Cover Image
close this bookOral Rehydration Therapy and the Control of Diarrheal Diseases (Peace Corps, 1985, 566 pages)
close this folderModule Two: Diarrhea, dehydration and rehydration
close this folderSession 5 - Rehydration therapy
View the document(introductory text...)
View the documentHandout 5A: ORT preparation worksheet
View the documentTrainer Attachment 5A: Materials and equipment needed for ORT stations
View the documentTrainer Attachment 5B: Using models to show why rehydration is important
View the documentTrainer Attachment 5C: Suggestions for a lecturette on the hows and whys of ORS
View the documentTrainer Attachment 5D: Oral rehydration therapy: the scientific and technical basis
View the documentTrainer Attachment 5E: Storing and maintaining supplies of oral rehydration salts (ORS)
View the documentTrainer Attachment 5F: Oral rehydration with dirty water?
View the documentTrainer Attachment 5G: A pinch of salt' a handful of molasses...
View the documentTrainer Attachment 5H: Cautious prescription

(introductory text...)

TOTAL TIME

4 hours

OVERVIEW

Effective treatment of dehydration requires the replenishment of salts, fluids, and nutrients to the body. Rehydration is necessary for all types of diarrhea. In Session 4 participants learned the signs and symptoms of diarrhea and dehydration that indicate the use of WHO Treatment Plan A (sugar and salt) to prevent dehydration, Plan B (ORS) to treat dehydration, and Plan C (IV or nasogastric tube) for severe dehydration and rapid Rehydration needs. In this session they develop a further understanding of the biological need for rehydration and the reasons for the effectiveness of ORS. Through hands on experience preparing solutions, participants explore the differences in ORT solutions. They also discuss the problems in preparing and giving ORT in the village.

OBJECTIVES

· To explain why oral rehydration is necessary for the prevention and/or treatment of moderate dehydration.
(Step 1)

· To accurately 01x two kinds of oral rehydration solutions.
(Steps 2, 3)

· To describe the components of two kinds of oral rehydration solutions and the appropriate use of each solution.
(Steps 1, 4)

· To describe problems in preparing and giving ORT in the village.
(Steps 5, 6)

RESOURCES

"Oral rehydration Therapy for Childhood Diarrhea, "Population Reports, The Treatment of Diarrhea (WHO Supervisory Skills).

Handout:

- 5A ORT Preparation Worksheet

Trainer Attachments:

- 5A Materials and Equipment Needed for ORT Stations
- 5B Using Models to Show Why rehydration is important
- 5C Suggestions for a Lecturette on the Hows and Whys of ORS
- 5D Oral rehydration Therapy: The Scientific and Technical Basis
- 5E Storing and Maintaining Supplies of Oral rehydration Salts
- 5F Oral rehydration With Dirty Water?
- 5G A Pinch of Salt, A Handful of Molasses
- 5H Cautious Prescription

MATERIALS

Newsprint, markers, Read Trainer Attachment 5A for list of materials and equipment needed for practice stations. Read Trainer Attachment 5B for materials needed for using models.

PROCEDURE

Trainer Note

In strict adherence to WHO guidelines, Peace Corps advocates the use of only two types of ORS solutions-prepackaged and sugar-salt solutions- in Peace Corps projects and in this training program. As discussed in Session 4 and reviewed in this session, WHO Treatment Plans A and B outline the appropriate and effective use of these two solutions in ORT. Before this session, find out what recipes for oral rehydration solutions the government and bother agencies are busing. In some areas more than one agency may be encouraging the use of ORT with different recipes. Be prepared to discuss these differences and their potential for confusing the public.

Please note that research is currently being conducted on "rice powder" ORS. Rice-powder ORS substitutes rice powder (i.e., ground rice) for glucose, an essential component of the standard OR formula (Rice-powder ORS should not be confused with rice water. Rice water is the fluid drained from the rice after cooking. Since it generally contains very little salt and variable amounts of rice starch, rice water is considered unsuitable for active rehydration. It is not an oral rehydration solution.) Possible advantages & disadvantages of rice powder ORS are being studied but no conclusions can be drawn until further research is done.

Trainers should only emphasize rice powder ORS in countries where a definite policy and guidelines on this subject have been developed and operationalized by the MOH. Only in countries where definite policies exist should rice powder ORS be incorporated as an ORT approach. In such cases, the trainer has the responsibility of becoming familiar with exact MOH guidelines and explaining those to the participants through discussion and a handout.

The main purpose of this session is to provide actual experience in correctly preparing the two kinds of solutions. Be sure to allow ample time for practice.

This session requires considerable preparation. Recruit the help of several participants to set up the work stations (with the materials, equipment and task descriptions explained in Trainer Attachment 5A), prepare for the demonstration, and clean up afterwards.

Identify individuals in the group or training center who have had experience preparing and using ORT to act as resource persons during Step 3.

If possible invite a local health worker to participate and assist in this activity. He or she may be able to help you arrange to give the solutions mixed during the session to children in the community or clinic during Step 7.

Ask participants to bring commonly used utenslis from their community work site. Each solution must be mixed as accurately as possible. Predetermine the quantities and weights measured by locally available utensils so recipe mixing may be done precisely under local conditions. Use these utensils in your demonstrations. (See Oral rehydration Therapies for Childhood Diarrhea in the ORT resource packet.)

Ask a participant to help you prepare the demonstration described in Trainer Attachment 5B (Using Models to Explain Why rehydration is important) and the lecturette described in Trainer Attachment 5C (Suggestions for a Lecturette on the Hows and Whys of ORS.)

If available, get copies of the WHO Treatment Chart in the local language. hive prepare a list of ORT terms in the local language with the assistance of Peace Corps language trainers.

Step 1 (20 min)

Demonstration and Discussion of Why Rehydration la important

Introduce this Session using the plastic bag, the gourd baby and the watered and wilted flowers to illustrate the need to rehydrate a child with diarrhea (as suggested in Trainer Attachment 5B).

Ask participants to describe Treatment Plan A on the WHO chart, which they discussed in Session 4 (Dehydration Assessment) and explain what this demonstration tells then about Plan A.

Briefly discuss the fluids available in village hoses that are already used or could be used during diarrhea to prevent dehydration (Including sugar salt solution). Also discuss any cultural beliefs that night help or hinder teaching mothers to give children liquids during diarrhea.

Trainer Note

The main point of this activity is to illustrate why rehydration is necessary during diarrhea in a clear simple way that can be used by participants with mothers in the village.

It also provides a way to reinforce and use their learning about Treatment Plan A in the WHO Chart. They should recognize that the plastic bog and other models provide an explanation of why plan

Is very important. Emphasize prevention of dehydration as a major goal for their health education efforts in ORT. Refer back to the circle of pictures that you made for the diarrhea story in Session 3 (Prevention and Control of Diarrhea Note that oral rehydration is one important intervention in the circle.

Step 2 (15 min)

Lecturette on the Hows and Whys of ORS

Point to the pictures showing the signs of dehydration that were introduced in Session 4. Ask someone to quickly summarize the signs of dehydration. Explain that these physical signs are caused by the loss of sodium, potassium and nutrients during diarrhea, in addition to the loss of water.

Present the lecturette that you prepared using Trainer Attachment SC (Suggestions for a Lecturette on the Hows and Whys of ORS). If possible use a simple diagram to illustrate the way that the body chemistry balance is affected by diarrhea.

Ask someone to describe Treatment Plan B on the HO chart. Discuss the ingredients in ORS and how they help the body regain its chemical balance. Ask someone to explain in their own words when they would give ORS to a child with diarrhea and what the ORS does for the child in comparison to sugar salt solution.

Briefly discuss how people in the village have responded to ORS packets (or are likely to respond it they have not been introduced to them). Build on the discussion of cultural beliefs regarding the acceptability of liquids (from Step 1).

Close this step by telling the participants that they will be spending the rest of the session preparing two different oral rehydration solutions' the kind that should be used at the first sign of diarrhea to prevent dehydration (sugar-salt) and the type used to treat mild dehydration (ORS).

Trainer Note

Prepare two sheets of newsprint with the recipes for ORS and for sugar-salt solution as stated in The Treatment of Diarrhea, pages 17 and 42.

During the group's discussion of these two recipes, make sure that the following points are covered:

- Potassium is an essential element in the body and is lost during diarrhea. A minimum level of potassium is needed for the body to function.

- The amount of salt listed in the recipe 16 sufficient to replace sodium and water loss.

- Glucose is preferred to sucrose (table sugar) because it helps the body absorb liquid more quickly.

- Sodium bicarbonate helps prevent acidosis, a condition which decreases a dehydrated child's appetite.

- Mention that, as of 1985, the new WHO formula will replace bicarbonate of soda with trisodium citrate which has a longer shelf life and also appears to reduce stool volume.

- Home-made sugar-salt solution, made properly and used correctly along with other nutrients, can prevent dehydration but is not adequate treatment for dehydration because it lacks potassium in sufficient amounts to replenish body losses.

- ORS packets which are pre-measured and contain the added ingredients of potassium and bicarbonate of soda or trisodium citrate are important to use when treating mild cases of dehydration and can prevent the need for implementing Treatment Plan C, (IV or Nasogastric Therapy).

- None of these solutions should be kept longer than 24 hours. A fresh quantity should be mode daily.

For more technical background see Trainer Attachment 5D (Oral Rehydration Therapy: The Scientific and Technical Basis).

Step 3 (20 min.)

Preparing to Mix Oral Rehydration Solutions

Demonstrate how to mix the two kinds of oral rehydration solution. Have one or two people do return demonstrations and have the group critique their demonstration. Pass the solution around so that everyone has a chance to taste it.

Explain that everyone will be working in small groups at oral rehydration stations for the next hour. Each group will carry out the following tasks at each station:

- Read the instructions for preparing the solution at the station and take turns in mixing and tasting that particular solution.

- Discuss and complete Handout 5A (The ORT Preparation Worksheet) prior to moving to the next station.

- Clean up the station before moving on to the next one.

Trainer Note

In doing the demonstration, make sure that you'

- Emphasize washing hands before you begin mixing the solutions.

- Show all the utensils needed, using locally available items.

- Clearly state the ingredients and proportions, stressing the importance of being as accurate as possible.

- Emphasize that too much salt is dangerous to the child: too much aster makes the solution ineffective.

- Cover the solution when it is mixed.

- Explain how to store ORS packets. You can refer to Trainer Attachment 5E (Storing end Maintaining Supplies of Oral rehydration Salts) and page 19 in The Treatment of Diarrhoea.

An alternative approach is to do a correct demonstration then tell participants that you will be doing an incorrect demonstration and you want thee to tell you what you did wrong. This repetition helps them learn and remember the steps in mixing the solutions.

Step 4 (60 min)

Preparing Oral rehydration Solutions

Ask the group to fore small groups, move to the first station and begin preparing the solutions.

Trainer Note

During this step you should:

- Have resource persons who have mixed these solutions observe, correct and assist the participants with any problems or questions they nay have. Also tints person should make sure everyone uses proper hygienic techniques when mixing the solutions (e.g. washing their hands and all utensils before and after making the solution).

- Make sure each station has adequate supplies and ingredients available for each new group.

- Assign each group the task of reporting on one solution. These reports should include information contained in Handout 5A (ORT Preparation Worksheet) and Incorporate Information from the WHO Diarrhea Treatment Chart as to how much solution should be given, when it should be given and what other fluids and foods should be given when the child is belay treated with their assigned solution.


Step 5 (30 min.)

Discussing The Use of Oral Rehydration Solutions in The Village

Reconvene the group and ask each small group to report on their experience at one of the stations. Have someone from each group record the answers on newsprint, using the format from Handout 5A (ORT Preparation Worksheet). Allow about 5 minutes for each work station report. Encourage comments and discussion after each presentation.

Ask participants to think about what they have learned and answer the following questions:

- Which treatment should be used when a child has diarrhea? Some signs of dehydration? severe dehydration? Why?

- What problems do you foresee in preparation and use of ORS in the village? What about sugar salt solution?

- What can you do to overcome some of the problems encountered in teaching and encouraging people to prepare and use these solutions?

Trainer Note

Be sure to discuss the following kinds of problems:

- Lack of understanding in the village about the importance of accurate measuring.
- Lack of uniform measures.
- The use of too such salt or sugar.
- The cost or lack of availability of the ingredients.
- No ORS packets available at the local health post.
- Limited water supply and/or dirty water.

Make sure that everyone understands the difference between preventing and treating dehydration sad recognizes the need for the potassium and sodium bicarbonate or trisodium citrate (In the ORS packets) for treating dehydration.

Emphasize the importance of adapting the sugar-salt solution recipe to use locally available ingredients and to amounts appropriate for the utensils available for measuring.

Trainer Attachments 5F (Oral rehydration with Dirty Water?) and 5G (A Pinch of Salt, a Handful of Molasses) discuss some of these problems and describe ways to deal with thee.

Following this step you may want to use the optional step (Discussing Drugs Used to Treat Diarrhea).

Step 6 (45 min.)

Practice in ORT

Demonstrate how to give oral rehydration solution to an infant, Including what to do if the infant spits up the solution or is reluctant to take it. Have one of the participants do a return demonstration.

If possible, give all the participants an opportunity to give the solution to an infant or child during or after this session.

After they finish practicing, discuss problems encountered and ways To overcome them.

Step 7 (15 min.)

Session Summary

Ask the participants to summarize the key points that should be taught about rehydration solution preparation and administration in the communities and how they would do this.

Trainer Note

Information that they should include on how to educate community and family members about home treatment of diarrhea can be found in The WHO Supervisory Skills Module, "Treatment of Diarrhoea" pages 4-6.

Optional Step (15 min)

Discussing Drugs Used to Treat Diarrhea

Depending on the health background and task assignments of the participants, you nay want to use Trainer Attachment 5H (Cautious Prescription) and page 55 of Treatment of Diarrhoea to discuss the types of diarrheal diseases that do require drugs in addition to oral rehydration.

- What kinds of drugs are commonly used to treat diarrhea in this country?
- Why is this use of drugs dangerous?
- How can we overcome the idea that drugs are the best cure for any kind of diarrhea?
- What do people in your communities think about the power and/or danger of medicines?
- Who should decide whether a drug is needed to treat a case of diarrhea?

Trainer Note

Emphasize that drugs should be "cautious prescriptions.. They should be given cautiously and only when there is a clear indication (such as bloody stools and high fever) that the cause of the diarrhea is a disease that requires drug treatment. They should be prescribed by a qualified health worker. Drugs should never be given as a routine practice for treating diarrhea. A drug that is not needed can be harmful to the body in a variety of ways; giving the drug is likely to divert the mother's attention from oral rehydration, widespread use of drugs promotes the development of drug-resistant strains of diseases; and antibiotics are expensive.

You nay want to assign two people to visit a local pharmacy or store to ask about and get samples of drugs commonly used to treat diarrhea in the host country. You can ask them to report their findings at the beginning of this step.