The United Republic of Tanzania Ministry of Health and Social Welfare Management of Sexually Transmitted and Reproductive Tract Infections Job Aids for Health Workers in Primary Health Care Facilities March 2009
History taking on an STI/RTI Client Create good rapport with your client Present illness Past medical history Social and sexual history Welcome and greet your client. Encourage your client to talk. Look at your client. Listen to your client. What is your main complaint? When did it start? Is there any change over time? Have you received any medication for the present illness? If so which? Did you have same symptoms before? Did you get any treatment? Do you have any other illness apart from this complaint? Are you on any medication now? Do you have any allergy for medicine? When did you have last sexual intercourse? Did you use a condom? Did your partner have any STI symptoms at that time? How many sexual partners did you have in the last three months? Do you take alcohol? Do you take drugs and/or any other substance? History Taking on an STI/RTI Client Female client When was your last normal menstrual period? How many children do you have? How old is the last born? Do you use any contraceptive? Which method? Have you had any abortions or stillbirths? 1
Physical Examination on a Male Client Prepare and set equipment and materials for examination: Examination coach, screen/curtain, good source of light, gloves, cotton wool, gauze, blood pressure machine, thermometer, stethoscope, soap, water, dustbin, three buckets, and hypochlorite solution Examine client by observing principles of inspection, palpation, percussion and auscultation. Steps for physical examination in a male client Introduction 1. Get consent from the client. 2. Wash your hands. 3. Tell the client what you are going to do at each step of the examination. 4. Ask the client to remove his shirt. Physical Examination on a Male Client Note: Put on gloves if the client has sores on the skin or if you (service provider) have sores on your hands! 2
General examination Genital examination 1. Inspect the head, skin and mouth for lesions. 2. Palpate for lymph nodes on the neck, axilla and elbows. 3. Cover the upper part or ask the client to put on his shirt (Not to expose the whole body). 4. Check for vital signs: blood pressure, pulse rate, respiration rate, and body temperature. 1. Ask the client to stand up or lie down and lower his underpants to the knees. 2. Inspect for rashes, swellings, discharge and ulcers on the thighs, buttocks and groins. 3. If the client is not circumcised tell him to pull back the foreskin. 4. If there is no obvious discharge tell the client to milk the urethra. 5. Put on clean gloves. 6. Examine the perineum and anus for abnormal discharge, ulcers, swellings or any other abnormalities e.g. gapping of the anus. 7. Palpate the inguinal region (groin) looking for enlarged lymph nodes. 8. Examine the glans penis, coronal sulcus, frenum for any abnormality. 9. Palpate the scrotum, feeling for the testis, epididymis, and spermatic cord on each side. 10. Remove the gloves and wash your hands. 11. Record findings and share them with the client. 3
Signs to Look for When Examining a Male Client Signs to look for Urethral discharge Ulcers, sores or blisters Painful swelling or lumps in the groin (inguinal lymphadenopathy) Painful swelling of testicles Follow flowchart for Urethral Discharge Syndrome Genital Ulcer Syndrome Inguinal Bubo Syndrome Painful Scrotal Swelling Syndrome (Epididymorchitis) Testicular tortion (Refer the client to the surgical clinic) Genital warts Anal sores, discharge, blisters or swelling around the anus Follow the instruction on page 91 of the national guideline for Management of STI s and RTI (Edition 2007). Consult surgical clinic. Gapping of the anus 4
Physical Examination on a Female Client Prepare and set equipment and materials for examination: Examination coach, screen/curtain, good source of light, gloves, cotton wool, gauze, blood pressure machine, thermometer, stethoscope, soap, water, dustbin, three buckets, hypochlorite solution and speculum Examine client by observing principles of inspection, palpation, percussion and auscultation. Steps for physical examination in a female client Introduction 1. Get consent from the client. 2. Wash your hands. 3. Tell the client what you are going to do at each step of the examination. Physical Examination on a Female Client Note: Put on gloves if the client has sores on the skin or if you (service provider) have sores on your hands! 5
General examination 1. Inspect the head, skin and mouth for any lesions. 2. Palpate for lymph nodes around the neck, axilla and elbows. 3. Check for vital signs: blood pressure, pulse rate, respiration rate, and body temperature. 4. Ask the client to remove her clothing from the chest down. 5. Always cover the parts of the body that are not being examined (only expose an area which you are examining). 6. Inspect for any rashes, swellings and ulcers at the chest and back. Abnominal examination 1. Inspect the movement of the abdomen. 2. Inspect for rashes, swellings or any abnormality. 3. Gently palpate the abdomen for tenderness and presence of any mass taking care not to hurt the client by observing facial expression. 4. Palpate the inguinal areas for tenderness and swelling of lymph nodes. 6
Genital examination External genital examination: 1. Put on clean gloves. 2. Inspect the pubic hair for nits/lice. 3. Inspect the perineum, vulva and anus look for swelling, unusual discharge, sores, tears, scars and gapping of the anus. Speculum examination: (Use disinfected speculum) 1. Change the gloves. 2. Separate the labia using two fingers, insert the speculum gently into the vagina at an oblique position while the woman is relaxing her muscles. 3. When speculum is halfway in, turn it so the handle is down. 4. Gently open the blades a little and locate the cervix. 5. Check for discharge, sores, bleeding or abnormal growth. 6. Pull back the speculum; turn it gently to look at the walls of the vagina. 7. Remove the speculum gently pull it towards you at an oblique position. 8. Be sure to disinfect the speculum soon after each examination. Note: Follow the laid down disinfection procedure (Refer to the page 129 of the National Guidelines for Management of STI and RTI Edition 2007). 7
Genital examination Bimanual examination: (Examination of reproductive organs inside the lower abdomen) 1. Put the index and middle fingers of your gloved hand in the vagina to feel the cervix. 2. Feel the uterus and posterior phoenix (pouch of Douglas) by gently pushing on her lower abdomen with your outside hand. 3. Feel the tube and ovary on both sides. 4. Conduct cervical excitation test by placing two fingers on one side of the cervix and pushing it gently toward one side and do the same for the other side, while observing the woman s facial expression. 5. Pull out the fingers slowly from the vagina and look at the glove if there is any discharge, blood or tissues and note the odour. 6. Remove the gloves and wash your hands. 7. Record findings and share them with the client. 8
Signs to Look for When Examining a Female Client Signs to look for Ulcers, sores or blisters, laceration of cervix Discharge and redness of the vulva Swelling or lumps in the groin (inguinal lymphadenopathy) Mucopurulent discharge from cervix and vaginal wall Lower abdominal tenderness when pressing down over lower abdomen Genital warts Bleeding from the vagina or tissue coming out Tumours or other abnormal-tissue on the cervix Swollen tender pouch of Douglas Anal sores, discharge, blisters, or swelling around the anus Gapping of the anus Pregnancy Follow flowchart for Genital Ulcer Syndrome Vaginal Discharge Syndrome Inguinal Bubo Syndrome Vaginal Discharge Syndrome Lower Abdominal Pain Syndrome also known as Pelvic Inflammatory Disease (PID) Follow the instructions on page 91 of the National Guidelines for Management of STI and RTIs Refer the client to gynaecological clinic. Refer the client to surgical clinic. Refer the client to ANC for routine care including syphilis and HIV testing. 9
History Taking on Neonate/Baby with an STI Symptom Create good rapport with the parent(s)/guardian History of parent(s) illness Prenatal history Natal history Welcome and greet the parent(s)/guardian. Encourage the parent(s)/guardian to talk. Look at the parent(s)/guardian. Listen to the parent(s)/guardian. Ask the parent(s)/guardian What is the problem of the baby? When did it start? Is there change over time? Did you have any genital discharge, sores or warts during the pregnancy? If yes, were you treated with your partner? Were you tested for syphilis and HIV during the pregnancy? Did you receive any treatment after getting the results? At what gestational age was the baby born? How was the condition of the baby at birth? History Taking on Neonate/Baby with an STI Symptom Postnatal history Did the baby receive any medicine after birth? Note: Confirm information with the antenatal card if available! 10
Physical Examination on a Neonate/Baby with an STI Symptom Prepare and set equipment and materials for examination: Examination coach, screen/curtain, good source of light, torch, gloves, cotton wool, gauze, thermometer, stethoscope, spatula, soap, water, dustbin, three buckets, and hypochlorite solution Examine client by observing principles of inspection, palpation, percussion and auscultation. Steps for physical examination in a neonate/baby Introduction 1. Get the consent from the parent(s)/guardian. 2. Tell the parent(s)/guardian each step of examination. 3. Wash and warm your hands (by rubbing the hands). 4. Tell the parent(s)/guardian to put the baby on the lap or examination coach. Note: Put on gloves if the client has sores on the skin or if you (service provider) have sores on your hands! Physical Examination on a Neonate/Baby with an STI Symptom 11
General examination Genital examination 1. Check the vital signs: body temperature, heart rate, respiration rate and reflexes. 2. Tell the parent(s)/guardian to remove the baby s clothes. 3. Inspect the head and skin for rashes, vesicles, bullae, peeling of the skin or any other abnormality. 4. Check for oedematous face. 5. Inspect the eyes for discharge, swelling of conjunctiva, pallor and jaundice. 6. Inspect the mouth for thrush, vesicles, sores or any abnormality. 7. Inspect the nose for discharge or any abnormality. 8. Palpate for lymph nodes on the neck, back of head, under the chin and axilla. 9. Inspect the chest and abdomen for rashes, abnormal movement or obvious swelling. 10. Palpate the abdomen to feel the liver, the spleen or any other mass. 11. Inspect limbs for skin peeling and abnormal positioning which is painful. 1. Put on clean gloves. 2. Inspect the genitalia for discharge, swelling, rashes and excoriation. 3. Inspect the perineum for rashes, abnormal growth or any other abnormality. 4. Inspect around the anus for rashes or abnormal growth. 5. Remove the gloves and wash your hands. 6. Record findings and share them with the mother/guardian. 12
Signs to Look for When Examining a Neonate /Baby Signs to look for Discharge from eye(s), redness and swelling of the conjunctiva Discharge from the nose Action to be taken Follow the flowchart on Neonatal Conjunctivitis (Ophthalmia Neonatorum). Refer to the page 68 and 90 the National Guidelines for Management of STI/RTI of on treatment of congenital syphilis. Pallor, yellow colouration of the eyes and oedamatous face Skin Rashes and peeling of the skin on the head, neck and back Painfull limbs and/with deformity Distended abdomen with organomegally Thrush, vesicles in the mouth Excoriation, discharge, abnormal growth around genitalia, anus and perineum Refer the client to paediatric surgeon/clinic. 13
Education and Counselling for an STI/RTI Client Disease Treatment Prevention and counselling on risk reduction 1. Tell the client about the disease he/she has. 2. Tell how the disease is spread. 3. Tell the symptoms and signs of the disease. 4. Talk about its complications and sequel. 5. Educate on its linkage with HIV infection. 1. Educate the client on the importance of compliance to treatment. 2. Tell the client to abstain from sex during treatment until they are cured (or practice safer sex) 3. Educate the importance of partner treatment and offer contact slip. 4. Tell the client to come back for follow up as per flowchart. 1. Tell the client about abstinence - especially young people. 2. Insist on the importance of delaying in having sex (adolescents). 3. Educate the client to reduce number of sexual partners and stick to one faithful partner who is not infected. 4. Tell the client about safer sex practices including condom use and risk of anal sex. 5. Do condom demonstration. 6. Provide condoms. 7. Discuss ways of reducing risky behaviours identified during history taking. 8. Allow client to express his/her concerns and decisions. 9. Help client to make right decisions. 10. Offer or refer for HIV counselling and testing. 11. For uncircumcised male client, advise on male circumcision as one of the preventive measure of STI & HIV 12. Provide IEC materials 14 Education and Counselling for an STI/RTI Client
Use of a Male Condom 1 2 3 4 Check the conom if is not demaged or expired, if it is demaged or expired throw it away and start with the new one If unsircumsized pull the foreskin back hold the condom by its tip and squeeze the air out of the tip of the condom. Remove the condom from the sachet carefully do not use teeth or sharp objects to tear the sachet 5 6 7 8 Unroll the condom onto the erect penis do not use oil based lubricant After ejaculation withdraw the penis from the vagina while the penis is still erect Hold on to the rim of the condom while withdrawing. Remove condom from penis and tie a knot in it to prevent spills or leaks Place the condom on the penis and unroll Dispose of condom safely e.g. in pit latrine or burn on fire. Do not reuse a condom Use of a Male Condom Note: If the client says that he knows how to use a condom then let him demonstrate on a penile mode infront of the service provider. 15
Use of a Female Condom 1 2 3 4 Check the conom if is not demaged or expired, if it is demaged or expired throw it away and start with the new one Remove the condom from the sachet carefully do not use teeth or sharp objects to tear the sachet Find the inner ring. which is at the closed end of the Condom Put the inner ringtogether in the vagina Squezze the inner ring together 5 6 7 8 If you do not, be awar that the penis could enter the vagina outside the condoms shealth. If this happens you will not be protected Be sure to guide the penis enters to outer ring of the female condom Twist condom Three times, remove and dispose. Put the inner ring together in your vagina with your finger. The outer ring stand outside the vagina Dispose of condom safely e.g. In pit latrine or burn on fire. Do not reuse a condom. Use of a Female Condom Note: If the client says that she knows how to use a condom then let her demonstrate infront of the service provider. 16
ANNEX 1 Contact Card for an STI Client KADI YA MWENZI Jina la kituo cha Tiba... Tarehe... Namba ya usajili ya mteja... (Registration) Chumba namba... Contact Card for an STI Client Tafadhari fika kwenye kituo kilichotajwa hapo juu-uonane na mtoa Huduma kwa ushauri. Saa za Kazi: 2.00 asubuhi 9.00 Mchana 17
ANNEX 2 Contact Card for a Client in Antenatal Clinic TAARIFA MUHIMU KWA MWENZI WA MAMA MJAMZITO Namba... (Mteja) Bw... (Jina la Mwenzi) Kufuatia uchunguzi uliofanywa kwa mwenzi wako wakati wa kliniki ya uzazi kuna matatizo ya kiafya yaliyogunduliwa Ambato yanaweza kuathiri afya ya mtoto. Tafadhari fika kituo cha Tiba cha...kwenye kliniki ya wazazi. Contact Card for a Client in Antenatal Clinic Saa za kazi 2.00 asubuhi 8.00 mchana 18
CONTACTS Ministry of Health and Social Welfare National AIDS Control Programme P.O. BOX 11857 Dar es salaam, Tanzania Tel: +255 22 2131213, Fax +255 22 2127175 Website: http://www.nacp.go.tz Designed by Wasanii Visual Arts and Printed by Jamana Printers Ltd Japan International Cooperation Agency National AIDS Control Programme World Health Organization