1 RN or PCA
Level II Cardiac Chair
Criteria: Stable hemodynamics, no vasopressors, FiO2 < 60%, PEEP < 10
•Sit at edge of bed
•Dangle legs over edge of bed
•Transfer to Cardiac Chair
•30 minutes in Cardiac Chair
Types of techniques:
Airway clearance techniques
Facilitating airway clearance technique with effective coughing techniques
Technique to facilitate ventilation pattern
Mobilization and Exercises
Airway clearance technique:
Postural drainage
Percussion
Vibration/shaking
Manual hyperinflation
Active cycle of breathing technique
Autogenic drainage
Positive expiratory pressure
High frequency chest compression
Exercises for airway clearance
Indications and cautions:
Cystic fibrosis
Atelectasis
Asthama
Respiratpry muscle weakness
Bronchiectasis
Mechanical ventilation
Neonatal respiratory distress syndrome
Contraindications:
Intracranial pressure (ICP) > 20 mm Hg
Head and neck injury until stabilized
Active hemorrhage with hemodynamic instability
Recent spinal surgery (e.g .• laminectomy) or acute spinal injury
Active hemoptysis Empyema
Bronchopleural fistula
Large pleural effusions
Pulmonary embolism
Aged, confused, or anxious patients
Rib fracture. with or without flail chest
Surgical wound or healing tissue
Types of techniques:
Airway clearance techniques
Facilitating airway clearance technique with effective coughing techniques
Technique to facilitate ventilation pattern
Mobilization and Exercises
Airway clearance technique:
Postural drainage
Percussion
Vibration/shaking
Manual hyperinflation
Active cycle of breathing technique
Autogenic drainage
Positive expiratory pressure
High frequency chest compression
Exercises for airway clearance
Indications and cautions:
Cystic fibrosis
Atelectasis
Asthama
Respiratpry muscle weakness
Bronchiectasis
Mechanical ventilation
Neonatal respiratory distress syndrome
Contraindications:
Intracranial pressure (ICP) > 20 mm Hg
Head and neck injury until stabilized
Active hemorrhage with hemodynamic instability
Recent spinal surgery (e.g .• laminectomy) or acute spinal injury
Active hemoptysis Empyema
Bronchopleural fistula
Large pleural effusions
Pulmonary embolism
Aged, confused, or anxious patients
Rib fracture. with or without flail chest
Surgical wound or healing tissue
Application of PEP devices in Cardiorespiratory physiotherapy.
It includes types of PEP devices and their uses in physiotherapy..
It stands for positive expiratory pressure.
It includes spirometry, flutter, rc cornet, acapella, etc.
useful in various cardiorespiratory disorders like COPD, asthma , cystic fibrosis, respiratory failure etc.
The goal in patients with primary lung disease is to teach them to relax the neck and chest accessory muscles and use more diaphragmatic breathing to reduce the work of breathing.
Secure development environment @ Meet Magento Croatia 2017Anna Völkl
Software development can sometimes be a mess: live database dumps needed for testing lying around, development files being forgotten or accidentally transferred to the live environment, untested code being written and deployed in a hurry. It's easy to mess up and fail, often without noticing for a long time. In this talk we'll have a look at how to bullet-proof your development workflow. It covers best practices and tools which you should use in your daily work that will improve the overall security and also speed up software development.
http://hr.meet-magento.com/en/speaker/anna-volkl/
Application of PEP devices in Cardiorespiratory physiotherapy.
It includes types of PEP devices and their uses in physiotherapy..
It stands for positive expiratory pressure.
It includes spirometry, flutter, rc cornet, acapella, etc.
useful in various cardiorespiratory disorders like COPD, asthma , cystic fibrosis, respiratory failure etc.
The goal in patients with primary lung disease is to teach them to relax the neck and chest accessory muscles and use more diaphragmatic breathing to reduce the work of breathing.
Secure development environment @ Meet Magento Croatia 2017Anna Völkl
Software development can sometimes be a mess: live database dumps needed for testing lying around, development files being forgotten or accidentally transferred to the live environment, untested code being written and deployed in a hurry. It's easy to mess up and fail, often without noticing for a long time. In this talk we'll have a look at how to bullet-proof your development workflow. It covers best practices and tools which you should use in your daily work that will improve the overall security and also speed up software development.
http://hr.meet-magento.com/en/speaker/anna-volkl/
Using Enhanced Recovery After Surgery (ERAS) to Enhance Postoperative OutcomesWellbe
Speaker: Francesco Carli, MD, MPhil, senior staff anesthesiologist at the McGill University Health Centre
Cost: Complimentary, sponsored by Wellbe
There is strong evidence that many of aspects of surgical care have little evidence, and therefore the Enhanced Recovery After Surgery (ERAS) program has been set up to accelerate the recovery process and decrease the rate of postoperative complications. There is an opportunity to improve outcomes by using team approach and revision of the standard procedures.
Learn about:
– The elements of ERAS protocols
– How to structure the Team approach
– The role of the patient in ERAS
– How to perform an audit of your program
About the Speaker:
Francesco Carli, MD, MPhil, is Professor of Anesthesia at McGill University and Associate Professor in the School of Dietetics and Human Nutrition at McGill University and a senior staff anesthesiologist at the McGill University Health Centre. He is currently an Elected Member of the American Academy of Anesthesia and a Board Member of the Enhanced Recovery After Surgery (ERAS) Society. Dr. Carli completed his medical training and anesthesia training in Turin, Italy, Paris, France, and London, England. He completed a Master’s Degree in surgical metabolism at the University of London, England.
His research interests are: metabolic changes associated with surgery and the impact of perioperative interventions (regional analgesia, nutrition, hormones, exercise) on postoperative recovery; evaluation of functional outcome measures during the surgical recovery process; prehabilitation of surgical patients. He is the author of over 250 peer-review scientific articles and has been a recipient of over 50 peer and non peer-review grants.
Presentation from the Enhanced Recovery Summit 2012 by Professor Henrik Kehlet
Enhanced recovery - future developments and transferability into acute medicine
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
2. Normal Mobility
• “On average, a healthy individual will alter his or her posture
during sleep every 11.6 minutes” (Hawkins,S.,Stone,K., &
Plummer, I., 1999)
3. DEFINED AS POSITIONING BODY PARTS
IN RELATION TO EACH OTHER TO
MAINTAIN CORRECT BODY POSTURE
DIRECT PATIENT CARE TOWARD
MAINTAINING NORMAL BODY
ALIGNMENT
ALIGNMENT
CORRECT ALIGNMENT HELPS PATIENT FEEL
MORE COMFORTABLE AND PREVENTS
FATIQUE.
4. Bed Rest
“Look at a patient lying in bed.
What a pathetic picture he makes.
The blood clotting in his veins,
the lime draining from his bones,
the scybala stacking up in his colon,
the flesh rotting from his sweat,
the urine leaking from his distended bladder,
and the spirit evaporating from his soul”
Richard Asher, MD 1947
5. Immobility
• Every organ and body system
progressively deteriorates when
inactivated.
• There is a remarkable similarity
between physiological effects of
aging and the adverse systemic
effects from prolonged
immobility.
6.
7. Physiological System Changes from Immobility
Cardiac
• Tachycardia
• Hypotension
- Orthostatic hypotension occurs after 15-24 days of immobility
- Avg. loss of 600ml plasma volume when on bed rest-contributes to
hypotension.
- After 12 hrs of bed-rest an upward fluid shift stimulates the baro-
receptors in the aortic arch and carotid artery to have an opposite
depressor effect. Must allow for hemodynamic equilibration when
moving patient.
• Inc. risk DVT
• Decreased maximal oxygen uptake
• Dec. total blood volume
• Heart Muscle atrophy and decreased stroke volume
8. Physiological System Changes from Immobility
cont’d
Pulmonary Complications
• Dec. vital capacity
• Dec. residual volume
• Less functional reserve
• Inc. secretions
• Inability to clear secretions (inc. aspiration risk)
• Increases risk for aspiration, pneumonia, pulmonary embolism and
development of ARDS
• Increases risk for atelectasis even in the absence of preexisting
respiratory disease
• Mucous film lining of smaller airways tends to pool
9. Physiological System Changes from Immobility cont’d
Musculoskeletal
• Skeletal muscle atrophy has rapid onset
- Begins 4 hours after start of hospitalization if pt is immobile
- Dec. muscle mass, muscle cell diameter and # of fibers per muscle
•1 week of bed rest = 20% decrease in muscle strength
• Loss of muscle strength is ongoing and progressive
-Additional 20% muscle strength loss for each week of bed rest
• Use of weakened muscles generates an increased oxygen
demand at the cellular level. Critically ill patients cannot meet this
demand!
• Loss of Bone Mass Density
• > 50% acceleration after 10 days bed-rest
• Calcium clearance 4-6 x normal after 3 weeks of total immobilization
• Contractures
• Can begin forming after 8 hours of bed rest
• Pressure Ulcers
• Develops within hours of immobilization if progressive turning schedule is not
implemented
10. Physiological System Changes from Immobility
cont’d
Gastrointestinal/Genitourinary Systems
• Constipation
- Decreased peristalsis
- Risk of Ileus
• Urinary stasis
- Inc. risk for UTI
- Calculus formation
- Increased calcium in urine is detected within a few
days after bed rest
• Fluid retention
11. Physiological System Changes from
Immobility cont’d
Metabolic
• Inc. excretion of calcium nitrogen,
phosphorus
- Renal Calculi
• Inc. risk of osteoporosis
- Increased risk of bone fracture
13. Burden of Complications
Ventilator-associated Pneumonia
• Increases need for vent support
• Increases ICU LOS by 4.3 days
• Increases Hospital LOS by 9 days
• Mortality from VAP 50-70%
Health Care
Resource Utilization
Quality Cost
Improvement Product
Utilization
I
Staff
Satisfactionn
Customer Information Care
Satisfaction Services Delivery
Pressure Ulcers
• Pain and Suffering
• Venous thrombus
Impact of
Decreased Mobility
• Sepsis
• Pneumonia
• Potential for Health Care Expenditures
14. Current Patient Mobility Practices
found in Literature
• Q 2 hour turning
• AROM/PROM
• OOB
• Cardiac Chair
• Ambulate
15. Q 2 Hour Turning
Widely accepted as a Standard of Nursing Care
Does it really happen?
Is it enough?
Corcoran, P., (1991). Use it or lose it -the hazards of bed rest and inactivity- adding life to years. Western Journal of Medicine,
C154, 536-538
16. Literature Findings
Krishnagdopalan et al. (2002)
Study: Prospective longitudinal observation study conducted to
determine compliance with Q 2 hr turning practices and how physicians
and nurses perceived the practice was carried out in their critical care
units
Setting: 3 separate ICU’s, 74 patients, with a total of 566 patient hour
observations.
Findings:
• 49.3% of observation time - No body position changes were noted
• 2.7% of Patients observed had Q 2 Hr. body position changes
• 80%-90% of survey respondents believed that Q 2 hr turning was an
accepted standard and that it prevented complications
• 57% of Physicians and Nurses surveyed believed that Q 2 hour
turning was achieved in their ICU’s
Krishnagdopalan, S., Johnson, W., Low, L,, & Kaufman, L., (2002. Body positioning of intensive care patients: clinical practice
versus standards. Critical Care Medicine, 30 (11) 2588-2592
17. Literature Findings, cont’d
Bailey, et al. (2007)
• Study: 6 month prospective cohort study in an 8 bed RICU conducted to determine safety
and feasibility of early activity in mechanically ventilated patients.
• Goal: Ambulate patients 100 ft before discharge from RICU
- **Pt movement to upright position in bed, cardiac chair and passive ROM were not
considered activity
• Definitions:
- Activity period: From time of hemodynamic stability throughout ICU stay
- Adverse Events: Fall to knees, tube removal, SB/P < 90mmHg >200 mmHg, Desat <
80% and extubation
• Criteria: Pt.’s on MV >4 days, Fio2 < 60%, Peep < 10 cm H20, no orthostatic B/P, no
vasopressor qtts.
• Interventions:
- Progressive increase in activity level from sit in chair to ambulate BID
- Pre & Post 30min rest period with AC ventilation prn to support activity
- Increase FI02 by 20% prior to activity & administer 02 during activity to prevent desaturation
- Vitals measurement pre & post activity
18. Literature Findings
Bailey, et al. (2007)
• Results:
- 103 patients participated
–89% patients on MV
– 42 % of pt’s with ETT tubes
ambulated
- 69% of patients ambulated
> 100ft.
- Median distance ambulated
• 400 ft.for pt.’s d/c home after
admission
• 270 ft for pt.’s d/c to SNF after
admission
• 230 ft for pt.s d/c to rehab after
admission
- Nurse to patient ratio 1:2
- No increase in nursing hours required
• Adverse Events:
- 9 patients had 14 adverse events
(14/1449 activity events =0.009%)
- 5 Falls to knees without injury
– 4 SBP< 90 mmHg
– 3 O2 desats < 80%
– 1 small bowel feeding tube removal
– 1 SBP > 200 mmHg
• No extubations, complications,
extended LOS, additional costs or
therapy required
• Clinical Significance:
Early activity is safe, feasible and beneficial
to ICU patients. It requires a
multidisciplinary team approach and is a
valuable therapy to reduce complications
associated with prolonged immobility.
19. Mobility Expectations
Range of Activity
(Intensive Care Mobility Guidelines)
• Position Change Q 2 hrs
• AROM/PROM upper & lower extremities Q 8 hrs
- Incorporated into routine daily care
• HOB elevation 30o while in bed
- Progressive activity as tolerated following mobility algorithm
• Cardiac Chair
• Dangle legs
- While sitting on side of the bed
• Stand
- Any amount of time patient can stand will be beneficial for expanding lung
capacity, enhance weight bearing and restores normal fluid balance
• Pivot -> Out of Bed to Chair
- Patient should not be OOB to chair for > 1- 2 hours at a time
• Levels of ADL
- Encourage participation in hygiene and feeding as appropriate
• Progress to steps->ambulation
20. Mobility Expectations
Documentation
• Appropriate documentation adhering to unit standards.
• Do not use:
- Checkmarks
- Q 2 o Turn
- Side to Side
- Lines drawn through boxes
• Use specific position change Q2:
- Right (R), Left (L), Supine, Prone
• Time Specific
- Number of steps taken or distance if pt. is ambulatory
- Amount of time if OOB to chair
21. Mobility Expectations
• Utilize OT/PT to reduce risks associated with health
co-morbidities, provide early intervention for
rehabilitation and contribute to the patients well
being and quality of life
• Occupational Therapy:
- Ask physician to order consult on admission
- OT will follow up weekly to evaluate patient for OT intervention
• Physical Therapy:
- Ask physician to order PT consult when patient is able to follow
commands or is ready to begin Spontaneous Breathing Trials
(SBT)
22. Mobility Expectations
Mobility Assist
Devices
• Over Head Lifts
• Hover Mattress
• Wedges (foam)
• Slider Boards
• Mobility Cart
Mobility Assistance
• Lift Team
• Patient Care Techs
• Peers
23. Intensive Care Progressive Mobility Guidelines
Goal of Early Mobilization:
Promote mechanical ventilator weaning process
Reduce ICU and Hospital LOS
Prevent physical deconditioning
Prevent Ventilator-Associated Pneumonia (VAP)
Prevent Pressure Ulcers
Maintain/achieve preadmission activity level
Enhance Patient physical and psychological well
being
Monitor for Physical Therapy /
Occupational Therapy Consult:
OT consult on admission, then weekly follow-up
evaluation
PT consult when patient is able to cooperate with
activity of begins SBT (Spontaneous Breathing Trials)
Document all Mobility on Flow Sheet
Level I Modified Mobility Process
Criteria: Admission to Intensive Care Unit or Progressive Care Unit
•Reposition and Turn Q 2 Hrs
•AROM/PROM
•Splints and / or boots (alternate) for contracture prevention
•HOB @ 30 degrees
Advance mobility using progressive Algorithm Level as Pt.
tolerates. Reassess q 12 hours
Exclusion criteria for advancing mobility level:
•Lobar collapse or atelectasis, excessive secretions and/or:
•Fio2 > 50% with Peep > 10
•SaO2 < 90% at rest or < 88% with activity
•Decreased MS or severe neurological insult
•Severe orthopaedic problems
•Hemodynamic instability SaO2 BP HR
Level II (Include Level I Interventions)
•HOB @ 450 to 650 if hemodynamically stable
•Place legs in dependent position
•Advance to Cardiac Chair
•OOB to Chair with assistive device ( 2X Daily for 1 hr)
•Time frame for OOB in Chair positioning is <1 hr
Hemodynamic Tolerance
5-10 minutes equilibration time is
required with each position change to
determine hemodynamic instability
If Pt has large abdomen try a lesser
HOB angle when in sitting position
Level III (Include Level I & II Interventions)
•Sit on Side of Bed
•Advance to Standing Position
•Initiate Pivot / Stand to bedside chair @ least 2 X Daily
Level IV (Include Level I, II & III Interventions)
•Independent: OOB, Sit in Chair, Stand, Ambulate
Ahrens, T., Burns, S., Phillips, J., Vollman, K., & W hitman, J. (2005). Progressive mobility guidelines for critically ill patients. 2005
Advancing Nursing., Retrieved September 24, 2006 from http://www..totalcare.tv/images/stories/138930_PMG.pdf.
24. REPOSITION
ICU
PATIENTS
“Teach us to live that we may dread
unnecessary time in bed.
Get people up and we may save
Our patients from an early grave.”
Richard Asher, MD. 1947