominal pain, palpable sausage shaped abdominal
masses and red currant jelly stool is present.
Most common cause of obstruction in children 6 - 36 months of age (60% <12 months of age)
•
•
•
Nutrient requirements are very high in young children, especially for iron between the ages of 6 months
and 24 months.
Two common conditions associated with poor nutrition include:
•
•
Failure to Thrive (FTT) - a child whose weight is less than the normal for children on the same
age and gender
Anaemia- low iron levels which impacts on development
Both conditions require intervention.
Failure to Thrive (FTT)
•
•
•
•
•
•
Refers to child whose weight is less than normal for gestational corrected age and or gender and
past medical history.
Children with genetic short stature, intrauterine growth retardation or prematurity, who have
appropriate proportional weight for length and normal growth velocity, are not regarded as FTT.
It is important in an underweight child to differentiate wasting (thin child) of acute failure to thrive
from stunting (short child) due to chronic failure to thrive.
Often both are present, and can be assessed on anthropometric measurements of weight and
height for age and sex.
A Medical Officer or Dietitian needs to perform complete examination and calculate the degree
of failure to thrive - mild, moderate or severe
Management is dependent on severity, with nutritional supplements and close monitoring an
effective strategy
Anaemia
Anaemia refers to low iron levels or iron deficiency in children and infants.
•
•
•
•
It is common in Aboriginal and Torres Strait Islander children particularly in the 6 to 30 months
age group.
Childhood anaemia is more likely if mother had low iron status or was anaemic in pregnancy and
or if baby was premature or low birth weight.
Anaemia is largely due to dietary deficiency in iron and or folate and the inhibitory effects of
infestations and infections.
There are higher rates of iron deficiency and anaemia in infants and toddlers where high cows’
PD3512 Paediatric Presentations
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milk intake is encouraged or allowed
Failure to thrive, overweight and obesity may or may not co-exist with anaemia
Iron deficiency of any degree affects child development
The aim to achieve haemoglobin level above 110 g / L
Iron supplements is the most effective treatment for anaemia and is required for
- babies aged 6 -12 months with haemoglobin < 105 g / L
- children over 1 year of age with haemoglobin < 110 g / L
A Medical Officer should be consulted immediately
- if any child has haemoglobin < 80 g / L
A child should be referred to the next Medical Officer clinic
- if their haemoglobin 80 -100 g / L
•
•
•
•
•
•
Urinary tract infection
Children with a urinary tract infection (UTI) may present with a range of symptoms including:
•
•
•
•
•
Fever; Irritability; Malaise
Vomiting; Diarrhoea; Poor feeding; Failure to thrive
Abdominal pain; Loin tenderness
Jaundice; Haematuria; Urine that is offensive smelling and cloudy
Increased urinary frequency; Dysuria; Changes to continence patterns
Some children with UTI may look quite well while others may appear very unwell.
Children with UTI commonly have acute pyelonephritis and particularly in infants, it is difficult to
distinguish between cystitis and pyelonephritis.
Finding a UTI in a sick child does not rule out other sources of infection so a complete assessment is
required.
Definitive diagnosis of urinary tract infection (UTI) by urine culture collected in a sterile fashion - mid
stream urine (clean catch), supra pubic aspiration, catheter specimen.
Collection of urine in a paediatric bag can only be used for urine dipstick testing. It has poor sensitivity
and specificity.
Some children require further imaging of renal tract depending on age.
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Bone and Joint
The most common causes of bone and joint problems in children are:
•
•
Osteomyelitis – infection of the bone by a variety of bacteria types and sources
Septic arthritis – infection of one or more joints by microorganisms
Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly involve the lower
limbs.
Referral to Orthopaedic Specialist if suspected osteomyelitis / septic arthritis.
Acute Rheumatic fever must be considered:
•
•
If a child presents with painful tender swollen joints which progress from one joint to another
(migratory polyarthritis)
One swollen or painful joint (aseptic monoarthritis) – may also be indicative of ARF.
Abuse and Neglect
When considering if there is a reasonable suspicion of abuse or neglect, it is important to identify
significant harm or risk of significant harm and how that is linked to actions or inactions of the parent.
Queensland Health policy deems that all health professionals have a duty of care to report reasonable
suspicion of child abuse and neglect to the Department of Communities - Child Safety Services.
Queensland legislation stipulates that all MO and RN (both public and private sector).
Are mandated to report concerns, regarding children about whom they hold a reasonable suspicion of
significant harm or risk of significant harm.
Under this legislation staff do not breach professional ethics and are not liable under civil or criminal
processes if the report is made in good faith and on reasonable grounds.
Relevant provision is made under legislation for information sharing to prevent serious risk to life,
health or safety.
Children should not be asked leading questions, but if the child volunteers information it needs to be
documented accurately and concisely.
In some circumstances e.g. child sexual assault (CSA), examination is best done once.
The best person to perform examination following CSA is usually a Paediatrician, a Medical Officer
specialising in child sexual abuse or a Forensic Medical Officer.
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Assessment of CSA is complex and requires multi-agency investigation. This includes consulting a
Child Protection Advisor (CPA).
Tests for sexually transmitted infections should not be done in an asymptomatic child.
The initial response to a suspicion of sexual abuse is reporting only.
There is no screening test for child abuse - informed vigilance is required.
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PD3512-2 Learning Activity
1.
Match the symptom with its most likely cause
No.
Symptom
1
Fluid behind ear, fever, ear pain, red and
bulging drum
Otitis Media with Effusion
2
Recurrence of three or more episodes of
acute otitis media
Acute Otitis Media with Acute
Perforation
3
Presence of fluid behind the ear drum
without signs of acute otitis media
Acute Otitis Media
4
Discharge of pus through a perforation in the
ear drum
Chronic Suppurative Otitis Media
5
Persistent discharge of pus through a
perforation in the ear drum
Recurrent Otitis Media
PD3512 Paediatric Presentations
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Problem
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PD3512 Theory to Practice Activity
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
You are working at a small remote area primary health care centre. Bonita enters the clinic and says
she has brought in her 3 year old son (Aboriginal), Bobby to get checked. Bobby is walking beside
Bonita and looks a bit unhappy. Bonita states “Bobby woke up from his afternoon nap crying with a
sore ear”.
Presenting Concerns
Bobby’s left ear started hurting this morning. Bobby was crying so he was given some Panadol which
helped a bit. There is no radiation, no pain anywhere else. Bobby has had a sore ear once before over
a year ago, he was given antibiotics. He has had no recent URTI, no nausea or vomiting but he has
had a fever which was first noticed this morning. Bobby has not had dyspnoea, diarrhoea, weight loss
or rash.
He is usually bright and chirpy, but has been miserable and whiny but still alert. Bobby is drinking
normally – has finished his drink bottle full of water today (500mL) plus had some juice (1 cup). He ate
breakfast, but only a little bit of lunch. Bobby has been passing urine normally – at least three times
today.
The only treatment mum has instigated is paracetamol at 10am which helped a bit with the pain.
1.
What immediate management is required?
Answer
2.
What clinical assessment needs to be conducted?
Answer
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Past Medical and Surgical History
Bobby was born 37 weeks gestation. His birth weight was 3085g, he was breast fed, and had no
neonatal concerns or concerns with growth and development. Bonita smoked but had no alcohol during
pregnancy.
Bobby had impetigo at 6 months of age which was treated with antibiotics. He also had Otitis Media at
18 months of age which was treated with Amoxyl. He had no hospital admissions or surgery.
Family and Social History
Bobby lives with his mother and 14 month old sister (who is well) and grandmother. His mother does
not drink, but does smoke tobacco (not in house). There are no health problems in family. His mother
does not work and his father left and lives in another community.
Medications
Bobby had a dose of Panadol at 10am. He is not on any regular medications. He completed the course
of antibiotics when treated previously for otitis media.
Allergies
Nil known
Immunisation Status
Up to date (documented evidence in clinic record)
Physical Examination
Standard observations
Temp. 38pa; Heart Rate 110bpm; Respiratory Rate 22pm; Weight 13.6kg; Hb: taken one month ago:
119g/L.
General Appearance
Bobby is well nourished, alert, looks well. He is wearing clean clothes. He has normal muscle tone. His
lips, tongue, finger and conjunctiva are normal colour. There is no increased work of breathing or use
of accessory muscles. Bobby is well nourished and is quietly sitting on mums lap, crying intermittently,
he has tears present, a clear runny nose evident and is consoled easily. He has no neck stiffness.
Hydration status
Bobby has had no recent weight loss. His eyes are normal; his mouth and tongue are moist and skin
turgor is normal.
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Skin
He has no rashes, bruises, petechiae, purpura, unexplained or unusual marks. Colour is normal.
There is no redness, swelling, tenderness. He has palpable cervical lymph nodes on the left side.
Growth
Bobby’s weight is 13.6kg (gain of 200g in last month) (just above 25th percentile), his height is 95 cm
(just below 50th percentile) (normal growth).
ENT
•
•
•
Nose – small clear rhinorrhoea
Throat – tonsils NAD, no redness, mouth looks normal, teeth good condition
Ears – right no abnormalities detected
- Left – pinna NAD, nil obvious swelling/redness/debri of ear canal. He has a bulging red, dull,
tympanic membrane, no bubbles or air seen, nil discharge. Mastoid area no abnormalities
detected.
- Bobby has not been swimming and is not under the care of an ENT physician. Mum says his
speech has been normal, he seems to be hearing normally but has not had hearing tested.
His ear is not itchy
Respiratory
Bobby has equal air entry, no crackles or wheezes or extra noises. His 02 sat is 98%.
Other systems
No abnormalities detected.
3.
What action would you now take?
Answer
PD3512 Paediatric Presentations
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4.
What steps will you now take (within your scope of practice) to ensure Bobby has safely
administered and appropriate medication.
Answer
PD3512 Paediatric Presentations
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Schedule
2
Paracetamol
DTP / IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic may proceed
Form
Strength
Route of administration Recommended doasage
Tablet
500 mg
Suspension
120 mg / 5 mL
(24 mg / mL)
or
Oral
100 mg / mL
drops
Suppository
125 mg
250 mg
500 mg
Duration
Adults & children >12 yrs
1-2 tabs every 4 hours to Stat
max. 8 tabs / day
Further
doses on
Children 7-12 yrs
MO / NP
1/2 - 1 tab every 4 hours
orders
to a max. 4 times / day
Stat
Child
Further
15 mg / kg / dose
doses on
every 4 hours if necessary
MO / NP
to a max. of 4 times / day
orders
Adults & children >12 yrs
500 - 1000 mg
Oral
Children 7-12 yrs
250 - 500 mg
Rectal
Stat
Child < 7 yrs
15 mg / kg / dose
Provide Consumer Medicine Information: not for administration to children under 1 month
Management of associated emergency: consult MO
[1] [2]
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Schedule
4
Amoxycillin
DTP / IHW / SM R&IP / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural and Isolated Practice Registered Nurses may proceed
Form
Capsule
Suspension
Strength
Route of administration Recommended doasage
250 mg
500 mg
125 mg / 5mL
250 mg / 5mL
Duration
Adult and child
25 mg / kg dose BD to a
max. of 1 g BD
Oral
7 Days
Provide Consumer Medicine Information:
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
[4] [6]
If Mum or the Health Care Worker thinks it will be difficult to comply with oral antibiotics or if Bobby has
significant diarrhoea or vomiting, he will need to be treated with IM procaine penicillin with the option to
return to oral antibiotic once vomiting settles.
Schedule
4
Procaine penicillin
DTP / IHW / IPAP
Authorised Indigenous Health Workers and Isolated Practice Area Paramedic must consult MO / NP
Scheduled Medicines Rural and Isolated Practice Registered Nurses may proceed
Form
Disposable
Syringe
Strength
1.5g
Route of administration Recommended doasage
Duration
Adult
1.5g daily
Child
5 Days
50 mg / kg / dose daily to a
max. of 1.5 g daily
IM
Provide Consumer Medicine Information:
Management of associated emergency: as for severe allergic reactions. See Anaphylaxis
Administration tips - as per patient preference:
- apply EMLA cream to the injection site 30-60 minutes prior to injection and allow medication to warm
up to room temperature or
- allow medication to warm up to room temperature, apply pressure with thumb (to the exact injection
site) 30 seconds prior to the injection, use 21 gauge needle and deliver injection very slowly (2 mins)
[3] [4]
PD3512 Paediatric Presentations
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5.
What follow up and referral will Bobby need?
Answer
Please note: this case scenario has been adapted from the Cunningham Centre’s Rural and Isolated
Practice Nurse Endorsement Education Program.
PD3512 Paediatric Presentations
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PD3512 Quiz
1.
Tick
The best treatment for an upper respiratory tract infection is a course of antibiotics
Choice
True
False
2.
Match the respiratory problem with its correct statement
No.
Symptom
1
Stridor which usually follows a mild URTI
Pneumonia
2
Caused by Haemophilus Influenza type B
Croup
3
Viral infection of the chest in infants < 12
months old
Epiglottitis
4
Prolonged illness with persistent barking
cough
Bronchiolitis
5
Common complication of bronchiolitis
Pertussis
PD3512 Paediatric Presentations
No.
31
Problem
Version1 (2014)
3.
Tick
Which of the following illnesses may lead to kidney failure?
Choice
Urinary tract infection
Pyloric stenosis
Acute post-streptococcal glomerulonephritis
Acute rheumatic fever
Intussusception
4.
Tick
Which of the following are strategies that could be used to reduce the incidence of otitis media?
Choice
Encouraging personal hygiene
Cigarette smoking
Breastfeeding
Presenting for treatment early
Avoid swimming
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5.
Which of the following assessments should be conducted on a child who presents with a low
grade fever, runny nose and cough?
No.
Symptom
1
Chronic diarrhoea following acute
gastroenteritis
Strongyloides
2
Gastroenteritis caused by a parasite
Lactose intolerance
3
Intestinal worm which may lead to
anaemia
Giardiasis
4
Narrowing of the duodenum
Hookworm
5
Intestinal worm which causes acute
diarrhoea
Pyloric stenosis
6.
Tick
No.
Problem
Overweight and obesity may co-exist with anaemia
Choice
True
Email
PD3512 Paediatric Presentations
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PD3512-1 Learning Activity Feedback
1.
Which of the following presentations require immediate referral to a medical officer?
Correct
Choice
Temperature of 37.5 in a 12 month old baby
✔
✔
✔
✔
Fever in a baby less than 3 months old
Child with fever but no obvious source of infection
Child with migratory polyarthritis
Unwell child with prolonged upper respiratory tract infection
PD3512-2 Learning Activity Feedback
2.
Match the symptom with its most likely cause
No.
Symptom
No.
Problem
1
Fluid behind ear, fever, ear pain, red
and bulging drum
2
Chronic Suppurative Otitis Media
2
Recurrence of three or more episodes
of acute otitis media
3
Acute Otitis Media
3
Presence of fluid behind the ear drum
without signs of acute otitis media
4
Recurrent Otitis Media
4
Discharge of pus through a perforation
in the ear drum
5
Otitis Media with Effusion
5
Persistent discharge of pus through a
perforation in the ear drum
1
Acute Otitis Media with Acute
Perforation
PD3512 Paediatric Presentations
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Version1 (2014)
PD3512 Theory to Practice Activity Feedback
Please read the scenario and complete the questions. You will need access to a copy of the PCCM to
complete this activity.
You are working at a small remote area primary health care centre. Bonita enters the clinic and says
she has brought in her 3 year old son (Aboriginal), Bobby to get checked. Bobby is walking beside
Bonita and looks a bit unhappy. Bonita states “Bobby woke up from his afternoon nap crying with a
sore ear”.
Presenting Concerns
Bobby’s left ear started hurting this morning. Bobby was crying so he was given some Panadol which
helped a bit. There is no radiation, no pain anywhere else. Bobby has had a sore ear once before over
a year ago, he was given antibiotics. He has had no recent URTI, no nausea or vomiting but he has
had a fever which was first noticed this morning. Bobby has not had dyspnoea, diarrhoea, weight loss
or rash.
He is usually bright and chirpy, but has been miserable and whiny but still alert. Bobby is drinking
normally – has finished his drink bottle full of water today (500mL) plus had some juice (1 cup). He ate
breakfast, but only a little bit of lunch. Bobby has been passing urine normally – at least three times
today.
The only treatment mum has instigated is paracetamol at 10am which helped a bit with the pain.
1.
What immediate management is required?
Answer
Nil
2.
What clinical assessment needs to be conducted?
Answer
Conduct a full history and examination, starting with the ears, nose and throat.
Take a full set of observations
PD3512 Paediatric Presentations
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Past Medical and Surgical History
Bobby was born 37 weeks gestation. His birth weight was 3085g, he was breast fed, and had no
neonatal concerns or concerns with growth and development. Bonita smoked but had no alcohol during
pregnancy.
Bobby had impetigo at 6 months of age which was treated with antibiotics. He also had Otitis Media at
18 months of age which was treated with Amoxyl. He had no hospital admissions or surgery.
Family and Social History
Bobby lives with his mother and 14 month old sister (who is well) and grandmother. His mother does
not drink, but does smoke tobacco (not in house). There are no health problems in family. His mother
does not work and his father left and lives in another community.
Medications
Bobby had a dose of Panadol at 10am. He is not on any regular medications. He completed the course
of antibiotics when treated previously for otitis media.
Allergies
Nil known
Immunisation Status
Up to date (documented evidence in clinic record)
Physical Examination
Standard observations
Temp. 38pa; Heart Rate 110bpm; Respiratory Rate 22pm; Weight 13.6kg; Hb: taken one month ago:
119g/L.
General Appearance
Bobby is well nourished, alert, looks well. He is wearing clean clothes. He has normal muscle tone. His
lips, tongue, finger and conjunctiva are normal colour. There is no increased work of breathing or use
of accessory muscles. Bobby is well nourished and is quietly sitting on mums lap, crying intermittently,
he has tears present, a clear runny nose evident and is consoled easily. He has no neck stiffness.
Hydration status
Bobby has had no recent weight loss. His eyes are normal; his mouth and tongue are moist and skin
turgor is normal.
PD3512 Paediatric Presentations
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Skin
He has no rashes, bruises, petechiae, purpura, unexplained or unusual marks. Colour is normal.
There is no redness, swelling, tenderness. He has palpable cervical lymph nodes on the left side.
Growth
Bobby’s weight is 13.6kg (gain of 200g in last month) (just above 25th percentile), his height is 95 cm
(just below 50th percentile) (normal growth).
ENT
•
•
•
Nose – small clear rhinorrhoea
Throat – tonsils NAD, no redness, mouth looks normal, teeth good condition
Ears – right no abnormalities detected
- Left – pinna NAD, nil obvious swelling/redness/debri of ear canal. He has a bulging red, dull,
tympanic membrane, no bubbles or air seen, nil discharge. Mastoid area no abnormalities
detected.
- Bobby has not been swimming and is not under the care of an ENT physician. Mum says his
speech has been normal, he seems to be hearing normally but has not had hearing tested.
His ear is not itchy
Respiratory
Bobby has equal air entry, no crackles or wheezes or extra noises. His 02 sat is 98%.
Other systems
No abnormalities detected.
3.
What action would you now take?
Answer
•
•
•
•
•
Bobby clearly has a left sided acute Otitis Media with an intact tympanic membrane
He will require antibiotic treatment and simple analgesia
Talk to Mum about the need to complete the full course of antibiotics and to return at 4 - 7 days
for the ear to be checked
Give or help to give the first dose in the clinic and ensure Mum knows the right dose to give.
If family do not have a fridge at home they may have to return to the health service for
medicine each day
PD3512 Paediatric Presentations
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4.
What steps will you now take (within your scope of practice) to ensure Bobby has safely
administered and appropriate medication.
Answer
The answer to this question depends on your scope of practice and the Health Management protocols you work under. The list below provides brief information.
Paracetamol can be given by Authorised Indigenous Health Workers (IHW) and Isolated Practice
Area Paramedics (IPAP)
Antibiotics
IHW and IPAP must consult the Medical Officer (MO) or Nurse Practitioner (NP)
Non-endorsed Registered Nurses must consult the MO or NP
Scheduled Medicines Rural and Isolated Practice Registered Nurse (SM R&IP) may proceed.
See tables over page for more information.
•
•
•
•
5.
What follow up and referral will Bobby need?
Answer
•
•
•
•
•
•
•
•
•
•
Review Bobby in 4 - 7 days
If not improving consult Medical Officer who may consider alternative or increased dose of
antibiotics
Bobby should be seen at the next MO visit.
If Bobby has not improved he needs weekly review. Bobby may need many weeks of antibiotics
Review after completion of treatment at the 1 week mark
If there are concerns about behaviour, speech or hearing following this infection, refer for
formal hearing assessment.
To prevent recurrent otitis media and transmission of bacteria to other children encourage
personal hygiene in Bobby - washing hands and face
Review at 3 months to ensure he has not developed chronic disease
If otitis media is recurrent (more than 3 episodes in 6 months or more than 4 in 12 months) the
MO may consider antibiotics for prophylaxis
Bobby should be referred to an ENT specialist if he suffers frequent painful AOM
Please note: this case scenario has been adapted from the Cunningham Centre’s Rural and Isolated
Practice Nurse Endorsement Education Program.
PD3512 Paediatric Presentations
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PD3512 Quiz Feedback
1.
Tick
The best treatment for an upper respiratory tract infection is a course of antibiotics
Choice
True
✔
2.
False
Match the respiratory problem with its correct statement
No.
Symptom
No.
Problem
1
Stridor which usually follows a mild URTI
2
Pneumonia
2
Caused by Haemophilus Influenza type B
3
Croup
3
Viral infection of the chest in infants < 12
months old
4
Epiglottitis
4
Prolonged illness with persistent barking
cough
5
Bronchiolitis
5
Common complication of bronchiolitis
1
Pertussis
PD3512 Paediatric Presentations
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3.
Tick
Which of the following illnesses may lead to kidney failure?
Choice
Urinary tract infection
Pyloric stenosis
✔
Acute post-streptococcal glomerulonephritis
Acute rheumatic fever
Intussusception
4.
Tick
✔
Which of the following are strategies that could be used to reduce the incidence of otitis media?
Choice
Encouraging personal hygiene
Cigarette smoking
✔
✔
Breastfeeding
Presenting for treatment early
Avoid swimming
PD3512 Paediatric Presentations
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5.
Which of the following assessments should be conducted on a child who presents with a low
grade fever, runny nose and cough?
No.
Symptom
No.
Problem
1
Chronic diarrhoea following acute
gastroenteritis
2
Strongyloides
2
Gastroenteritis caused by a parasite
3
Lactose intolerance
3
Intestinal worm which may lead to
anaemia
4
Giardiasis
4
Narrowing of the duodenum
5
Hookworm
5
Intestinal worm which causes acute
diarrhoea
1
Pyloric stenosis
6.
Tick
✔
Overweight and obesity may co-exist with anaemia
Choice
True
Email
PD3512 Paediatric Presentations
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