This document discusses hypovolemic shock, which is characterized by decreased circulating blood volume resulting in reduced tissue perfusion. It can be hemorrhagic, due to blood loss from wounds or internal bleeding, or non-hemorrhagic from digestive, renal, skin or third space losses. The pathophysiology involves a macrocirculatory reaction with centralization of circulation and microcirculatory changes impairing capillary function. Treatment involves stopping losses, aggressive volume resuscitation with isotonic fluids, monitoring for efficacy, and inotropic support if needed to boost cardiac output after volume is restored.
Acute respiratory distress syndrome (ARDS) is a sudden, progressive form of respiratory failure characterized by severe dyspnea, refractory hypoxemia, and diffuse bilateral infiltrates.
SHOCK SYNDROMESHOCK SYNDROME
• Shock is a condition in which the cardiovascular system
fails to perfuse tissues adequately
• An impaired cardiac pump, circulatory system, and/or
volume can lead to compromised blood flow to tissues
• Inadequate tissue perfusion can result in:
– generalized cellular hypoxia (starvation)
– widespread impairment of cellular metabolism
– tissue damage organ failure
– death
ATHOPHYSIOLOGYPATHOPHYSIOLOGY
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death
Acute respiratory distress syndrome (ARDS) is a sudden, progressive form of respiratory failure characterized by severe dyspnea, refractory hypoxemia, and diffuse bilateral infiltrates.
SHOCK SYNDROMESHOCK SYNDROME
• Shock is a condition in which the cardiovascular system
fails to perfuse tissues adequately
• An impaired cardiac pump, circulatory system, and/or
volume can lead to compromised blood flow to tissues
• Inadequate tissue perfusion can result in:
– generalized cellular hypoxia (starvation)
– widespread impairment of cellular metabolism
– tissue damage organ failure
– death
ATHOPHYSIOLOGYPATHOPHYSIOLOGY
Cells switch from aerobic to anaerobic metabolism
lactic acid production
Cell function ceases & swells
membrane becomes more permeable
electrolytes & fluids seep in & out of cell
Na+/K+ pump impaired
mitochondria damage
cell death
50% of blood volume loss within 3 hours (eg, 2500ml for 70 kg adult)
Blood loss of 150ml/min
HR>120 min , SBP <90mmhg indicate occult bleeding
Bleeding –goals
Find the bleeding, stop bleeding
Rapid restoration of effective blood volume
Maintain haemostasias , oxygen carrying capacity
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
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https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
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5. PATHOPHYSIOLOGY
Hypodynamic shock:
Macrocirculatory reaction:
• sympatho-adrenergic + humoral reaction (ADH, cortizol, SRAA)
o EFFECTS: centralisation of the circulation (compensatory effect)
worsening of tisular hypoperfusion (decompensatory effect)
Microcirculatory reaction:
• Alterations of capillary exchanges
o EFFECTS: transcapilary filling (compensatory effect)
capilary leak (decompensatory effect)
• Maldistribution of blood flow
o EFFECTS: preferential renal blood flow towards medular region (cortical
vasoconstriction)
• Abnormal peripheral oxygen extraction
o EFFECTS: early - increased (compensatory effect)
late - decreased (decompensatory effect)
• Rheologic changes
o EFFECTS: ↑ blood viscosity, blood flow, CID
• Endhotelial modifications
o EFFECTS: morpho-functional modifications
proinflamatory and procoagulatory status,
altered permeability
6. HYPOVOLEMIC SHOCK
CLINICAL SIGNS:
Intense thirst
Tachycardia
Tachypnea
– Positive orthostatic test
Small pulse wave
hTA (blood hypotension)
Agitation, anxiety , confusion, coma
Oliguria
Cold extremities
Profuse sweating
Collapsed peripheral veins
Delayed return of color to the nail bed
+ History of hemorrhagic or non-hemorrhagic losses
7. CLASSIFICATION OF HYPOVOLEMIC SHOCK
Class I Class II Class III Class IV
Blood loss- ml < 750ml 750-1500ml 1500-2000ml >2000ml
Blood loss-% <15% 15-30% 30-40% >40%
Pulse rate <100/min < 100/min 120-140/min >140/min
BP N N
Pulse wave
amplitude
N
Capillary refill N + + +
Respiratory rate 14-20/min 20-30/min 30-40/min >40/min
Urinary output >30ml/oră Oliguria Oligoanuria Anuria
Mental status Mild anxiety Anxiety Confused Lethargy
8. HR BP CO CVP PAOP SVR Da-vO2 SvO2
Hypovolemic
shock
↑ ↑ ↑
Cardiogenic
shock
↑ ↑ ↑ ↑ ↑
Septic shock
↑ ↑ N N N ↑
DIFFERENTIAL DIAGNOSIS
WITH OTHER FORMS OF SHOCK
11. TREATMENT OF HYPOVOLEMIC SHOCK
• Causative treatment – STOP losses
– essential role
– surgical treatment (when appropriate)
– emergency surgery for ongoing hemorrhage
12. TREATMENT OF HYPOVOLEMIC SHOCK
• volume replacement
– Vascular access site
– Solutions for volume replacement
– Rhythm of administration
13. TREATMENT OF HYPOVOLEMIC SHOCK
• Volume replacement – SITE of VASCULAR ACCESS
– Peripheral vascular access
• Multiple access (2-4 veins)
• Large peripheral catheters
• External jugular vein
Advantages:
– Short time of instalation
– Requires basic knowledge and simple matherials
– Minor complications (hematomas, cutaneous seroma, etc.)
Disadvantages:
– The diameter of peripheral catheter must be adapted for peripheral veins dimensions
– Vascular access can be lost (restless patient, during transportation); must be changed at 24-48
hours;
– no catecholamines administration (except in emergency for a short time period,until a central
venous access is available)
– Central venous access
• After peripheral vascular access is established and volume replacement is initiated
Advantages:
– Reliable and long lasting venous access (7-10 days)
– Allows CVP measuring and guiding of treatment
– Allows the administration of catecholamines and hypertonic substances
Disadvantages:
– Risk of complication (at instalation – pneumothorax, cervical or mediastinal hematoma, cardiac
dysrhytmias; during utilization – infection, gas embolism)
14. TREATMENT OF HYPOVOLEMIC SHOCK
• Volume replacement - Solutions for volume
replacement
– Isotonic crystalloid solutions
– Hypertonic crystalloid solutions
– Colloid solutions
– Whole blood and red blood cells
– Fresh-frozen plasma
– Platelets
15. TREATMENT OF HYPOVOLEMIC SHOCK
Solutions for volume replacement
-Isotonic crystalloid solutions
• Normal saline (NaCl 0,9 %), Ringer solution, lactated Ringer solutions
• Advantages:
– easy available
– cheap
– reduced risks
• Disadvantages:
– Small volume effect (out of 1000ml infused solution – 250-300ml remains
intravascullarly, the rest is distributed to the interstitial space)
– short duration of volume effect
– risk of interstitial edema, metabolic hyperchloremic acidosis
-Hypertonic crystalloid solutions
• hypertonic saline (NaCl 7,4%)
• Advantages:
– Efficient blood volume resuscitation with small solution volume (water is atracted
from interstitial space )
– Avoidance of fluid overload and peripheral edema
• Disadvantages:
– may result in acute pulmonary edema
16. TREATMENT OF HYPOVOLEMIC SHOCK
Solutions for volume replacement
Colloid sollutions
• Dextrans: Dextran 70, Dextran 40
• Gelatines: Gelofusin, Haemacel, Eufusin
• Hetastarch: Haes, Voluven, Refortan
• Human albumin 5%, 20%
– Advantages:
• Good volume effect
• Long duration of volume effect
– Disadvantages:
• expensive
• risk for anaphylactic reactions
• interfere with blood groups determination
• can induce/ aggravate coagulation disorders
17. TREATMENT OF HYPOVOLEMIC SHOCK
Solution for volume replacement
Blood and blood products are not volume solutions
• Only isogroup isoRh blood
• Only after restauration of intravascular volume with cristalloid /colloid
solutions;
• For correction of oxygen transport
• In case of posthemorragic anemia (after volume replacement) or
ongoing hemorrhage
• In case of massive blood transfusion – add fresh-frozen plasma and
platelet concentrate
18. TREATMENT OF HYPOVOLEMIC SHOCK
Volume replacement
RHYTHM OF ADMINISTRATION
– Rhytm of administration depends on:
• Ongoing losses / stopped losses
• Rhytm of losses – rapid (minutes, hours) or slow (days) instalation
– For the patient with hypotension – normal saline (2000 ml
in the first 15-30 minutes)
– after the first 15-30 minutes - volume replacement
continues depending on the clinical and hymodinamic
parameters (BP, HR, etc..)
19. TREATMENT OF HYPOVOLEMIC SHOCK
Volume replacement –
MONITORING THE TREATMENT EFFICIENCY
– Clinical parameters
• normalisation of BP, HR, pulse amplitude, skin colour and
temperature, mental status, urinary output
– Hemodynamic parameters
• Normalization of CVP, PCPB, DC, RVS, so
– Laboratory parameters
• Normalization of acid-base balance, liver, renal tests, Hb şi Ht, so
20. TREATMENT OF HYPOVOLEMIC SHOCK
• Inotropic support
– Only after volume replacement
– Used to improve cardiac output
– Dobutamine
• inotropic positive support
• peripheral arterial vasodilatation
21. TREATMENT OF HYPOVOLEMIC SHOCK
Vasopressor therapy
• NOT RECOMMENDED (may aggravate peripheral
hypoperfusion and metabolic acidosis)
EXCEPTIONS
• Only temporary
• In case of ongoing hemorrhage, which outruns the
possibilities of volume replacement
• Only until surgical procedure stops the hemorrhage
(emergency surgical treatment)
• Noradrenaline, dopamine, adrenaline