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Suicide and Suicidal Behaviour

Suicide

Suicide is the deliberate act of ending one’s life

Suicide refers to deliberate act of self harm that result into death.

Reasons for committing suicide
  • To solve problems like adultery for his/her spouse, poverty, stigma, discrimination,
  • To harm others incase of anger to parents decisions for children.
  • To end life in-case of terminal illnesses e.g. Newly diagnosed HIV, cancer
Conditions which predispose to suicide
  • Schizophrenia
  •  Hysteria
  •  Dementia: is an organic degenerative psychiatric disorder characterized by progressive deterioration of cognitive functions of an individual.
  •  PTSD
  •  Rape and defilement

Other risk factors include;

  • Depression with suicidal feelings
  • Family history of suicide attempts
  • Exposure to violence
  • Impulsivity [acting without thinking]
  • Aggressive or disruptive behaviour
  • Assess to fire arms and other harmful objects
  • Bullying and teasing at school
  • Feelings of hopeless or helpless
  • Acute loss or rejection
  • Death of a loved one
  • Loss of boyfriend of girlfriend
  • Humiliation by family members or friends
  • Trouble with the law
  • Failure at school
  • Alcohol and drug abuse
  • Sexual harassment
  • Chronic illness
  • Family disruption
  • Other mental disorders such as schizophrenia and PTSD

Methods of suicide

  •  Hanging
  •  Poisoning
  • Intentional accidents, gunshots, drowning
  •  Intentional rupturing of the main arteries e.g. radial artery
  •  Drug over dose
  • Self Starvation
Suicidal tendencies/ behavior

This is the act of an individual to harbor suicidal ideas, gestures or behavior.

Suicidal attempt

Is a psychiatric emergency characterized by trial to commit suicide but survives or fails.

MANAGEMENT OF SUICIDE ATTEMPT

Suicide attempt is a psychiatric emergency and therefore collaborative interventions should be implemented.

Aims of management:
(1). To prevent self harm.
(2). To restore the patient’s functional state.
(3). To restore patient’s self esteem.

  1. Establish a positive nurse patient relationship, that will help you in dealing with the patient i.e. attain the patient’s cooperation and trust.
     Immediately sign a caution card for such a patient for easy observation. The patient should be handed over and taken
    over physically using a caution card.
  2. Immediate admission of the patient to an isolated room while taking brief history and waiting for the doctor.
  3. Create a safe environment for the patient i.e. remove all potentially harmful objects from the patient’s vicinity e.g. sharp objects, belts, glass items, drug tray.
  4. Immediate assessment of the patient for; Vital observations, physical injuries of the patient and if they are life threatening we give urgent emergency treatment i.e. arresting of hemorrhage incase ruptured arteries, if cyanotic administration of prescribed oxygen, gastric lavage for ingested poison, immobilization incase of fractures.
  5. Also observe patient’s behavior’s like talking about ending his or her life (suicide).Handling dangerous objects, Refusing food,
    Accumulating drugs, Giving away property, Observe feeding since some starve themselves to death, and observe sleep pattern.
  6. Assess the patient’s mental status by interviewing the patient, attendants or family member to identify any underlying mental illnesses.
  7. Administration of prescribed drugs while re-assuring the patient if conscious
    >  Hydrocortisone 100mg to 200mg 3 times to 4 times incase of poisoning         > Chlorpromazine 100mg nocte incase psychosis induced suicidal attempt
    >   Amitriptyline 75mg nocte incase of depression induced attempted suicide
    >  Prophylactic antibiotics e.g. cloxacillin 500mg qid for 5 days incase of wounds.
  8. Chemotherapy 97% of patients with suicidal tendencies have depression hence give;
    > Antidepressants: e.g. Laroxyl 25mg-75mg ddd, Imipramine
    25mg-75mg ddd
    > Mood stabilizers e.g. Carbamazepine, Lithium carbonate,
    Sodium valproate
  9. The psychiatrist may order for therapeutic modalities to the patient e.g.
    >  ECT incase of severe depression, 2-3 shocks per week.
    >  Cognitive therapy incase of maladaptive feelings and behaviors
    > Psychotherapy e.g. group therapy, cognitive therapy, individual therapy, family therapy, Occupational therapy to divert the mind from the worries.

Nursing Concerns

  1.  Encourage the patient to express his feelings including anger.
  2.  Enhance self esteem of the patient by focusing on his strengths rather than his weaknesses.
  3. Rehabilitation to acquire skills to earn a living.
  4. Occupation of the patient in different activities like board games, football e.t.c to divert his mindset from suicidal thoughts
  5. Diet: provision of foods liked by the patient to stimulate his appetite
  6. Ensuring 24 hour around the clock close monitoring and observation of the patient
  7. Minimizing the number of nurses caring for this patient
  8.  Ensuring a good nurse patient relationship
  9.  Teaching the patient relaxation techniques incase of stress
  10.  Involvement of family members in the management of this patient i.e.
    >  Advising them to keep out reach items that the patient might use to harm herself
    >  Advise them to avoid being discriminative and be more of supportive to patient’s adaptation
    of suicide free life

Advice on Discharge.

  •  Patient should take treatment as prescribed.
  •  Patient should come back for review.
  •  Report any side effects to the nearest health center.
  •  Avoid psychosocial stresses others that may cause relapse.
  •  Avoid abuse of addictive drugs and alcohol.
  •  Family involvement in supporting the patient.
  •  Advise community and family members not to isolate the
    patient.
Prevention.
  1.  Patient should be properly managed in hospital i.e. show a
    good attitude to the patient while in hospital.
  2.  Early identification of problems that may cause mental health
    disorders.
  3.  Early and proper treatment of physical and psychological
    problems
  4.  Teach the community about factors that contribute to mental
    and physical illness.
  5.  People should learn to plan for their lives i.e. not someone to plan for them.
  6.  People should learn to be job creators but not job seekers.
  7.  Avoid harsh punishments to children.
  8.  People should learn to deal with difficult situations and
    effective copying mechanisms and stress management skills.
  9.  Counseling to people with social and physical health
    problems.
  10.  People should learn to share problems.
  11. Family should be helped to stay together.

Suicide and Suicidal Behaviour Read More »

research

Research

Introduction to research

Research is the systematic collection, analysis and interpretation of data to answer a certain question or solve a problem

Research is a term derived from the combination of two words: “re” and “search.” “Re” is a prefix meaning “again” or “anew,” and “search” is a verb signifying a close and careful examination, testing, probing, or trying. When combined, research becomes a noun describing a meticulous, systematic, and persistent study and investigation in a specific field of knowledge, carried out to establish facts or principles.

Research can also be defined as;

Research is an investigative process aimed at finding reliable solutions to problems through a systematic selection, collection, analysis, and interpretation of data related to the issue at hand.

 It encompasses all activities that enable us to discover new knowledge about the world around us. The process of research involves defining and redefining problems, formulating theories or suggested solutions, collecting, organizing, and evaluating data, making deductions and reaching conclusions, and rigorously testing those conclusions against the formulated hypothesis or theory.

Can also be defined as;

  • A search for knowledge.
  • A careful investigation or inquiry especially through search for new facts in any branch of knowledge.
  • A systematized effort to gain new knowledge.
  • It is an organized investigation of a problem.
  • It is a planned, systematic search for information for the purpose of increasing the total body of man’s knowledge.
  • A careful inquiry or examination, seeking facts or principles, a diligent investigation to ascertain something.
Purpose of research
  1. Finding answers to questions or solutions to problems.
  2. Discovering and interpreting new facts.
  3. Testing theories to revise accepted theories or laws in the light of new facts.
  4. Formulation of new theories.
  5. To test existing knowledge and theories.
  6. To determine the frequency and associations of events or phenomena.
  7. To provide a reliable guide or framework for decision-making.
  8. To predict, explain, and interpret behavior or occurrences.
  9. To expand the existing knowledge base and add to the collective understanding.
  10. To propose and implement solutions to problems and challenges.
  11. To achieve academic qualifications and enhance expertise.

CHARACTERISTICS OF RESEARCH

For research to be credible and valuable, it should possess the following characteristics:

  1. Clear purpose: The research must have a well-defined and specific objective.
  2. Transparent procedure: The methods and procedures used in the research should be described in sufficient detail to enable others to replicate the study.
  3. Objective design: The research design should be carefully planned to minimize bias and produce objective results.
  4. Honesty and truthfulness: Research findings should be reported with complete honesty and without distortion.
  5. Adequate data analysis: The data analysis should be appropriate and sufficient to reveal the significance of the findings.
  6. Validity and reliability: The data collected should be valid and reliable, ensuring the accuracy of the results.
  7. Generalizability: The research should be applicable and relevant beyond the specific study population.
  8. Limited and justifiable conclusions: Conclusions should be based solely on the data obtained from the research and should be well-supported.

Other characteristics include;

  • Directed towards the solution of a problem.
  • Emphasizes the generalizations of principles or theories
  • Demands accurate observations and description
  • Involves gathering new data from primary or first hand source or existing data for a new purpose.
  • Carefully designed
  • Requiring expertise
  • Striving to be objective and logical
  • Involves the quest for answers to unresolved problems
  • Involves patient and unharried activity
  • Carefully recorded and reported
  • Sometimes requiring courage

TYPES OF RESEARCH

  1. Applied research
  2. Basic research
  3. Correlational research
  4. Descriptive research
  5. Ethnographic research
  6. Experimental research
  7.  Exploratory research
  8.  Grounded theory research
  9.  Historical research
  10. Phenomenological research

APPLIED RESEARCH: Refers to the scientific study that solves practical problems. Applied research is used to find solutions to every day problems, cure illness and develop innovative technologies, rather than to acquire knowledge for the knowledge’s sake. E.g. improve agricultural crop production, Treat or cure specific diseases

BASIC REASEARCH:  It is driven by a scientist’s curiosity or interest in a scientific question. The main motivation is to expand man’s knowledge, not to create or invent something.
There is no obvious commercial value to the discoveries from results from basic research E.g. How did the universe begin ?, What is the specific genetic code of a fruit fly ?

CORRELATIONAL RESEARCH: Refers to the systematic investigation or statistical study of relationships among two or more variables without necessarily determining the cause and effect. It seeks to establish a relation/association/correlation between two or more variables. E.g. testing whether listening to music lowers blood pressure levels i.e. assign the groups to experimental and control

DESCRIPTIVE RESEARCH:  Refers to research that provides an accurate portrayal of characteristics of a particular individual, situation, or group. It is also known as statistical research, these studies are a means of discovering new meaning, describing what exists, determining the
the frequency with which something occurs, and categorizing information. E.g Finding the most frequent disease that affects
children of a given town.

ETHNOGRAPHIC RESEARCH:  Refers to an investigation of culture through an in-depth study of the members of the culture; It involves systematic collection, description, and analysis of data for development of theories of cultural behavior

EXPERIMENTAL RESEARCH:  

Refers to an objective, systematic, controlled investigation for the purpose of predicting and controlling phenomena and examining probability and causality among selected variables. E.g determining the efficacy of a particular drug in population

EXPLORATORY RESEARCH:  Is the type of research conducted for a problem that has not been clearly defined. Exploratory
research helps to determine the best research design, data collection method, and selection of subjects. The results of exploratory research are not usually useful for decision making by themselves, but they can provide significant insight into a given situation. It is not typically generalizable to the population
at large.

GROUNDED THEORY RESEARCH:  Is a research approach designed to discover what problems exist in a given social environment and
how persons involved handle them; It involves formulation, testing and reformulation of propositions until a theory is developed. Grounded theory is the research method operates almost in reverse fashion from
traditional research at first may appear to be in contradiction with to the scientific method.

HISTORICAL RESEARCH:  This is research involving analysis of events that occurred in remote or recent past. Historical research can show patterns that occurred in the past and over time which can help us to see where we came from and what kind of solutions we used in the past.

PHENOMENALOGICAL RESEARCH:  It is an inductive, descriptive research
approach developed from phenomenological philosophy; its aim is to describe an experience as it actually lived by the person. Phenomenology is concerned with the study of experience from the perspectives of the individuals.

 

Types of Research by Classification

Research can be classified into three main categories:

I. Classification by Purpose
  • Basic (Pure) research
  • Applied research
  • Action research
  • Evaluation research
Basic (Pure) Research
  • This is concerned with the production of results and findings which lead to the development of theory.
  • The primary motive is to expand one’s knowledge. This research is not involved in the creation and expansion of anything.
  • There are not any apparent commercial values to the discoveries that are associated with pure research.
Applied Research
  • This is conducted for the purpose of applying or testing theory and evaluating its usefulness in solving problems.
  • It is concerned with the usefulness of ideas or theories or practical situations.
  • The goal of the researcher is to bring about improvements and transformations within the human conditions.
  • In this research, it is the main duty of the researchers to investigate the ways that may bring about improvements and transformations, aiming at productivity and profitability.
Action Research
  • Advances the aims of basic and applied research to the point of utilization.
  • Concerned with the production of results for immediate application or utilization.
  • It improves practices and methods and generates technologies and innovations for application to specific technological situations.
  • Emphasis is here and now.
Evaluation Research
  • This involves the generation of results in research that help in decision making.
  • It looks at what was set to be done, what has been achieved, and thereafter makes a decision on what next steps need to be done.
II. Classification by Method
  • Historical research
  • Descriptive research
  • Analytical research
  • Correlational research
  • Experimental research
Historical Research
  • Historical research can show patterns that occurred in the past and over time, which can help us to see where we came from and what kinds of solutions we have used in the past.
  • Understanding this can add perspective on how we examine current events and educational practices.
Descriptive Research
  • Refers to research that provides an accurate portrayal of characteristics of a particular individual, situation, or group. Descriptive research, also known as statistical research.
  • These studies are a means of discovering new meaning, describing what exists, determining the frequency with which something occurs, and categorizing information.
  • In short, descriptive research deals with everything that can be counted and studied, which has an impact on the lives of the people it deals with. For example, finding the most frequent disease that affects the children of a town. The reader of the research will know what to do to prevent that disease thus, more people will live a healthy life.
Correlational Research
  • Refers to the systematic investigation or statistical study of relationships among two or more variables, without necessarily determining cause and effect.
  • Seeks to establish a relation/association/correlation between two or more variables that do not readily lend themselves to experimental manipulation.
  • For example, to test the hypothesis “Listening to music lowers blood pressure levels,” there are 2 ways of conducting research:
    1. Experimental – group samples and make one group listen to music and then compare the blood pressure levels.
    2. Survey – ask people how they feel? How often they listen? And then compare.
Analytical Research
  • Whereas as descriptive research attempts to determine, describe, or identify what is, analytical research attempts to establish why it is that way or how it came to be.
  • Analytical research looks at the association and the statistical significance of that occupancy.
Experimental Research
  • Is an objective, systematic, controlled investigation for the purpose of predicting and controlling phenomena and examining probability and causality among selected variables.
III. Classification based on the Approach
  • Qualitative research
  • Quantitative research
  • Mixed approach
Qualitative Research
  • Understanding of human behavior and the reasons that govern such behavior, involves analysis of data using words (e.g., from interviews), pictures (e.g., video), or objects (e.g., an artifact).
  • Qualitative research is research dealing with phenomena that are difficult or impossible to quantify mathematically, such as beliefs, meanings, attributes, and symbols.
  • Qualitative researchers aim to gather an in-depth understanding of human behavior and the reasons that govern such behavior.
  • The qualitative method investigates the why and how of decision making, not just what, where, when.
Quantitative Research
  • Involves analysis of numerical data and their relationship.
  • Quantitative research is generally made using scientific methods, which can include:
    • The generation of models, theories, and hypotheses.
    • The development of instruments and methods for measurement.
    • Experimental control and manipulation of variables.
    • Collection of empirical data.
    • Modeling and analysis of data.
    • Evaluation of results.
Mixed Method Approach
  • Qualitative + Quantitative.
  • Employs the use of numerical data and boosts them by the in-depth understanding of such occurrences.
REASONS FOR STUDYING RESEARCH
  1. Promote basic knowledge for infrastructure management including drug treatment, nursing or medical management of disease or health care.
  2. Development of new tools e.g drugs, vaccines, diagnostic tools etc.
  3. Informs public regarding research findings to emulate in health practice and lifestyles to maintain their health.
  4. Effective planning. It provides data for better management.
NEED FOR RESEARCH IN NURSING
  1. Molding the attitudes and intellectual competence and technical skills.
  2. Filling the gaps in the knowledge and practice
  3. Fostering a commitment accountability to clients
  4. Providing basis for professionalism
  5. Providing basis for professional accountability
  6. Identifying the role of nurse in changing society
  7. Discovering new measures for nursing practice
  8. Helping to take prompt decisions by the administration to relate problems
  9. Helping to improve standards in nursing education
  10. Refining existing theories and discovering new theories
Main benefits of research
  1. Development of a critical and scientific attitude
  2. Provides the chance to study a subject in depth
  3. Getting to know how to use library
  4. Learning to assess nursing/medical literature critically
  5. Development of special interest and skills
  6. Understanding the attitude of others whether in routine or research laboratories
  7. Academic awards.
Nurse’s responsibility in relation to research

All registered nurses should:

  • Read and interpret reports of research in their own nursing fields.
  • Identify areas of nursing where research is needed.
  • Collaborate intelligently with researchers.
  • Discuss with patients any research in which they are being asked to participate.

PRINCIPLES OF A GOOD RESEARCH

  • A clear statement of research aims, which defines the research question
  • Consenting all the respondents prior to research beginning
  • The methodology is appropriate to the research question
  • The research should be carried out in an unbiased fashion
  • The research should have appropriate and sufficient resources in terms of people, time, transport, money etc. allocated to it right from the start.
  • The people conducting the research should be trained in research and research methods
  • Those involved in designing, conducting, analyzing and supervising the research(supervisors) should have a full understanding of the subject area.
  • The researcher should have experience of working in the area
  • If applicable, the information generated from the research should inform the policy-making process.
  • All research should be ethical and not harmful in any way to the participants.

Research techniques

  1. Qualitative research
  2. Quantitative research

Qualitative research, refers to any research based on something that is impossible to accurately and precisely measure. For example, although you certainly can conduct a survey on job satisfaction and afterwards say that the percent of your respondents were very satisfied with their jobs, it is not possible to come up with an accurate, standard numerical scale to measure the level of job satisfaction precisely.

Quantitative research,  also called empirical research, refers to any research based on something that can be accurately and precisely measured. It deals with numbers i.e. data is presented in statistics like percentages like (heart rate, temperature, etc)

Differences between qualitative and quantitative research

research

Research Read More »

Concepts of Primary Health Care phc and cbhc

Concepts of Primary Health Care

Concepts of Primary Health Care – PHC

  1.  Essential Health Care: This is the care that meets the local needs of majority that enable individual to live a  socially and economically productive life.
  2.  Practically, scientifically sound methods and technology: The health care system should be able to solve the health problems in that community.
  3.  Accessibility Health Care: The services to promote health in the community should be easily reachable by individual / community.
  4.  Full community participation and involvement: The community should acquire responsibility for their own health and welfare in the community (in other words, the community members should not be left out) in any activities. When people are involved in organizing, planning, prioritizing, implementing, monitoring and evaluation, these services then will be socially acceptable and sustainable.
  5. Affordability of Health care: The cost of health care and its maintenance should be cheap and easily met by the community and country.
  6. Self-Reliance: The community should be independent, confident and trusting itself by doing from passive recipients to active partners with government/ Non –government and donors thus the community,
    government should be able to maintain (sustain) PHC activities without external interference.
  7. Self-determination: The community should be able to decide on its own and take action on matter concerning their own health and development.
  8. Integration: All sectors work together towards social economic development of the community with health as a nucleus in order to promote the health status of the people and refer where necessary.

INTRODUCTION TO PRIMARY HEALTH CARE

Historical Background of PHC

  • In 1976, Haldan T Mahlar of Denmark (who was by then the WHO Director General) proposed the goal of “health for all by the year 2000”. This was during the World health Organization assembly.
  •  The international conference on primary health care took place at Alma-Ata was the capital of the soviet republic of Kazakhstan located in the Asiatic region of the Soviet Union (Russia). The conference was attended by 300 delegates from 134 governments and 67 international organizations from all over the world.
  •  The 3rd world health assembly that took place in Geneva in 1979 endorsed the conference as declaration i.e. the declaration of Alma-Ata (WHO 1978). This declaration highlighted a minimum set of activities
    considered essential if there were to be implemented. These set of activities were later the components of PHC.
  •  Primary health care was endorsed by all countries attending a world conference in Alma-Ata,  USSR (Russia) as an approach to reach the goal of HFA/2000 (WHO, UNICEF 1978).

Definition According to World Health Organization WHO :

WHO defines PHC as essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individual and families in the community through their full participation and at the cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination.

Primary Health Care is different in each community depending upon:

  • Needs of the residents;
  • Availability of health care providers;
  •  The communities geographic location; 
  •  Proximity to other health care services in the area.
Levels of PHC
Primary health care
  •  The “first” level of contact between the individual and the health system.
  •  Essential health care (PHC) is provided.
  •  A majority of prevailing health problems can be satisfactorily managed.
  •  They are closest to the people.
  •  Provided by the primary health centers.
  • This is the care provided by nurses, clinical officers, and village health teams.
  • These include(Uganda) Health centers up to HC3, Private clinics, Community church based medical centers.
Secondary health care
  •  More complex problems are dealt with.
  •  Comprises curative services
  •  Provided by the district hospitals
  •  The 1st referral level
  • At this level, physicians and health care team carry out assessment and also treat health problems, and at this level, minor surgeries can be carried out.
  • These include Health Centre 4’s, KCCA Hospitals and district based hospitals.
Tertiary health care
  •  Offers super-specialist care
  •  Provided by regional/central level institution.
  •  Provide training programs
  • At this level, is where specialists are responsible for giving care and where major surgeries are performed.
  • These include Regional Referral Hospitals, All regional and national hospitals acting as Teaching and Training Hospitals, National Referral Hospitals, Specialist medical centers.

Concepts of Primary Health Care – PHC

  1.  Essential Health Care: This is the care that meets the local needs of majority that enable individual to live a  socially and economically productive life.
  2.  Practically, scientifically sound methods and technology: The health care system should be able to solve the health problems in that community.
  3.  Accessibility Health Care: The services to promote health in the community should be easily reachable by individual / community.
  4.  Full community participation and involvement: The community should acquire responsibility for their own health and welfare in the community (in other words, the community members should not be left out) in any activities. When people are involved in organizing, planning, prioritizing, implementing, monitoring and evaluation, these services then will be socially acceptable and sustainable.
  5. Affordability of Health care: The cost of health care and its maintenance should be cheap and easily met by the community and country.
  6. Self-Reliance: The community should be independent, confident and trusting itself by doing from passive recipients to active partners with government/ Non –government and donors thus the community,
    government should be able to maintain (sustain) PHC activities without external interference.
  7. Self-determination: The community should be able to decide on its own and take action on matter concerning their own health and development.
  8. Integration: All sectors work together towards social economic development of the community with health as a nucleus in order to promote the health status of the people and refer where necessary.

Principles of Primary Health Care

There are 6 basic principles identified in the primary health care approach.

  1.  Equitable distribution.
  2.  Man power development
  3.  Community participation.
  4.  Appropriate technology.
  5.  Multi-Sectoral approach.
  6.  Self-reliance.

1. Equitable distribution: This means that health services must be shared equally by all people irrespective of their social, economic, cultural and religious differences. All the people- the rich or poor, the urban or rural must have access to health services. So this principle is to address the imbalance currently in health care by distributing the health care budget to rural areas other than concentrating the budget only in cities.
2. Manpower development: Primary health care aims at mobilizing the human potential of the entire country by making use of available resources. This ensures that there is availability of adequate number of appropriate health personnel required to devise and implement plan and action. The strategies required
would be re-orientation of the existing health workers development of new categories of workers in health, motivation and training of all manpower to serve the community.
3. Community participation: This is a process by which individuals, families and communities assume responsibility in promoting their own health and welfare. To promote the development of the community and community’s self-reliance, residents themselves need to participate in decisions about their health in
the community. Community members and health workers/providers need to work together in partnership to seek solutions to the complex problems facing communities today.
4. Appropriate technology: Is technology that is sound scientifically, flexible and adaptable to the community’s local needs, acceptable to those who use it and to it is used to (served), and it can be maintained by the community people themselves in keeping with the principle of self-reliance, using the resources the community has and can afford. Refers to health care that is relevant to people’s health needs and concerns as well as being acceptable to them. It includes issues of costs and affordability of services within the context of existing resources i.e. the number and type of health professionals’ equipment, and their pattern of distribution throughout the community. Appropriate technology means a technology which requires low capital investment, conserves natural resources, is managed by its users and is in harmony with the environment.
5. Multisectoral approach: Health and family welfare programs cannot stand on their own in an isolated manner. It is recognized that the health of a community cannot be improved within just the health sector; other sectors are equally important in promoting the community’s health and self-reliance, These sectors
include, agriculture, animal husbandry, education, housing, public works, communication, water, environment, rural development, cooperatives, industries etc. These sectors need to work together in a multi-sectoral partnership to coordinate their goals, plans and activities to ensure that they contribute to
the health of the community and to avoid conflicting or duplicity efforts.
6. Self-reliance: this principle self-reliance applies at the three client level of individual family and community.
PHC practitioners play a major role in helping people achieve self-reliance in relation to their health care through community participation and involvement. This means the individuals, families and or communities are encouraged to change the attitude of being passive recipients to active partners with or without government or donor support.

Pillars of Primary Health Care

  1.  Community participation; this is very important for PHC programs to be socially acceptable and sustainable. Community participation is a process whereby the individuals and families assume  responsibility for their own health and that of their community. The community can participate by providing resources e.g. finances and raw material like bricks, sand, stones etc.
  2.  Intersectoral/multi-sectoral partnership: there is no sector which works in isolation but the activity one sector has influence on the other e.g. agriculture, water and sanitation, finance etc.
  3. Equity – all the people irrespective of color, tribe, race, nationality in every country should have access to essential health care.
  4.  Appropriate Technology: This is the technology which is scientifically sound, adaptable to local needs, culturally acceptable and financially feasible
  5. Political and social support; political leaders must be committed in policy formation, resource mobilization and allocation and mobilization of the community to support PHC programs.
    Positive Effects of political will:
    >  Policy making
    >  Monitoring and evaluation of PHC activities.
    >  Ensure adequate budgetary allocation
    >  Mobilization that is made from up (top) to bottom
    > Ensuring priority plans at different levels to reflect PHC characteristics, elements and pillars
    >  Active involvement and participation
    >  Setting aside a day for observing PHC e.g. PHC Day.
    Negative Effects of political will:
    >  Embezzlement of funds
    >  Civil wars
    >  Self centeredness
    >  Delay of service delivery due to top – bottom approach.
    >  Conflict ideas.
    >  Need to get high salaries by the political leaders

Elements or Components of PHC

  1.  Education concerning prevailing health problems including the methods of preventing or controlling them. (Health education). This was a broad component and each country was supposed to make strategies for its implementation. For example in Uganda; STI/HIV/AIDS, Malaria, Tuberculosis and epidemics have a priority in the health education department – MOB.
  2. Promotion of safe food supply and proper nutrition: this involves the process of improving food production, processing, storage, marketing, preparation and consumption with the ultimate goal of improving the nutritional status as well as economy of the community. Education is necessary especially on cultural beliefs and practices on nutrition for proper nutrition.
  3.  Provision of adequate safe water supply and proper sanitation.
    >  The quality of water sources and their availability in the communities.
    >  Sanitation involves control of those factors in total human environment that has a bearing to the health e.g. housing for proper sanitation, more emphasis is put on;
    >   Latrine coverage.
    >   Refuse disposal,
    >   Sewage management
  4.  Provision of maternal child health and family planning: These are health services rendered to mothers and children through ante-natal, maternity, post natal, family planning clinic; with the aim of improving the life of the mother and child. Most of the donor funding in form of conditional grants is targeted to this component so that the services are subsidized in terms of costs.
  5.  Provision of immunization against major infectious diseases: This gets a lion’s share on the donor funding than other components. WHO/UNICEF & CDC have been spearheading immunization worldwide. In Uganda 8 diseases are immunized i.e. poliomyelitis, tuberculosis, measles, diphtheria, whooping cough (pertussis), tetanus, hemophilic influenza type B and hepatitis B under EPI. Other vaccines like pneumococcal and Rotavirus are proposed to be included in EPI. The Human Papilloma Virus (HPV) against Cervical Cancer is also being introduced.
  6.  Prevention and control of locally endemic diseases: Special programs have been established to eradicate these endemic diseases e.g.
    >  Malaria- malaria control program.
    >  Leprosy and Tuberculosis- TB/Leprosy control program.
    >  Onchocerciasis.
    >  Schistosomiasis.
    >  Guinea worm.
  7.  Appropriate treatment of common diseases and minor injuries: this involves; Establishing of primary health centers i.e. HC II, III and IV with qualified health professionals. Establishment of home based care
    through community health workers(CHW) who should be trained to treat and for refer to the next level of service delivery.
  8.  Provision of essential drugs: The aim is to supply the community with the most needed drugs that meet the community’s needs. This also depends on the level of the health facilities or health service delivery.
    NB: These 8 elements of PHC were the first and original under the declaration of Alma-Ata conference. 

In case of Uganda, more components have been added
These include;

9.   Dental health and oral care
>  Oral hygiene education.
>  Prevention of oral and dental diseases.
>  Treatment of dental diseases.
10.  Mental health (community mental health): This is directed to care and rehabilitate the mentally sick in their community and prevention of mental illness.
11.  Rehabilitative health services (physically and mentally handicapped): Those services are provided by the community based rehabilitation programs to help PLW/PLWDs to live an independent life, earning and feel important and acceptable to the community.
12. STI/HIV/AIDS prevention and care. Efforts are geared to prevention and control of STI/HIV infection and treatment and care of the sick.
13.  Eye care (primary comprehensive eye care)
>   To prevent eye related problems in the community through health education.
>   Treatment and referral of patients with eye related problems in the community.

Concepts of Primary Health Care Read More »

Anaemia

Anaemia in Pregnancy

ANAEMIA IN PREGNANCY

Anaemia during pregnancy refers to a condition where the red blood cell count or haemoglobin  level in the mother’s blood is lower than normal. Anaemia in pregnancy is defined as haemoglobin (Hb) concentration is less than 11 g/dl.

Anaemia means a reduction in oxygen carrying capacity or in quantity of red blood cells. Red blood cells carry oxygen throughout the body, and low levels can lead to oxygen deprivation for both the mother and developing fetus.

This may be due to:

  • A reduction in the number of red blood cells.
  • A low concentration haemoglobin .
  • A combination of both
Classification or degree of anaemia (1)

Classifications/Degrees of Anaemia

  • Mild anaemia: haemoglobin  levels between 9.0 and 10.9 g/dL.
  • Moderate anaemia: haemoglobin  levels between 7.8 and 9.0 g/dL.
  • Severe anaemia: haemoglobin  levels below 7.0 g/dL.
  • Very Severe anaemia: haemoglobin  levels below 4.0 g/dL.
Causes of anaemia in Pregnancy

Causes of anaemia in Pregnancy

1. Social and Economic Factors:

  • Ignorance about utilizing food: Lack of knowledge about nutritious food sources and dietary practices, especially for iron-rich foods.
  • Poverty: Inability to afford a balanced diet rich in protein, iron, and other essential nutrients.
  • Unstable country / Insecurity: Conflict, displacement, and lack of access to healthcare resources can contribute to malnutrition and anaemia.
  • Beliefs and Cultural Superstitions: Certain cultural beliefs or practices might restrict the consumption of essential foods like chicken, eggs, or other iron-rich sources.

2. Obstetrical Causes:

  • Frequent childbearing: Closely spaced pregnancies can deplete iron stores, making anaemia more likely.
  • Repeated Hemodilution: The blood volume expands significantly during pregnancy to accommodate the needs of the growing fetus. This expansion can dilute the existing red blood cells, leading to lower haemoglobin  levels even if the body is producing enough red blood cells.
  • Multiple Pregnancy: The fetus requires iron for growth and development. The mother also needs extra iron to support the increased blood volume and oxygen delivery. This increased demand can deplete iron stores, leading to iron-deficiency anaemia.
  • Hyperemesis Gravidarum: Severe morning sickness can lead to poor absorption of nutrients, including vitamin B12, which is crucial for red blood cell production.
  • Abortions, Ruptured Ectopic Pregnancies, Postpartum Hemorrhage (PPH), Antepartum Hemorrhage (APH), and Heavy Periods: These conditions can lead to blood loss and iron deficiency.

3. Medical Causes:

  • Frequent Attacks of Malaria: Malaria infection destroys red blood cells, contributing to anaemia.
  • Hookworm Infestation: Hookworms can cause blood loss from the intestines, leading to iron deficiency anaemia.
  • Infections: Infections like septicemia (blood poisoning) and tuberculosis (TB) can impair red blood cell production.
  • Sickle Cell anaemia: A genetic blood disorder characterized by abnormal red blood cells, leading to chronic anaemia.
  • Drugs: Certain medications like chloramphenicol can interfere with red blood cell production and contribute to anaemia.

Other Factors

  • Dietary Deficiencies: Inadequate intake of iron, folate, and vitamin B12 are common contributing factors to anaemia.
  • Underlying Medical Conditions: Conditions like celiac disease, chronic kidney disease, or certain types of cancer can impair the body’s ability to produce red blood cells.
  • Previous anaemia: Women with a history of anaemia before pregnancy are more likely to experience it again.

Types of Anaemia

  1. Physiological anaemia.
  2. Nutritional anaemia.
  3. Aplastic anaemia.
  4. Haemorrhagic anaemia.
  5. Haemolytic anaemia.
  6. Pernicious anaemia.

1.  Physiological Anaemia: A temporary, physiological decrease in haemoglobin levels, often during pregnancy. This type of anaemia is considered “normal” during pregnancy and is primarily due to hemodilution. As the blood volume increases by 25-30% during pregnancy to accommodate the growing fetus, the concentration of red blood cells (and haemoglobin) appears to decrease, leading to a diluted blood picture.

  • Hemodilution: During pregnancy, blood volume increases significantly, diluting the haemoglobin concentration. This is a normal adaptation to support the growing fetus and placenta.
  • Increased Iron Demand: The growing fetus requires a substantial amount of iron for development, potentially leading to a temporary iron deficiency.
  • Physiological anaemia is usually mild and resolves itself after childbirth. 

2. Nutritional Anaemia: Anaemia caused by dietary deficiencies of essential nutrients required for RBC production. Nutritional anaemia can present as;

  • Iron Deficiency Anaemia: The most common type, caused by insufficient iron intake or absorption. Iron is essential for haemoglobin synthesis. Inadequate iron leads to smaller, paler RBCs (hypochromic microcytic anaemia). The increased fetal demand for iron, especially from the 28th week onwards, exacerbates this issue. Excessive morning sickness can also contribute by reducing iron absorption.
  • Folate Deficiency Anaemia (Megaloblastic Anaemia): A lack of folate (vitamin B9) disrupts DNA synthesis, leading to the formation of large, immature RBCs (megaloblasts). These cells are less effective at carrying oxygen.
  • Vitamin B12 Deficiency Anaemia (Pernicious Anaemia): A deficiency in vitamin B12, important for DNA synthesis and maturation of RBCs, results in megaloblastic anaemia. A lack of protein can also contribute to this type.
  • Vitamin C Deficiency: Vitamin C is important for iron absorption. Its deficiency can worsen iron deficiency anaemia.
  • Impact: Nutritional anaemia is preventable and treatable with dietary modifications and supplementation.

3. Aplastic Anaemia: A rare and serious condition characterized by the suppression of bone marrow activity, resulting in reduced production of all blood cell types, including RBCs. The most common cause being Bone Marrow Failure, The bone marrow, responsible for blood cell production, becomes unable to generate enough RBCs. This can be caused by various factors, including:

  • Drug-induced: Prolonged use of certain medications like chloramphenicol can suppress bone marrow function.
  • Radiation Exposure: Exposure to ionizing radiation can suppress bone marrow function, since they can damage bone marrow cells.
  • Diseases: Conditions like leukemia, cancer, and autoimmune diseases can affect bone marrow activity.
  • Toxins: Exposure to toxic chemicals can damage bone marrow cells.
  • Aplastic anaemia can be life-threatening. It requires immediate medical attention and may necessitate bone marrow transplantation or other intensive treatments.

4. Hemorrhagic anaemia: Anaemia resulting from excessive blood loss, leading to a reduction in circulating RBCs. This type results from excessive blood loss, which can occur due to a variety of reasons:

  • Frequent Childbearing: Closely spaced pregnancies can deplete iron stores and increase the risk of blood loss during delivery.
  • Worm Infestations: Hookworm infestation can lead to chronic blood loss from the intestines.
  • Abortions, PPH, and APH: These conditions can lead to significant blood loss.
  • Ruptured Ectopic Pregnancy: A ruptured ectopic pregnancy can cause internal bleeding.
  • Trauma and Accidents: Trauma or accidents can cause severe blood loss.
  • Gastrointestinal Bleeding: Conditions like ulcers, gastritis, and esophageal varices can cause internal bleeding.
  • Acute Blood Loss: Sudden and significant blood loss, often due to trauma, surgery, or internal bleeding, causes a rapid decrease in RBCs.
  • Chronic Blood Loss: Persistent, slow blood loss, often from gastrointestinal bleeding or heavy menstrual periods, gradually depletes the body’s iron stores and reduces RBC production.
  • Hemorrhagic anaemia can be severe, particularly in cases of acute blood loss. Treatment focuses on stopping the bleeding and replacing lost blood.

5. Hemolytic anaemia: Anaemia caused by the premature destruction of RBCs (hemolysis), leading to a shortage of healthy RBCs in circulation. This may be due to,

Intrinsic Defects: Hemolysis can be caused by abnormalities within the RBCs themselves, such as:

  • Sickle Cell Disease: This genetic disorder leads to the production of abnormal red blood cells that are easily destroyed. An inherited disorder where RBCs adopt a sickle shape, making them fragile and prone to destruction.
  • Thalassemia: Genetic disorders that impair haemoglobin production, leading to weakened RBCs.

Extrinsic Factors: Factors outside the RBC can also trigger hemolysis:

  • Infections: Infections like septicemia, pyelonephritis, and bacterial streptococcal infections can destroy red blood cells.
  • Diseases: Malaria is a common cause of hemolytic anaemia due to its destruction of red blood cells.
  • Mismatched Blood Transfusion: Receiving mismatched blood can lead to an immune reaction that destroys red blood cells.
  • Immune Reactions: Antibodies against RBCs, often due to blood transfusions or autoimmune disorders, can cause hemolysis.
  • Drugs: Certain medications like primaquine can cause hemolytic anaemia.

6. Pernicious anaemia: A specific type of megaloblastic anaemia caused by a deficiency in vitamin B12, usually due to a lack of intrinsic factor, a protein produced in the stomach that helps the body absorb vitamin B12. Pernicious anaemia is less common during childbearing years, but can occur due to:

  • Autoimmune Destruction of Parietal Cells: In most cases, pernicious anaemia is caused by an autoimmune attack on the parietal cells in the stomach, leading to a deficiency of intrinsic factor.
  • Diseases of the Stomach: Conditions like stomach cancer can interfere with intrinsic factor production.
  • Hyperemesis Gravidarum: Severe morning sickness can lead to vitamin B12 deficiency due to poor absorption.
  • Gastrectomy or Gastric Bypass Surgery: These procedures can reduce intrinsic factor production, impairing vitamin B12 absorption.
  • Other Causes: Conditions like Crohn’s disease and celiac disease can also interfere with vitamin B12 absorption.
Anaemia in pregnancy

Signs and Symptoms of Anaemia in Pregnancy

Anaemia’s signs and symptoms can vary depending on the severity and underlying cause. 

On History Taking

  • General Body Weakness: This is usually the most common symptom, resulting from the body’s reduced oxygen-carrying capacity.
  • Dizziness and Faintness: Reduced blood flow to the brain can cause lightheadedness and a feeling of faintness.
  • Palpitations: The heart may beat faster to compensate for the reduced oxygen supply.
  • Loss of Appetite (Anorexia): A decrease in appetite can be associated with anaemia.
  • Headaches: Headaches can be caused by reduced oxygen to the brain.
  • Breathlessness: The lungs may work harder to deliver oxygen to the body’s tissues.
  • Shortness of Breath: Increased effort for the heart to pump oxygenated blood.
  • History of Heavy Bleeding: A history of significant blood loss, such as from trauma, surgery, or gastrointestinal bleeding, can be a contributing factor.

On Examination

  • Pale Mucous Membranes and Conjunctiva: This refers to the paleness of the gums, lips, tongue, soles of the feet, and palms of the hands, which are visible indicators of reduced haemoglobin.
  • Distention of the Jugular Veins: This can be seen in severe cases of anaemia due to a decrease in blood volume.
  • Edema (Swelling): Swelling of the ankles, feet, or even generalized edema can occur in severe cases.
  • Enlarged Spleen and Liver: Palpation of the abdomen might reveal an enlarged spleen and liver, indicating an increase in red blood cell destruction or storage.
  • Jaundice: Yellowing of the skin and whites of the eyes can occur in some types of anaemia, particularly those related to red blood cell breakdown.
  • Cold Hands and Feet: Poor blood flow can lead to cold extremities.

Laboratory Tests

  • Haemoglobin Level: The most crucial test for anaemia, measuring the amount of haemoglobin in the blood. Levels below 12.5 g/dL are generally considered anaemic.
  • Increased Susceptibility to Infections: A weakened immune system makes pregnant women more prone to infections.

Diagnosis

Anaemia diagnosis relies on a combination of factors:

  • History: A detailed history of the patient’s symptoms, diet, medical history, medications, and potential exposures helps narrow down the possible causes.
  • Physical Examination: Careful assessment for physical signs like pallor, edema, and enlarged organs provides further clues.
  • Laboratory Investigations:
  • Haemoglobin Estimation: Confirming a low haemoglobin level.
  • Packed Cell Volume (PCV): Measures the percentage of red blood cells in the blood.
  • Blood Film: Examining the shape, size, and maturity of red blood cells, identifying specific features like:
  • Microcytosis and Hypochromia: Small, pale red blood cells (iron deficiency)
  • Megaloblastic Cells: Large, immature red blood cells (vitamin B12 and folate deficiency)
  • Sickle Cells: Abnormal, crescent-shaped red blood cells (sickle cell anaemia)
  • Target Cells: Red blood cells with a bullseye appearance (thalassemia)
  • Reticulocytes: Immature red blood cells (indicating red blood cell production)
  • Blood Sugar (BS) for Malarial Parasites: To rule out malaria, a common cause of anaemia in certain regions.
  • Sickling Test: To confirm the presence of sickle cells in cases of suspected sickle cell disease.
  • Coombs Test: To detect antibodies against red blood cells, suggesting autoimmune hemolytic anaemia.
  • Bone Marrow Examination: To assess the bone marrow’s ability to produce red blood cells and identify any abnormalities.
  • Urinalysis: To check for protein, indicating kidney damage, and to examine for red blood cells or other abnormalities.
  • Stool Examination: To identify intestinal parasites like hookworms, which can cause anaemia.
  • Haemoglobin Electrophoresis: To confirm sickle cell disease.

Iron Requirements During Pregnancy

  • Increase in Maternal Haemoglobin (400-500 mg): The mother’s blood volume expands significantly during pregnancy, requiring an increased production of red blood cells, which in turn need iron to carry oxygen.
  • The Fetus and Placenta (300-400 mg): The growing fetus requires iron for its own red blood cell production and development. The placenta also needs iron for its own functioning and to support fetal growth.
  • Replacement of Daily Loss (250 mg): Iron is lost daily through urine, stool, and skin. This loss needs to be replenished to maintain adequate iron stores.
  • Replacement of Blood Lost at Delivery (200 mg): Labour and delivery can involve significant blood loss, requiring iron replenishment afterwards.

Total Iron Needs: These factors contribute to a total iron requirement of approximately 1,500 mg during pregnancy.

Other Essential Nutrients:

  • Elemental Iron: Recommended daily intake is 30 mg to 60 mg for pregnant women.
  • Folic Acid: Recommended daily intake is 400 µg (0.4 mg) to prevent neural tube defects in the fetus.

Effects of anaemia on pregnancy and labour

Effects on Pregnancy:

General Body Fatigue: Anaemia leads to decreased oxygen carrying capacity, causing widespread fatigue, breathlessness, palpitations, and headaches.

Placental Insufficiency: Reduced oxygen delivery to the placenta can lead to:

  • Intra-Uterine Fetal Death (IUFD): The fetus may not receive enough oxygen to survive.
  • Small for Dates (SFD): The fetus may not grow at the expected rate due to insufficient nutrient and oxygen supply.
  • Neonatal Death: anaemia can increase the risk of death in the newborn.
  • Abortion and Premature Labour: Anaemia can increase the risk of both.

Increased Risk of Complications:

  • Postpartum Haemorrhage: Anaemia can impair blood clotting, making mothers more susceptible to excessive bleeding after delivery.
  • Heart Failure: The heart works harder to compensate for lower oxygen levels, increasing the risk of heart failure.
  • Venous Thrombosis: Anaemia can increase blood viscosity, leading to blood clots in the veins.
  • Infections: A weakened immune system due to anaemia makes mothers more vulnerable to infections.
  • Poor Lactation: Anaemia can impact milk production and quality.
Effects on Labour:
  • Stress of Labour: Anaemic women may struggle to tolerate the stress of labour, and even minor blood loss can be life-threatening.
  • Fetal and Maternal Distress: Low oxygen levels can lead to fetal and maternal distress, potentially necessitating an instrumental delivery (e.g., forceps or vacuum extraction).
  • Increased Risk of Complications: Anaemia can increase the risk of complications during labor, including postpartum haemorrhage, infection, and prolonged labor.

Management of anaemia in Pregnancy

Management of anaemia in pregnancy depends on the severity of the anaemia, stage of gestation, and underlying cause.

Early Pregnancy with Mild or Moderate anaemia in a Maternity Center and Hospital:

Outpatient Management:

  • Put the mother in bed.
  • Take a history from the mother concerning diet, lifestyle, and surroundings to determine the cause of anaemia.
  • Conduct a general examination to assess the degree of anaemia using a Tallquist book.
  • The midwife can treat mild and moderate anaemia in early pregnancy.
  • Manage the condition according to the underlying cause.
  • Refer the mother to the hospital for further investigations if haemoglobin is found to be below 60%.

Active Treatment for haemoglobin  of 60% and Above:

  • Administer three doses of Fansidar 960 mg tablets where malaria is common.
  • Administer Mebendazole 200 mg twice daily for three days for hookworm.
  • Provide iron therapy with ferrous sulfate (200 mg twice daily) and folic acid (5 mg once daily). Review after 2 months.

Note: In the maternity centre, refer moderate anaemia in late pregnancy to the hospital.

In the Hospital:

  • Admit the mother to the antenatal ward.
  • Take a history about diet, environment, and hygiene.
  • Monitor observations: temperature, pulse, respirations, and blood pressure.
  • Treat any underlying cause accordingly.
  • Provide routine nursing care.
  • Ensure proper hygiene.
  • Provide a high-protein diet.

Severe anaemia in Early and Late Pregnancy:

In a Maternity Center:

  • Refer to the hospital.

In the Hospital:

  • Admit the mother and take a history.
  • Conduct observations and investigations.
  • Resuscitate immediately with:
  • Blood transfusion or parenteral iron dextran (Inferon) infusion if blood is unavailable. Note: Total dose of Inferon is given slowly, only in severe anaemia close to delivery. After delivery, transfuse with packed cells under Lasix.
  • Administer diuretics, e.g., Lasix 120 mg IV.
  • Nurse the patient with severe anaemia propped up in bed and provide comprehensive care.
  • Pay special attention to mouth care, as stomatitis and glossitis are common in anaemia patients.
  • Provide a high-protein diet with green vegetables and fresh fruit.
  • Maintain a strict fluid balance chart and observe for signs of impending cardiac failure, such as increasing pulse and respirations. Report breathlessness, especially if the patient has tuberculosis. 
  • Note: IV Inferon: 5 ampoules of 250 mg each in 100 ml of dextrose 5% or normal saline 500 ml.

Management During Labor:

1st Stage:

  • Comfortable Positioning: Ensure the mother is in a comfortable position on the bed.
  • Light Analgesia: Consider light pain relief measures as needed.
  • Oxygenation: Administer oxygen to increase maternal blood oxygenation and prevent fetal hypoxia.
  • Strict Asepsis: Maintain strict sterile practices to minimize infection risk.

2nd Stage:

  • Usually No Specific Issues: This stage typically proceeds without major issues related to anaemia.
  • Methergin or Oxytocin Administration: Administer 0.2 mg of Methergin or 20 units of oxytocin in 500 ml of Ringer’s Lactate intravenously, followed by 10 units intramuscularly, to prevent postpartum haemorrhage.

3rd Stage:

  • Good management of the 3rd stage of labour to prevent much blood loss.
  • Intensive Observation: Closely monitor for postpartum haemorrhage and other complications.
  • Blood Replacement: Replace any significant blood loss with fresh packed red blood cells.
  • Avoid Overloading: Be cautious not to exceed the amount of blood loss replaced to avoid fluid overload.

Puerperium (Postpartum Period):

  • Bed Rest: Encourage bed rest to allow for recovery.
  • Infection Monitoring and Treatment: Monitor for signs of infection and treat promptly.
  • Continuation of Iron Therapy: Continue iron supplementation until haemoglobin levels return to normal.
  • Dietary Guidance: Continue to promote a healthy, iron-rich diet.
  • Counselling: Provide education and support to the mother and family regarding baby care and household chores.

Prevention of anaemia:

  • Good Antenatal Care: Detect and treat anaemia and malaria early.
  • Health Education: Teach about diet, personal hygiene, and environmental sanitation, including proper use of latrines.
  • Malaria Protection: Take preventive measures against malaria.
  • Blood Loss Reduction: Manage all stages of labour to reduce blood loss in the third stage.
  • Protein Replacement: Provide extra protein during lactation.
  • Folic Acid Supplementation: Administer as needed.
  • Routine Blood Examinations: Monitor haemoglobin levels regularly.
  • Avoidance of Frequent Childbirths: Spacing pregnancies adequately allows the body time to recover iron stores.
  • Dietary Advice: Encourage a diet rich in iron-rich foods like red meat, fish, beans, lentils, and leafy green vegetables.
  • Supplementary Iron Therapy: Prescribe iron supplements as needed, based on individual needs and blood tests.
  • Treatment of Underlying Illnesses: Address any underlying medical conditions that may contribute to anaemia, such as infections, parasitic infestations, or chronic diseases. Early diagnosis and treatment are crucial.

Advice to the Mother:

  • Tell the mother to report immediately when they become pregnant in order to receive appropriate prophylactic treatment of  iron therapy.
  • Explain the cause of anaemia, its dangers, and how to prevent it.
  • Advise rest to avoid overworking.
  • Discuss diet and types of food.
  • Encourage taking any prescribed treatment regularly.
  • Stress the importance of preventing mosquito bites to avoid malaria.
  • Advise on family planning to avoid frequent childbearing.
  • Recommend delivery in the hospital.

Complications of Anaemia in Pregnancy

Maternal Complications

Fetal Complications

Increased risk of PPH

Premature birth

Increased risk of infection

Low birth weight

Increased risk of heart failure

Fetal growth restriction

Fatigue and weakness

Stillbirth

Shortness of breath

Cerebral palsy

Increased risk of preeclampsia

Congenital anomalies

Increased risk of delayed wound healing

Cognitive impairment

Increased risk of death

Delayed development

Anaemia in Pregnancy Read More »

Domiciliary care

Domiciliary Care

Domiciliary care is an obstetric care given to a mother in her home during pregnancy, labour and puerperium

Types of Domiciliary Care

  1.  Type one domiciliary midwifery care “continuity:; In this type the woman is cared for in her home all through during antenatal period delivery and postnatal care. The woman will only visit a health unit or hospital only when there is a problem that requires specialized care or more gadgets to be used. This care is known as continuity of care or fragmented care. In this case one midwife provides all the care to the woman.
  2.  Type two, community, integrated or centralized care; In this care service is integrated (mixed) in a way that part of the care may be given at home and some in the health setting like a hospital. Usually antenatal or delivery may be offered in the hospital and puerperium period managed at home. This is the type of care that student midwives and nurses offer as part of their midwifery part two and is compulsory for them.
  3.  Employee or independent practitioner in domiciliary; This is a type of care in which a midwife practices as a private midwife in the community but not necessarily on one woman. The midwife may have a maternity Centre for all or part of the care or she may combine it with one to one community midwifery care. This is the commonest type of domiciliary care in Uganda.

Forms of Domiciliary Care
Characteristics of patterns of domiciliary care depend on a number of factors and these can be:

  • Decision of the midwife
  • Decision of the woman / family
  •  Location and nature of community
  •  Availability of basic requirements for domiciliary care

Objectives of Domiciliary Care.

  1.  Domiciliary midwifery care  to take midwifery near to the community thus increasing accessibility to services

  2.  To encourage full participation and involvement of male partners and family members in the birth process so as to get their full support

  3.  To reduce on maternal / infant morbidity and mortality as the midwife has less workload and concentrates on one woman.

  4.  To reduce on hospital/health facility over crowding

  5.  To promote midwife-mother relationship and mutual understanding between the woman and the midwife.

Domiciliary Care given by midwives
  1.  Care before conception
    >   Health education to young girls on good nutrition and hygiene
    >   Teaching young girls about life skills
    >    Immunization of young girls with tetanus toxoid
    >    Counselling adolescents on reproductive health and other social issues
  2.  Care during pregnancy
    >   Immunization
    >   Antenatal check ups
    >   Treatment of minor problems.    >   Health education on problems in pregnancy
  3. Care during labour
    >   Care of mother in Labour
    >   Use of partograph to monitor labour
    >   Delivering of the baby
    >   Infection prevention
  4. Care after delivery
    >   Immunization
    >   Care of mother and baby
    >   Postnatal exercises
    >   Family planning

Advantages of Domiciliary Services.

  • Domiciliary services promotes midwife – mother relationships and thus minimizing fears and phobias of childbirth
  • It promotes continuity of care and close supervision of the mother thus – contributing to the reduction of maternal / infant morbidity and mortality
  •  Increases access to health services as the woman is found in her home instead of herself looking for the services
  •  Domiciliary is cost effective to a certain level as only relevant care will be given to individual women and at the same time the woman will continue her responsibilities especially supervision of the home
  •  It gives peace of mind to the mother, husband children and other house members because the woman remains at home
  •  It promotes woman centered care including choice control over services rendered and also encourages continuity of care.
  •  It promotes privacy and security and respect the mother with less interference and exposure
  • Promotes good communication and openness. Only relevant information is given to the mother and her family. As the midwife knows the woman personally, she understands better their concerns, lives, and challenges and assists them accordingly.
  •  Promotes autonomy to the midwife and there is job satisfaction
  •  It promotes creativity, problem solving skills and maturity in service with good experience.

Brief History of Domiciliary Care

 Throughout the ages, women have depended upon a skilled person, usually another
woman to be with them during child birth
 In United Kingdom, the midwives skills are increasingly valued and midwives are being urged to expand their role even further in the field of public health.

  • In Uganda in 1960’s(May 1968), this is when the midwife would look after the mother in the home environment.  Midwives would do antenatal care, deliver mothers in their own homes and continue to give post natal care in the mother’s home.
     >    This would also give opportunity for the midwife to give health education to the other family members.
    >     In the 1970s when the political system in Uganda changed, leading to a lot of insecurity, the midwives stopped delivering mothers at home  and instead delivered mothers in hospitals and maternity units. Then the midwives continued to nurse the mothers and their babies at the mother’s home.
     > These services have continued today and are being practiced by Private Midwives and the student midwives who are undertaking Registered Midwifery Course of Diploma in Midwifery Course.
Types/ Groups of mothers Needing Domiciliary care
  • Group 1: Women with less risk of getting complications
    Women who have ever delivered one baby but have not exceeded five – that is gravid two to four.
    This group of women if they did not experience any major complication in pregnancy labour and puerperium, can be care for in the community throughout, pregnancy labour and puerperium
  • Group 2: These are the women who are suspected of developing a complication, though they may not develop them at all. For examples: primigravida – pregnant for the first time,
    Grandmultipara – has delivered more than four times, short women- less than 152cm high, women with previous complications that are likely to occur again e.g. cord prolapsed.
    This group of women may be cared for only for antenatal or delivery and puerperium depending on other factors as detected on history and assessment.
  • Group 3: These are the high Risk Mothers, women who come with obvious complications, or are highly suspected of developing various complications. Examples: Multiple pregnancy – those with medical conditions like cardiac diseases, diabetes mellitus, sickle cell disease.

Common Drugs used in Domiciliary 

  •  Ergometrine
  •  Ferrous sulphate
  •  Folic acid
  •  Panadol
  •  Chloroquine

How Domiciliary is carried out.

  •  Booking

A mother who has to be booked must be with the following
>  Must be normal with no risk factors like CPD,
>  Grandemultparity, multiple pregnancy

  •  Home delivery

The following must be put in consideration
(a).   Well ventilated home without without overcrowding
(b).   Clean house, good hygiene in and around the house
(c).   The house should have more than 4 bedrooms, toilets
and kitchen
(d).   The floor must be cemented
(e).   There must be tap water
(f).   There must be easy means of boiling water

  •  Enough equipment especially for the mother and baby(bathing)
  •  Husband and wife should be willing for the care
  •  The distance from the home to hospital should be less than 2 miles.

QUALITIES OF A MIDWIFE

In normal circumstances the midwife should be a qualified senior student midwife with enough knowledge
(a)  She must create a friendly relationship between her, the mother and family
(b)   She must remember that she does not belong to the family and is only a guest so she must adopt her behavior in relation to the family routine
(c)   No commands or orders should be given but advices, the midwife should be flexible
(d)   She should show interest in the family
(e)   Avoid embarrassing the mother in the family

(f)   She has to apply her professional code of conduct and stay in the home only as a midwife
(g)   Quick and correct judgment has to be applied in providing the best care expected


DOMICILIARY BAGS

The midwife must be equipped with the following

  •  Sphyginomanometer
  •  Stethoscope
  •  Urine testing strips
  •  Clinical thermometer
  •  Spirit for baby’s cord
  •  Swabs in the gallipot and cord ligatures
  •  Receivers, dissecting forceps, artery forceps, scissors
  •  Antiseptic lotion
  •  Plastic apron and tape measure
  •  Drugs like Panadol, and iron tablets

 

Care

Here in Uganda a mother is delivered in the hospital then cared for in her home for seven day including the 1st days in the hospital
ANTENATAL CARE
Normally a mother is booked on her 1st visit at 12wks.It should be during this time when the midwife inspect the home of the mother until the mother is delivered in the hospital and cared for the first 2 days and  then 5 days at home
PUEPERIUM
During puerperium the midwife continues to visit the mother daily at her home. If there is any indication of complication arising of the mother requires extra supervision and support additional visits will be made
The midwife observes the mother’s general condition both mentally and physically, ask her how she is feeling. Inquire about the baby particularly feeding, sleeping, passage of urine and stool.
If the mother appears stressed, depressed, or anxious about the baby or any other problem. The midwife should sit, listens and responds. The time spent listening and discussing problems with the mother invariably of great value to her wellbeing
The midwife inquires whether the mother is sleeping and eating well passing urine without difficult or discomfort and has had a bowel action.
She take the mothers vitals and carries out a full postnatal examination of the breast, abdomen to palpate the uterus, vulva to inspect lochia and perineum.
Any abnormality detected should be discussed with the mother and appropriate advice is given. Postnatal exercises are taught on the first day after delivery and the mother is encouraged to practice them dairy throughout puerperium
On the first postnatal visit the midwife usually assists the mother to bath there after the mother should have a bath on her own should be twice or more daily, mother should be advised to change her pads frequently.

Adequate rest and sleep are essential and though ambulating is good but the mother should rest and sleep at appropriate time each day.
The mid wife performs a daily examination on the baby and shows the mother how to bath and dress the baby and attend to the cord.
> She observes its general condition,  examine him from head to toe observing the skin, eyes, mouth and cord for any signs of infection or any abnormality.
> Stool should be observed and the passage of urine.
> Baby should be observed whether breastfeeding well
> At the last visit, the mid wife advises the mother when to go back to postnatal clinic and the baby to health clinic.
> Health educate and demonstrates to the mother the postnatal exercises.

Domiciliary Care Read More »

terms in anatomy

 Terms used in Anatomy and Physiology

Module Unit CN-111: Anatomy and Physiology (I)

Contact Hours: 60

Module Unit Description: Introduces students to the anatomy and physiology of the human body, covering the structure and function of different body parts and systems, specifically skeletal, muscular, circulatory, and digestive systems.

Learning Outcomes for this Unit:

By the end of this unit, the student shall be able to:

  • Identify various parts of the human body and their functions.
  • Differentiate the normal structure and functioning of various systems from that of abnormal conditions of the skeletal, muscular, cardiovascular and digestive systems.

Topic: Introduction to Anatomy and Physiology (Part 1)

Welcome to the study of the human body, a fascinating and complex machine! In this module, we will learn about the different parts of the body and how they work together to keep us healthy. Understanding the normal structure and function of the body is essential for recognizing what happens when something goes wrong (illness or disease).

We will cover the foundational concepts in anatomy and physiology and then look specifically at the skeletal, muscular, cardiovascular, and digestive systems.

Common Terms In Anatomy And Physiology

To begin our study, let's define some important terms that are like the basic language of this subject:

  • Anatomy: This is the study of **structures** that make up the body and how they relate with each other.
  • Physiology: This word is derived from a Greek word for study of nature. It is the study of how the body and its part **work together** or function.
  • Homeostasis: This is defined as how the composition of the **internal environment is well controlled** in a fairly constant state.
  • Atoms molecules and compounds: The smallest level of the body is in form of **atoms**.
  • Cell: A Cell is the **basic living structural and functional unit** of the body, and the study of cells is called Cytology.
  • Tissue: A Tissue is a **collection of many similar or related cells** that perform a specific function. The various tissues are grouped into four groups. 1. Epithelial, 2. Connective, 3. Nervous and 4. Muscle tissue.
  • Organ: – This is a collection of **two or more groups of tissues** that works harmoniously together to perform specific function.
  • System: This is a **group of organs** that work together to perform major function.
  • Pathology: This is the study of the "**damage**" or "**disease**" in the body. Pathology looks at **abnormal changes** in the body's structure and function that are caused by illness, injury, or disease. It describes what happens to tissues and organs when they are not healthy.
  • Pathophysiology: This is the study of the "**effects of the damage**". Pathophysiology explains how the changes caused by a disease affect the normal functions of the body and lead to the **signs and symptoms** that a person experiences when they are sick. It connects the damage (pathology) to the symptoms (what the patient feels or shows).
  • Health: When all the body's parts and systems are working correctly and together in a balanced way (**homeostasis** is maintained), the person is considered to be in a state of health.
  • Illness/Disease: When the body's systems are not working correctly, and the body cannot maintain its normal balance, a person becomes ill or develops a disease. This can happen when one part fails, putting a strain on other parts.

Abbreviations (Commonly Used)

Terms commonly used in Anatomy will be understood after these abbreviations are understood since they will be used occasionally:

  • Ach: Acetylcholine
  • ACTH: Adrenal Cortico- trophic Hormone
  • ADH: Anti diuretic Hormone
  • ANS: Autonomic Nervous System
  • ATP: Adenosine Tri Phosphate
  • C: Cervical, cervical vertebrae, (i.e. C4 cervical vertebrae 4)
  • cm: Centimeter
  • CNS: Central Nervous System
  • CRH: Corticotropin Releasing Hormone
  • CSF: Cerebrospinal Fluid
  • DNA: Deoxyribonucleic Acid
  • /d: Per day
  • FSH: Follicular stimulating hormone
  • GHRH: Growth Hormone Releasing Hormone
  • GI: Gastro Intestinal
  • GnRH: Gonadotrophin Releasing Hormone
  • HCG: Human Chorionic Gonadotrophin hormone
  • Hcl: Hydrochloric acid
  • GH: Growth Hormone
  • ICSH: Interstitial Cell Stimulating Hormone
  • IGF: Insulin Growth Factors
  • IUD: Intra Uterine Device
  • L: Lumbar, lumbar vertebrae, ( i.e L3, lumbar vertebrae 3)
  • LH: Luteinizing Hormone
  • PNS: Peripheral Nervous System
  • PRH: Prolactin Releasing Hormone
  • PTH: Para Thyroid Hormone
  • RNA: Ribonucleic Acid
  • rRNA: Ribosomal Ribonucleic Acid
  • T: Thoracic, thoracic vertebrae, (T1 thoracic vertebrae 1)
  • T3: Triiodothyronine
  • T4: Thyroxin

Human body Organisation

The human body is built up in layers of complexity, like building something from the ground up. Each level works with the others.

  1. Chemical level: This is the starting point – the very tiny non-living building blocks. It involves atoms combining through chemical bonds to form molecules. These are the chemical ingredients of life.
  2. Cellular level: The molecules come together in specific ways to create cells. Cells are the basic living units of the body. There are many different types of cells, each with a specialised job.
  3. Tissue level: When many similar types of cells group together and work as a team to perform a particular job, they form a tissue. (We will look at the main tissue types below).
  4. Organ level: Different types of tissues are organised together to form an organ. An organ is a distinct structure with a specific function.
  5. System level: A group of organs that work together to perform a major function essential for the body's survival is called a system.
  6. Organism level: All the body systems work together in a coordinated way to make a complete human being (the organism). The health of the whole person depends on all the systems working together effectively.

Anatomical Positions

Anatomical positions are accepted universally as the starting points for positional references to the body. In anatomical positions, the subject (body of patient or client to be observed) is standing erect and facing the observer (the medical examiner), the feet are together, and the arms are hanging at the sides with the palms facing forward.

Relative Directional terms

Standard terms of reference are used when anatomists Or medical examiners, describe the location of a certain body part.

Relative means the location of one’s body part is always described in relation to another body part of the same human body.

Terms used and Description:

  • Superior (cranial): Means towards the head. The leg is superior to the foot.
  • Inferior (caudal): Toward the feet. The foot is inferior to the leg.
  • Anterior (ventral): Toward the front part of the body. The nose is anterior to the ears.
  • Posterior (dorsal): Towards the back of the body. The ears are posterior to the nose.
  • Medial: Towards the midline of the body. The nose is medial to the eyes
  • Lateral: Away from the midline of the body. The eyes are lateral to the nose.
  • Proximal: Toward (nearer) the trunk of the body or the attached end of a limb. The shoulder is proximal to the wrist.
  • Distal: Away (further) from the trunk of the body or the attached end of a limb. The wrist is distal to the forearm.
  • Superficial: Nearer to the surface of the body. The ribs are superficial to the heart.
  • Deep: Further from the surface of the body. The heart is deeper to the ribs.
  • Peripheral: Away from the central axis of the body. Peripheral nerves radiate away from the brain and spinal cord.

Body parts Regions

The body parts regions are:

  • Axial: – This is the part of the body that is near the axis of the body. This includes head, neck, thorax (chest), abdomen, and pelvis.
  • Appendicular body part: – This is the part of the body out of the axis line. This includes the upper and lower extremities.

The abdomen is divided into nine regions or more, easily divided into four quadrants.

Body planes and sections

Body planes are imaginary surfaces like, plane lines that divide the body into sections. This helps for further identification of specific areas.

  • Sagittal plane: – divides the body into right and left half.
    1. – Mid sagittal plane: – divides the body into two equal left and right halves.
    2. – Para sagittal plane: – divides body into two unequal left and right
  • Frontal plane: – divides the body into asymmetrical anterior and posterior sections.
  • Transverse plane: – divides the body into upper and lower body section.
  • Oblique plane: – divides the body obliquely into upper and lower section.

Revision Questions for Page 1 (Part 1):

1. Define the following terms in your own words: Anatomy, Physiology, Homeostasis, Pathology, Pathophysiology.

2. List the six levels of structural organization in the human body from simplest to most complex.

3. Describe the standard anatomical position.

4. Use directional terms to describe the location of the nose relative to the ears, and the elbow relative to the wrist.

5. What is the difference between the axial and appendicular regions of the body?

6. Differentiate between the sagittal, frontal, and transverse body planes.

References (from Curriculum for CN-111):

Below are the core and other references listed in the curriculum for Module CN-1102. Refer to the original document for full details.

  • Cohen, JB and Hull, L.K (2016) Memmlers – The Human body in Health and diseases 13th Edition, Wolters, Kluwer. (Core Reference)
  • Cohen, J.B and Hull, L.K (2016) Memmler's Structure and Function of the Human Body. 11th Edition. Wolters Kluwer, China
  • Kumar, M and Anand, M (2010) Human Anatomy and Physiology for Nursing and Allied Sciences. 2nd Edition. Jaypee Brothers Medical Publishers Ltd.
  • Scott, N.W. (2011) Anatomy and Physiology made incredibly easy. 1st Edition. Wolwers Kluwers, Lippincotts Williams and Wilkins.
  • Moore, L. K, Agur, M.R.A and Dailey, F.A. (2015) Essential Clinical Anatomy.15th Edition. Wolters Kluwer.
  • Snell, S. R. (2012) Clinical Anatomy by Regions. 9th Edition. Wolters Kluwer, Lippincott Williams and Wilkins, China
  • Wingerd, B, (2014) The Human Body-Concepts of Anatomy and Physiology. 3rd Edition Lippincott Williams and Wilkins and Wolters Kluwer.
  • Rohen, Y.H-Orecoll. (2015) Anatomy.A Photographic Atlas 8th Edition. Lippincott Williams & Wilkins
  • Waugh, A., & Grant, A. (2014). Ross and Wilson Anatomy & Physiology in Health and Illness (12th ed.). Churchill Livingstone Elsevier. (Added as per user's reference)

 Terms used in Anatomy and Physiology Read More »

Pulmonary hemorrhage

Pulmonary Hemorrhage

PULMONARY HEMORRHAGE

Pulmonary hemorrhage (PH) is a serious condition in children, characterized by bleeding into the alveoli and airways of the lungs. 

Pulmonary haemorrhage is an acute bleeding from the lung, from the upper respiratory tract, the trachea, and the alveoli. 

Pulmonary hemorrhage (PH) in infants is a serious condition characterized by bleeding into the lungs, often presenting as fresh, bloody fluid from the endotracheal tube (ETT) or lower respiratory tract.

Defining Pulmonary Hemorrhage:

  • Massive Pulmonary Hemorrhage: Involves at least two lobes of the lungs.
  • Histological Definition: Presence of red blood cells (RBCs) within the alveolar spaces or interstitium of the lung tissue.

 

The onset of pulmonary hemorrhage is characterized by productive cough with blood (hemoptysis) and worsening of oxygenation leading to cyanosis.

Causes of Pulmonary Heamorrhage

Infectious:

  • Viral: Respiratory syncytial virus (RSV), influenza, parainfluenza
  • Bacterial: Mycoplasma pneumoniae, Chlamydia pneumoniae
  • Other: Adenovirus, rhinovirus

Non-infectious:

  • Idiopathic: Occurs without a known cause, often associated with Goodpasture’s syndrome, an autoimmune disease
  • Trauma: Chest trauma, blunt force injury
  • Vascular abnormalities: Pulmonary arteriovenous malformations, pulmonary hypertension
  • Coagulation disorders: Hemophilia, von Willebrand disease
  • Drug–induced: Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs)

Risk Factors of Pulmonary Heamorrhage

Maternal Risk Factors:

  • Pregnancy-related complications:

    • Preeclampsia/Eclampsia (Pregnancy-induced hypertension)

    • Toxemia

    • Infection

  • Bleeding Disorders: Hemophilia, von Willebrand disease, etc.

  • Medications:

    • Anticonvulsants

    • Antitubercular drugs

    • Vitamin K antagonists

  • Lack of antenatal steroids: In preterm labor, this can weaken the infant’s lungs.

Infant Risk Factors:

  • Prematurity: Most common risk factor.
  • Low Birth Weight: Infants weighing less than 1000 grams are at increased risk.
  • Intrauterine Growth Restriction (IUGR): Limited growth in the womb.
  • Respiratory Problems:

    • Hypoxia (low oxygen levels)

    • Asphyxia (lack of oxygen)

    • Respiratory Distress Syndrome (RDS)

    • Meconium Aspiration

    • Pneumothorax (collapsed lung)

    • Surfactant Treatment

  • Sepsis: Bloodstream infection.

  • Mechanical Ventilation: Can irritate the lungs.

  • Patent Ductus Arteriosus (PDA), Heart Failure: Cardiovascular complications.

  • Disseminated Intravascular Coagulation (DIC), Coagulopathy: Bleeding disorders.

  • Multiple Births, Male Sex: Increased risk factors.

  • Hypothermia: Low body temperature.

  • Polycythemia: High red blood cell count.

  • Erythroblastosis Fetalis: Blood incompatibility between mother and fetus.

  • Extracorporeal Membrane Support: Used for severe respiratory distress.

  • Previous Use of Blood Products: Can increase the risk of bleeding.

  • Hypoplastic Lung Disease: Underdeveloped lungs.

Clinical Presentations of Pulmonary Heamorrhage

  • Bleeding from Airways: Oozing of blood from the nose, mouth, or ETT.
  • Secretions: Frothy pink tinged secretions followed by fresh bloody secretions.
  • Rapid Clinical Deterioration:

    • Increased work of breathing

    • Bradycardia (slow heart rate)

    • Apnea (cessation of breathing)

    • Cyanosis (blue discoloration of the skin)

    • Hypotension (low blood pressure)

    • Pallor (paleness)

    • Poor systemic perfusion (inadequate blood flow)

  • Signs of Infection or Congestive Heart Failure: Fever, cough, wheezing, edema, hepatosplenomegaly, murmur.

  • Lung Auscultation: Decreased breath sounds and crepitations (crackling sounds).

  • Respiratory distress: Difficulty breathing, rapid breathing, wheezing, coughing.

  • Hemoptysis: Coughing up blood, which can range from streaks of blood to frank blood.

  • Hypoxia: Low blood oxygen levels, leading to cyanosis (blue discoloration of the skin)

  • Fever: May be present if the PH is caused by an infection.

  • Chest pain: May be present if the PH is caused by trauma or a vascular abnormality.

  • Respiratory failure: Severe cases can lead to respiratory failure, requiring mechanical ventilation.

  • Anaemia: Continuous bleeding with decreased hematocrit (HCT) level resulting in anemia

Diagnosis of Pulmonary Hemorrhage

The common method of identifying the disease symptoms as well as the progression includes the following:

History and physical examination: Taking a detailed medical history and performing a physical examination to assess the severity of the condition.

Common Laboratory Investigations: These include:

  • Blood tests: Check for infection, coagulation disorders, Platelets count and other underlying conditions.
  • Complete Blood Count or CBC
  • Coagulation studies (Prothrombin time n-11-13.5 sec), thrombin time n- 14-19 sec, activated partial thromboplastin n- 30-40 sec)

Pulmonary function tests including elevated DLCO (diffusion capacity of the lungs for Carbon Monoxide), usually restrictive, is greater than an obstructive pattern with the low exhalation of Nitric Oxide.

Radiographic Imaging: The radiographic diagnosis includes –

  • Chest X-ray for detecting patchy alveolar opacification, Shows infiltrates and atelectasis (collapsed lung) consistent with pulmonary hemorrhage.
  • CT chest for detecting spreading of the disease in normal areas
  • Bronchoscopy: A procedure where a thin, flexible tube is inserted into the airways to visualize the lungs directly and obtain samples for testing.

Serologic tests are performed to find out the exact underlying disorders.

Echocardiography may also require if there is mitral stenosis.

Lung or renal biopsy is often done when a cause is undetectable or if the progression of the disease is very fast. Specimens usually show blood along with numerous siderophages and erythrocytes; lavage fluid characteristically remains hemorrhagic or becomes highly hemorrhagic just after consecutive sampling.

Management of Pulmonary Heamorrhage

Aims

  • To decrease and stop the bleeding in the lungs.
  • To identify the underlying cause.
  • To improve gaseous exchange.
  • To improve distress

Treatment for Pulmonary Hemorrhage depends on the underlying cause and severity. It may include:

  • Supportive care: Oxygen therapy, mechanical ventilation, and fluid management.
  • Antibiotics: For bacterial infections.
  • Antivirals: For viral infections.
  • Corticosteroids: To reduce inflammation.
  • Plasmapheresis: A procedure to remove antibodies from the blood, used in cases of autoimmune disorders like Goodpasture’s syndrome.
  • Surgery: May be necessary to repair vascular abnormalities or remove blood clots.

Initial Stabilization and Support:

Airway Management: Secure a patent airway and ensure adequate ventilation.

  • Intubation may be required to facilitate mechanical ventilation.
  • Suctioning should be performed gently to minimize airway trauma.

Oxygenation: Provide supplemental oxygen as needed to maintain adequate oxygen saturation levels.

Hemodynamic Support:

  • Volume Expansion: Correct hypovolemia with intravenous fluids. Colloids may be used to improve vascular volume. Colloids are intravenous solutions that contain large molecules that remain in the vascular space, increasing blood volume and improving hemodynamic stability, and include Albumin.
  • Inotropes: Administer medications (e.g., dopamine, dobutamine) to improve cardiac output and blood pressure if needed.
  • Inotropes are medications that increase the force of myocardial contraction, leading to improved cardiac output and blood pressure
  • Packed Red Blood Cells (PRBCs): Transfuse PRBCs to correct anemia and maintain adequate hematocrit.

Acidosis Correction:

  • Address underlying causes of acidosis, including hypovolemia, hypoxia, and low cardiac output.
  • If necessary, administer sodium bicarbonate intravenously.

Emergency Measures

  • Through or by suctioning the airway initially until the bleeding subsides.
  • By increasing oxygen support.
  • Mechanical ventilation should be given in massive pulmonary hemorrhage.

Continuous Management

  • Packed Red Blood Cells to correct blood volume and hematocrit levels. Through administering blood, this will correct hypovolemia, hypoxia and also correct low cardiac output.
  • Rescue Surfactant: Consider administering a single dose of surfactant after the infant is stabilized on mechanical ventilation. This is plausible because blood inhibits surfactant function, but more research is needed to confirm its benefit. Rescue surfactant by using a single dose of surfactant after the infant has been stabilized on the ventilator.
  • Endotracheal Epinephrine: Administering epinephrine via the endotracheal tube or nebulized epinephrine may be considered in some cases, but effectiveness is not well-established.

Pharmacology Management

  1. Hemocoagulase: Is a new treatment method discovered from a brazilian snake’s venom. It has a thromboplastin-like effect that coverts prothrombin to thrombin and fibrinogen to fibrin. Its measured in KU(Klobusitzky Units) and dose os 0.5KU every 4-6 hours until hemorrhage is stopped.
  2. Activated Recombinant Factor VIIa (rFVIIa): This drug works by activating the extrinsic pathway and binds to tissue factor which will eventually bind and seal sites with vascular injury. For effectiveness o this drug, platelets can be administered too. The dosage is 50mg/kg twice daily for 2 – 3 days.
  3. Low-molecular-weight Heparin: This drug is found to provide better patient outcome for neonatal pulmonary hemorrhage as it does improve the pulmonary function and coagulation function and reduce the incidence of getting complications.
  4. Diuretics and steroids can also be helpful.

Complications of Pulmonary Heamorrhage

Respiratory Complications:

  • Respiratory Distress: The accumulation of blood in the alveoli can lead to severe respiratory distress, characterized by tachypnea, retractions, and cyanosis.
  • Hypoxemia: Blood in the alveoli can impair gas exchange, resulting in low blood oxygen levels (hypoxemia).
  • Pneumothorax: The pressure from blood in the lungs can cause a pneumothorax (collapsed lung).
  • Atelectasis: Blood in the alveoli can collapse the lung tissue, leading to atelectasis.
  • Bronchospasm: Some infants may develop bronchospasm in response to the irritation caused by blood in the airways.
  • Acute Respiratory Distress Syndrome (ARDS): Severe pulmonary hemorrhage can lead to ARDS, a life-threatening condition characterized by diffuse lung inflammation and impaired gas exchange.

Circulatory Complications:

  • Hypovolemia: The loss of blood into the lungs can lead to hypovolemia (low blood volume), which can result in hypotension, shock, and organ dysfunction.
  • Cardiac Dysfunction: Severe hypovolemia can impair cardiac function, leading to decreased cardiac output and heart failure.
  • Cerebral Edema: Hypotension and hypoxemia can lead to cerebral edema (swelling of the brain), which can cause neurological complications.

Other Complications:

  • Anemia: Significant blood loss can lead to anemia, which can further compromise oxygen delivery to the tissues.
  • Infection: Blood in the lungs can provide a breeding ground for bacteria, increasing the risk of infection.
  • Neurological Damage: Severe hypoxemia or cerebral edema can cause long-term neurological damage.

Long-Term Complications:

  • Chronic Lung Disease: Repeated episodes of pulmonary hemorrhage or severe ARDS can lead to chronic lung disease.
  • Developmental Delays: Severe hypoxemia or neurological damage can lead to developmental delays.



Nursing care plan for a patient with Pulmonary Hemorrhage

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

1. Child presents with hemoptysis (coughing up blood), tachypnea, and respiratory distress (nasal flaring, use of accessory muscles).

Ineffective Airway Clearance related to bleeding in the lungs as evidenced by hemoptysis and respiratory distress.

The child will maintain a clear airway with reduced respiratory distress and no further episodes of hemoptysis.

– Continuously monitor respiratory status, including respiratory rate, effort, and oxygen saturation.

– Position the child in a semi-Fowler’s or upright position to facilitate breathing and reduce aspiration risk.

– Administer humidified oxygen to maintain adequate oxygenation.

– Prepare for possible intubation or mechanical ventilation if respiratory status worsens.

Continuous monitoring helps detect changes in respiratory status and guide interventions.

Positioning promotes optimal lung expansion and airway clearance.

Humidified oxygen eases breathing and reduces the work of breathing.

Mechanical ventilation may be necessary in severe cases to maintain adequate oxygenation.

The child’s respiratory rate and effort normalize, oxygen saturation remains above 92%, and hemoptysis is reduced or absent.

2. Child exhibits pale skin, cold extremities, and decreased capillary refill time.

Ineffective Tissue Perfusion related to blood loss from pulmonary hemorrhage as evidenced by pallor, cold extremities, and delayed capillary refill.

The child will maintain adequate tissue perfusion as evidenced by normal capillary refill time, warm extremities, and stable vital signs.

– Monitor vital signs, including heart rate, blood pressure, and capillary refill time, every 15-30 minutes initially.

– Administer intravenous fluids or blood products as prescribed to maintain circulatory volume and improve perfusion.

– Monitor hemoglobin and hematocrit levels regularly.

– Assess for signs of hypovolemic shock and initiate emergency interventions if needed.

Frequent monitoring of vital signs is crucial to assess the child’s circulatory status.

Fluid and blood product administration help restore circulating volume and improve tissue perfusion.

Hemoglobin and hematocrit monitoring guide transfusion and fluid therapy decisions.

Early detection of shock allows for prompt life-saving interventions.

The child’s capillary refill time improves to less than 2 seconds, skin color and temperature normalize, and vital signs stabilize.

3. Child is at risk for further bleeding due to underlying conditions (e.g., coagulopathy, infection).

Risk for decreased tissue perfusion related to pulmonary hemorrhage and underlying conditions.

The child will experience no further episodes of bleeding as evidenced by stable hemoglobin levels and the absence of hemoptysis.

– Monitor coagulation profiles (PT, PTT, INR) and platelet count regularly.

– Administer anticoagulants or clotting factors as prescribed to manage underlying coagulopathy.

– Avoid invasive procedures and handle the child gently to minimize the risk of provoking further bleeding.

– Educate parents on signs of bleeding and the importance of minimizing the child’s activity.

Regular monitoring of coagulation profiles helps identify and address coagulopathies.

Anticoagulants or clotting factors correct underlying coagulation abnormalities.

Gentle handling and avoiding invasive procedures reduce the risk of inducing further bleeding.

Parental education ensures early recognition of bleeding and adherence to activity restrictions.

 

4. Child exhibits anxiety and restlessness due to difficulty breathing and fear of bleeding.

Anxiety related to respiratory distress and fear of bleeding as evidenced by restlessness and verbalization of fear.

The child will demonstrate reduced anxiety as evidenced by calm behavior and verbalization of feeling more relaxed.

– Provide a calm and reassuring presence to reduce the child’s anxiety.

– Use age-appropriate communication to explain procedures and care to the child and family.

– Encourage the presence of a parent or caregiver at the bedside to provide comfort and support.

– Administer prescribed anxiolytics if the child’s anxiety remains severe despite non-pharmacological measures.

A calm presence helps alleviate the child’s fear and anxiety.

Age-appropriate explanations foster understanding and cooperation.

Parental presence provides emotional support and reassurance.

Anxiolytics may be necessary to reduce severe anxiety and facilitate care.

The child appears more relaxed, with reduced restlessness and verbalizes feeling less anxious.

5. Child is at risk for infection due to potential aspiration and compromised lung function.

Risk for Infection related to aspiration of blood and compromised lung function.

The child will remain free from infection as evidenced by normal temperature and absence of signs of infection.

– Monitor for signs of infection, including fever, increased WBC count, and changes in respiratory status.

– Maintain strict aseptic technique during all procedures and interventions.

– Administer prophylactic antibiotics as prescribed to prevent infection.

– Educate parents on the importance of hand hygiene and infection prevention measures at home.

Early detection and treatment of infection are critical to preventing complications.

Aseptic technique minimizes the risk of introducing pathogens.

Prophylactic antibiotics may reduce the risk of secondary infections.

Parental education ensures adherence to infection prevention practices.

 

 

Pulmonary Hemorrhage Read More »

Meconium Aspiration Syndrome

Meconium Aspiration Syndrome

Meconium aspiration syndrome is troubled breathing (respiratory distress) in a newborn who has breathed (aspirated) a dark green, sterile fecal material called meconium into the lungs before or around the time of birth
  • Meconium is the earliest stool of a newborn. Occasionally, newborns pass meconium during labor or delivery, resulting in a meconium-stained amniotic fluid (MSAF).  Meconium is the first intestinal discharge from newborns, a viscous, dark-green substance composed of intestinal epithelial cells, lanugo, mucus, and intestinal secretions (eg, bile.
  • Meconium aspiration syndrome (MAS) is the inhalation of stained amniotic fluid, which can occur before, during, or immediately after birth.
Causes of Meconium Aspiration Syndrome
  • Placental insufficiency. When a mother has placental insufficiency, there is a lack of adequate blood flow to the baby, which can cause fetal distress, leading to the untimely passage of meconium.
  • Preeclampsia. When the placenta does not carry adequate oxygen and nutrition for the fetus due to maternal underperfusion such as preeclampsia, the placental villi show increased syncytial knots, villous agglutination, intervillous fibrin, and distal villous hypoplasia, while maternal vessels in the deciduadisclose atherosis or mural hypertrophy of the arterioles.
  • Maternal infection/chorioamnionitis. When the placental membranes are ruptured and amniotic fluid infection occurs, the placenta shows acute chorioamnionitis (as the maternal inflammatory response) and funisitis (as the fetal inflammatory response).
  • Fetal hypoxia. Fetal hypoxia leads to passage of meconium from neural stimulation of a maturing gastrointestinal system.
Clinical Features
  • Severe respiratory distress. Severe respiratory distress may be present; symptoms include cyanosis, end-expiratory grunting, nasal flaring, intercostal retractions, tachypnea, barrel chest due to the presence of air trapping, and in some cases, auscultated rales and rhonchi.
  • Staining of the fingernails. Yellow-green staining of fingernails, umbilical cord, and skin may be also observed.
  • Green urine. Green urine may be noted in newborns with MAS less than 24 hours after birth; meconium pigments can be absorbed by the lung and can be excreted in urine.
  • Meconium or dark green stains in the amniotic fluid
  • Tachypnea
  • Nasal flaring
  • Retractions
  • Cyanosis or desaturation
  • Rales
  • Rhonchi
  • Greenish yellow staining of the umbilical cord, nail beds, or skin. Meconium staining may be visible in the oropharynx and (on intubation) in the larynx and trachea.
  • Neonates with air trapping may have a barrel-shaped chest
  • Fetal distress
  • Signs of neonatal asphyxia
Pathophysiology

In utero, meconium passage results from neural stimulation of a maturing gastrointestinal (GI) tract, usually due to fetal hypoxic stress.

  • As the fetus approaches term, the GI tract matures, and vagal stimulation from the head or spinal cord compression may cause peristalsis and relaxation of the rectal sphincter, leading to meconium passage.
  • Meconium directly alters the amniotic fluid, reducing antibacterial activity and subsequently increasing the risk of perinatal bacterial infection.
  • In addition, meconium is irritating to fetal skin, thus increasing the incidence of erythema toxicum(common rash seen in full-term newborns)
  • However, the most severe complication of meconium passage in utero is perinatal aspiration of stained amniotic fluid (before, during, or immediately after birth)—ie, meconium aspiration syndrome (MAS).
  • Aspiration of meconium-stained amniotic fluid may occur if the fetus is in distress, leading to a gasping breathing pattern.
  • This aspiration induces hypoxia via four major pulmonary effects: airway obstruction, surfactant dysfunction, chemical pneumonitis, and pulmonary hypertension.
Diagnosis
  • Acid-base status. Measurement of arterial blood gas (ABG) pH, partial pressure of carbon dioxide (pCO2), and partial pressure of oxygen (pO2), as well as continuous monitoring of oxygenation by pulse oximetry, are necessary for appropriate management; the calculation of an oxygenation index (OI) can be helpful when considering advanced treatment modalities, such as extracorporeal membrane oxygenation (ECMO).
  • Serum electrolytes. Obtain sodium, potassium, and calcium concentrations at 24 hours of life in infants with MAS, because syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and acute renal failure are frequent complications of perinatal stress.
  • Complete blood cell count. Hemoglobin and hematocrit levels must be sufficient to ensure adequate oxygen-carrying capacity; thrombocytopenia increases the risk for neonatal hemorrhage; neutropenia or neutrophilia with left shift of the differential may indicate perinatal bacterial infection.
  • Chest radiography. Chest radiography is essential in order to confirm the diagnosis of meconium aspiration syndrome (MAS) and determine the extent of the intrathoracic pathology; identify areas of atelectasis and air leak syndromes; ensure appropriate positioning of the endotracheal tube and umbilical catheters. Diagnosis is confirmed by chest x-ray showing hyperinflation with variable areas of atelectasis and flattening of the diaphragm
  • Echocardiography. Echocardiography is necessary to ensure normal cardiac structure and for assessment of cardiac function, as well as to determine the severity of pulmonary hypertension and right-to-left shunting.

  • Meconium passage and Respiratory distress

Differential Diagnosis
  • Aspiration Syndromes
  • Congenital Heart Disease with Pulmonary Hypertension
  • Pediatric Congenital Diaphragmatic Hernia
  • Pediatric Idiopathic Pulmonary Artery Hypertension
  • Pediatric Pneumonia
  • Pediatric Sepsis
  • Persistent Pulmonary Hypertension of the Newborn (PPHN)
  • Surfactant Deficiency
  • Transient Tachypnea of the Newborn
  • Transposition of the Great Arteries
Management of Meconium Aspiration Syndrome
  • Infants born with meconium aspiration syndrome should have routine neonatal care while monitoring for signs of distress according to the general neonatal resuscitation guidelines e.g. Suctioning to open up the airway
  • Pediatrics no longer recommend routine endotracheal suctioning for non-vigorous infants with meconium aspiration syndrome, Chest tube insertion under water seal drainage to treat atelectasis and pneumothorax in vigorous infants.
  • Newborns are admitted to the neonatal intensive care unit (NICU) if necessary.
  • Oxygen therapy: Supplemental oxygen is often needed in meconium aspiration syndrome with goal oxygen saturation > 90% to prevent tissue hypoxia and improve oxygenation.
  • Surfactant: The use of surfactant in meconium aspiration syndrome is not standard of care, however, as discussed above, surfactant inactivation has a role in the pathogenesis of meconium aspiration syndrome. Therefore surfactant may be helpful in some cases
  • Cardiac exam. In patients with meconium aspiration syndrome (MAS), a thorough cardiac examination and echocardiography are necessary to evaluate for congenital heart disease and persistent pulmonary hypertension of the newborn (PPHN).
  • Rooming-in. If the baby is vigorous (defined as having a normal respiratory effort and normal muscle tone), the baby may stay with the mother to receive the initial steps of newborn care; a bulb syringe can be used to gently clear secretions from the nose and mouth.
  • Placing in a radiant warmer. If the baby is not vigorous (defined as having a depressed respiratory effort or poor muscle tone), place the baby on a radiant warmer, clear the secretions with a bulb syringe, and proceed with the normal steps of newborn resuscitation (ie, warming, repositioning the head, drying, and stimulating).
  • Minimize handling. Minimal handling is essential because these infants are easily agitated; agitation can increase pulmonary hypertension and right-to-left shunting, leading to additional hypoxia and acidosis; sedation may be necessary to reduce agitation.
  • Insertion of umbilical artery catheter. An umbilical artery catheter should be inserted to monitor blood pH and blood gases without agitating the infant.
  • Respiratory care. Continue respiratory care includes oxygen therapy via hood or positive pressure, and it is crucial in maintaining adequate arterial oxygenation; mechanical ventilation is required by approximately 30% of infants with MAS; make concerted efforts to minimize the mean airway pressure and to use as short an inspiratory time as possible; oxygen saturation should be maintained at 90-95%.
  • Surfactant therapy. Surfactant therapy is commonly used to replace displaced or inactivated surfactant and as a detergent to remove meconium; although surfactant use does not appear to affect mortality rates, it may reduce the severity of disease, progression to extracorporeal membrane oxygenation (ECMO) utilization, and decrease the length of hospital stay.
  • IV fluids. Intravenous fluid therapy begins with adequate dextrose infusion to prevent hypoglycemia; intravenous fluids should be provided at mildly restricted rates (60-70 mL/kg/day).
  • Diet. Progressively add electrolytes, protein, lipids, and vitamins to ensure adequate nutrition and to prevent deficiencies of essential amino acids and essential fatty acids.
  • Antibiotics such as Ampicillin and Gentamicin to prevent or treat any infection
  • Systemic vasoconstrictors. These agents are used to prevent right-to-left shunting by raising systemic pressure above pulmonary pressure; systemic vasoconstrictors include dopamine, dobutamine, and epinephrine; dopamine is the most commonly used.
  • Pulmonary vasodilator. Inhaled nitric oxide is a pulmonary vasodilator that has a role in pulmonary hypertension and persistent pulmonary hypertension (PPHN)
  • Neuromuscular blocking agents. These agents are used for skeletal muscle paralysis to maximize ventilation by improving oxygenation and ventilation; they are also used to reduce barotrauma and minimize oxygen consumption.
  • Sedatives. These agents maximize the efficiency of mechanical ventilation, minimize oxygen consumption, and treat the discomfort of invasive therapies.
meconium aspiration syndrome treatment
Nursing Diagnosis
  • Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia.
  • Fluid volume deficit related to failure of regulatory mechanism.
  • Ineffective tissue perfusion related to impaired transport of oxygen across alveolar and on capillary membrane.
  • Interrupted breastfeeding related to neonate’s present illness as evidenced by separation of mother to infant.
  • Risk for Impaired parent/neonates attachment related to neonates physical illness and hospitalization
Nursing Care Planning and Goals
  • Patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC level.
  • Patient will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.
  • Patient will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.
  • Patient will demonstrate increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema.
  • The mother will identify and demonstrate techniques to sustain lactation until breastfeeding is initiated.
  • The mother shall still be able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.
  • The mother will identify and demonstrate techniques to enhance behavioral organization of the neonate
  • After discharge, the parents will be able to have mutually satisfying interactions with their newborn.
Nursing Intervention
  • Reduce body temperature. Provide TSB to help lower down the temperature; ensure that all equipment used for the infant is sterile, scrupulously clean; do not share equipment with other infants to prevent the spread of pathogens, and administer antipyretics as ordered.
  • Improve fluid volume level. Monitor and record vital signs to note for alterations; provide oral care by moistening lips & skin care by providing daily bath; administer IV fluid replacement as ordered to replace fluid losses.
  • Increase tissue perfusion. Note quality and strength of peripheral pulses; assess respiratory rate, depth, and quality; assess skin for changes in color, temperature, and moisture; elevate affected extremities with edema once in a while to lower oxygen demand.
  • Improve frequency of breastfeeding. Demonstrate the use of manual piston-type breast pump.; review techniques for storage/use of expressed breast milk; provide privacy, calm surroundings when the mother breastfeeds; recommend for infant sucking on a regular basis, and encourage the mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake.
  • Improve infant-parent relationship. Educate parents regarding child growth and development, addressing parental perceptions; involve parents in activities with the newborn that they can accomplish successfully, and recognize and provide positive feedback for nurturing and protective parenting behaviors.
Evaluation

Goals are met as evidenced by:

  • Patient maintained normal core temperature as evidenced by vital signs within normal limits and normal WBC level.
  • Patient was able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.
  • Patient was able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous membranes, good skin turgor and prompt capillary refill and resolution of edema.
  • Patient demonstrated increased perfusion as evidenced by warm and dry skin, strong peripheral pulses, normal vital signs, adequate urine output and absence of edema.
  • The mother identified and demonstrated techniques to sustain lactation until breastfeeding is initiated.
  • The mother was able to identify and demonstrate techniques to sustain lactation and identify techniques on how to provide the newborn with breast milk.
  • The mother identified and demonstrated techniques to enhance behavioral organization of the neonate
  • After discharge, the parents were able to have a mutually satisfying interaction with their newborn.
Complications
  • Persistent pulmonary hypertension
  • Pneumothorax
  • Aspiration pneumonia
  • Brain damage due to lack of oxygen
  • Breathing difficulty that lasting for several days
  • Atelectasis (Collapsed lung)

Meconium Aspiration Syndrome Read More »

Broncho pulmonary dysplasia

Broncho pulmonary dysplasia

Broncho Pulmonary Dysplasia (BPD) is also known as 

  • Chronic lung disease of premature babies
  • Chronic lung disease of infancy
  • Neonatal chronic lung disease
  • Respiratory insufficiency
  • Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease that affects newborns, most often those who are born prematurely and need oxygen therapy.
  • Bronchopulmonary dysplasia (BPD) is a persistent or prolonged respiratory disease characterized by irregular and scattered parenchymal densities or consolidated lungs.
  • In BPD the lungs and bronchi are damaged, causing tissue destruction (dysplasia) in the alveoli.
Causes of Broncho Pulmonary Dysplasia
  • Supplemental oxygen and mechanical ventilation in prematurity: When babies are born premature, their lungs often are not developed fully and they need help breathing. This breathing assistance usually comes from a mechanical ventilator or oxygen. In most cases, bronchopulmonary dysplasia develops after a premature baby receives this breathing assistance for a period of time because it can damage their already fragile lungs. 
  • Prolonged high oxygen delivery in premature infants causes necrotizing bronchiolitis and alveolar septal injury, with inflammation and scarring. This results in hypoxemia.
  • Vitamin A deficiency
  • Lung infections such as pneumonia
  • Congenital (present at birth) malformations of the lung
Pathophysiology
  • The pathogenesis of bronchopulmonary dysplasia remains complex and poorly understood.
  • Bronchopulmonary dysplasia results from various factors that can injure small airways and that can interfere with alveolarization/alveolar septation( Alveolarization represents a process during lung development that leads to the formation and maturation of the distal parts of the lung: the alveoli) , leading to alveolar simplification which means a reduction in the overall surface area for gas exchange.
  • Alveolar and lung vascular development are intimately related, and injury to one may impair development of the other. Damage to the lung during a critical stage of lung growth can result in clinically significant pulmonary dysfunction.
Pathogenesis

In the lungs, BPD causes damage to the current and developing alveoli. Additionally, the tiny blood vessels surrounding the alveoli may be affected, making the passage of blood through the lungs more difficult. The lower the number of working alveoli, the longer the infant may need to remain on a ventilator, which can cause further damage to the child’s lungs.

In the long run, increased pressure inside the blood vessels in the lungs and between the heart and lungs can cause pulmonary hypertension. In severe cases, heart failure can occur. Newborns who suffer from BPD may also experience trouble feeding, leading to delayed development.

Clinical Features

  • Tachypnea
  • Tachycardia
  • Increased respiratory effort (with retractions, nasal flaring, and grunting)
  • Frequent desaturations
  • Labored breathing
  • These infants are often extremely immature, have a very low birth weight, and have significant weight loss during the first 10 days of life.
  • Wheezing (a soft whistling sound as the baby breathes out)
  • The need for continued oxygen therapy after the gestational age of 36 weeks
  • Difficulty feeding
  • Repeated lung infections that may require hospitalization
  • There is bluish discoloration around the mouth or lips.
  • There are frequent alarms of the apnea monitor and/or pulse oximeter.

Diagnosis / Investigation

  • The diagnosis of BPD is based on the clinical evaluation, the degree of prematurity, and the need for oxygen after a certain age (2weeks).
  • Arterial blood gas (ABG) levels
  • Pulmonary function tests
  • Chest radiography
  • High-resolution chest computed tomography scanning
  • Chest magnetic resonance imaging
  • Echocardiography
Differential Diagnosis
  • Airway Injury
  • Nosocomial Infection
  • Patent Ductus Arteriosus (PDA)
  • Pediatric Hypertension
  • Pediatric Pneumonia
  • Pediatric Subglottic Stenosis Surgery
  • Pulmonary Atelectasis
  • Tracheomalacia

Management of Broncho Pulmonary Dysplasia

  • There is no specific cure for BPD, but treatment focuses on minimizing further lung damage and providing support for the infant’s lungs, allowing them to heal and grow. Newborns suffering from BPS are frequently treated in a hospital setting, where they can be continuously monitored
  • Surfactant replacement with oxygen supplementation
  • Continuous positive airway pressure (CPAP)
  • Mechanical ventilation
  • Treatment of the maternal inflammatory conditions and infections, such as chorioamnionitis
  • Diet
  • Maximization of protein, carbohydrates, fat, vitamins A
  • Early enteral feeding of small amounts (tube feeding), followed by slow, steady increases in volume: To optimize tolerance of feeds and nutritional support
Medical treatment
  • Diuretics: This class of drugs helps to decrease the amount of fluid in and around the alveoli. (eg, furosemide)
  • Bronchodilators: These medications help relax the muscles around the air passages, which makes breathing easier by widening the airway openings. They are usually given as an aerosol by a mask over the infant’s face and using a nebulizer or an inhaler with a spacer (eg, salbutamol, caffeine citrate, theophylline, ipratropium bromide)
  • Corticosteroids: These drugs reduce and/or prevent inflammation within the lungs. They help reduce swelling in the windpipe and decrease the amount of mucus that is produced. Like bronchodilators, they are also usually given as an aerosol with a mask with the use of a nebulizer or an inhaler. (eg, dexamethasone)
  • Vitamins (eg, vitamin A)
  • Keep the baby warm
  • Viral immunization: Children with BPD are at increased risk for respiratory tract infections especially respiratory syncytial virus (RSV)
  • Cardiac Medications: A few infants with BPD may require special medications that help relax the muscles around the blood vessels in the lung, allowing the blood to pass more freely and reduce the strain on the heart.
Complications
  • Difficulty feeding and reflux
  • Pulmonary hypertension
  • Hypercapnia
  • Increased bronchial secretions
  • Hyperinflation
  • Frequent lower respiratory infections
  • Delayed growth & development

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Respiratory distress syndrome

 Respiratory distress syndrome

  • Infant respiratory distress syndrome (IRDS), also called neonatal respiratory distress syndrome, (previously called hyaline membrane disease (HMD), is a syndrome in premature infants caused by developmental insufficiency of pulmonary surfactant production and structural immaturity in the lungs.
  • Respiratory distress syndrome (RDS) occurs in babies born early (premature) whose lungs are not fully developed. The earlier the infant is born, the more likely it is for them to have respiratory distress syndrome RDS and need extra oxygen and help breathing.
  • RDS is caused by the baby not having enough surfactant in the lungs. Surfactant is a liquid made in the lungs at about 26 weeks of pregnancy. As the fetus grows, the lungs make more surfactant.
  • Surfactant is a liquid that coats the inside of the lungs. It helps keep them open so that infants can breathe in air once they are born.

Causes of Respiratory Distress Syndrome

  • Lack or insufficient surfactant
  • It can also be a consequence of neonatal infection.
  • It can also result from a genetic problem with the production of surfactant associated proteins.

Risk Factors

  • Premature birth (before 37 weeks)
  • A sibling with respiratory distress syndrome
  • Multiple pregnancy (twins, triplets)
  • Impaired blood flow to the baby during delivery
  • Delivery by cesarean
  • Maternal diabetes
  • infection
  • Induction of labor before the baby is full-term
  • Multiple pregnancy (twins or more)
  • Cold stress. Baby with trouble of maintaining body temperature
  • Patent ductus arteriosus
  • Rapid labor
  • Prematurity

Pathophysiology

The lungs of infants with respiratory distress syndrome are developmentally deficient in a material called surfactant, which helps prevent collapse of the terminal air-spaces throughout the normal cycle of inhalation and exhalation.

This deficiency of surfactant is related to an inhibition from the insulin that is produced in the newborn especially in diabetic mothers. Deficient surfactant production causes un equal inflation of alveoli on inspiration and collapse of alveoli on end of expiration.

In this case their lungs inflate and therefore exert a great deal of effort to re-expand the alveoli with each breath with increasing exhaustion, they will be able to open the alveoli.

Inability to maintain lung expansion produces a wide spread of atelectasis. Progressive atelectasis with absence of alveolar stability will lead to increased pulmonary vascular resistance where as in normal cases it is supposed to decrease. Consequently there will be hypertension to the lung tissue a (pulmonary hypertension)decrease in effective pulmonary blood flow.

 

respiratory distress syndrome Pathophysiology

Phases of ARDS (Pathogenesis) 

ARDS has three phases—exudative, proliferative, and fibrotic. 

1.  Exudative Phase

In this phase, alveolar capillary endothelial cells and type I pneumocytes (alveolar epithelial cells) are injured, and tight alveolar barrier is damaged giving away the entry to fluid and macromolecules. The protein rich edema fluid accumulates in the interstitial and alveolar spaces. Pro-inflammatory cytokines are increased in this acute phase, leading to the recruitment of leukocytes (especially neutrophils) into the pulmonary space and alveoli. There is plasma proteins aggregation in air spaces with cellular debris and dysfunctional pulmonary surfactant to form hyaline membrane whorls of which Alveolar edema predominantly leads to  lung  diminished aeration. Collapse of large sections of dependent lung can contribute to decreased lung compliance. It causes intrapulmonary shunting and hypoxemia develop and the work of breathing increases, leading to dyspnea.

The exudative phase encompasses the first 7 days of illness after exposure to a precipitating ARDS risk factor. Tachypnea and increased work of breathing result frequently in respiratory fatigue and ultimately in respiratory failure.

2. Proliferative Phase

This phase of ARDS usually lasts from day 7 to day 21. Most patients recover rapidly and are liberated from mechanical ventilation during this phase. Despite this improvement, many patients still experience dyspnea, tachypnea, and hypoxemia. Histologically, the first signs of resolution are often evident in this phase, with the initiation of lung repair, the organization of alveolar exudates, and a shift from neutrophil- to lymphocyte- pulmonary infiltrates.

As part of the reparative process, type II pneumocytes proliferate along alveolar basement membranes. These specialized epithelial cells synthesize new pulmonary surfactant and differentiate into type I pneumocytes.

3. Fibrotic Phase

Most patients with ARDS recover lung function within 3–4 weeks, very few progresses into fibrotic phase that may require long-term support on mechanical ventilators and/or supplemental oxygen. There is extensive alveolar-duct and interstitial fibrosis. Marked disruption of acinar architecture leads to emphysema-like changes, with large bullae.

Intimal fibroproliferation in the pulmonary microcirculation causes progressive vascular occlusion and pulmonary hypertension. The physiologic consequences include an increased risk of pneumothorax, reductions in lung compliance, and increased pulmonary dead space.

Signs and Symptoms

  • Infant respiratory distress syndrome begins shortly after birth
  • Fast breathing
  • Fast heart rate
  • Chest wall retractions (recession)
  • Expiratory grunting
  • Nasal flaring
  • Cyanosis
  • Ventilatory failure (rising carbon dioxide concentrations in the blood) as condition progresses
  • Prolonged cessations of breathing (“apnea”).
  • Reduced urine output
Diagnosis/Investigation
  • Signs and symptoms
  • Chest x-ray
  • Pulse Oximetry
  • Echocardiography
  • CT scans
  • Arterial blood gas (ABG) test to assess the level of oxygen, CO2, and acids in blood
Differential Diagnosis
  • Acute Anemia
  • Aspiration Syndromes
  • Pediatric Gastroesophageal Reflux
  • Pediatric Hypoglycemia
  • Pediatric Pneumonia
  • Pediatric Polycythemia
  • Pneumomediastinum
  • Pneumothorax
  • Transient Tachypnea of the Newborn

Management / Treatment

  • Delivery and resuscitation: A neonatologist experienced in the resuscitation and care of premature infants should attend the deliveries of fetuses born at less than 28 weeks’ gestation.
  • Keep the child warm
  • Oxygen is given with a small amount of continuous positive airway pressure
  • I.V. fluids (N/S, D5%; (Neonatalyte i.e. D50%= 70mls, D5% = 310 & R/L=120ML) are administered to stabilize the blood sugar, blood salts, and blood pressure.
  • In severe cases an endotracheal tube is inserted into the trachea and intermittent breaths are given by a mechanical device.
  • A preparation of surfactant (e.g. survanta or beraksurf), is given through the breathing tube into the lungs.
  • Administer a glucocorticoid e.g. dexamethasone (0.15mg /kg/dose; max dose 4mg)
  • Give an antibiotic to prevent secondary bacterial infection
  • Respiratory monitoring, pulse rate, Bp, temperature, ECG monitoring.
  • Monitor conscious level
  • Reassure the mother
  • NG tube feeding
  • Vitamin k 0.5-1mgm I.M due to risk of intraventricular hemorrhage.
Prevention
  • Giving the mother glucocorticoids speeds the production of surfactant. Glucocorticoid treatment is recommended for women at risk for preterm delivery prior to 34 weeks of gestation (dose 12-40mg)
  • Early antenal care
  • Eat healthy diet rich in vitamins
  • Avoid smoking and alcohol during pregnancy
Complications
  • Metabolic disorders (acidosis, low blood sugar)
  • Patent ductus arteriosus
  • Low blood pressure
  • Chronic lung changes
  • Bleeding in the brain.

CASE SCENARIO

  1. A 1-day-old boy is brought to the intensive care unit from the nursery due to increased work of breathing. The patient was born at 31 weeks to a mother with a history of multiple preterm deliveries, polysubstance abuse and HIV. His temperature is 38°C (100.4°F), pulse is 215/min, respirations are 76/min, blood pressure is 60/41 mmHg, and oxygen saturation is 85% on room air. Physical exam shows tachypnea, nasal flaring, and subcostal retractions. Administration of supplemental oxygen and positive pressure ventilation improve the patient’s oxygen saturation to 95%. Blood glucose is 95 mg/dL. Chest x-ray and laboratory results are shown below:

     

Laboratory value  Result 
Blood Gases, Serum 
pH  7.23 
 PCO2  55 mmHg 
 PO2  30 mmHg 

Which of the following best describes the etiology of this infant’s disease process?

2.  Mike, a 55-year-old man, presents with shortness of breath, high fever, and cough. A chest x-ray was ordered and it showed a right lower lobe infiltrate, which is suggestive of pneumonia. He was then started on IV antibiotics but the following day Mike became hypoxic and hypotensive. Because his hypotension didn’t improve despite intubation, IV fluids, and vasopressors, he is diagnosed with septic shock. Next, a repeat x-ray detected newly-developed bilateral alveolar opacities, heart echography ruled out heart failure, and arterial blood gas analysis revealed a PF ratio of 109 milligrams Mercury.

3.   Dona, an infant delivered by cesarean section at 36 weeks’ gestational age, with an Apgar score of 9 at birth. A few hours after delivery, she develops tachypnea, chest wall retractions with nasal flaring, and tachycardia. Aside from increased work of breathing, her physical examination findings are normal. A chest x-ray was ordered and it showed diffuse reticulogranular ground glass appearance with air bronchograms.

Detailed Review.

All the above scenerio’s point to respiratory distress syndrome

But first, a bit of physiology.

Normally, when you breathe in, the air reaches the alveoli, which are made up of two types of pneumocytes.

First, type I pneumocytes are thin, and have a large surface area that that facilitate gas exchange.

More important for the exams are the type II pneumocytes, which are smaller, thicker and have the ability to proliferate in response to lung injury.

They are in charge of making a fluid called surfactant which contains various phospholipids. This lets it act like droplets of oil that coats the inside of the alveoli, decreasing surface tension, so if it’s missing, the alveoli will collapse.

These cells also act like stem cells, meaning they can give rise to type I cells and type II pneumocytes.

Ok, so acute respiratory distress syndrome, or ARDS, is characterized by rapid onset of widespread inflammation in the lungs which can lead to respiratory failure.

ARDS is not a primary disease, as it is usually triggered by conditions like sepsis, aspiration, trauma, and pancreatitis.

Now ARDS starts when these conditions cause alveolar damage, and a high yield fact is that the injury triggers the pneumocytes to secrete inflammatory cytokines like TNF-alpha and interleukin 1.

This subsequently leads to neutrophil recruitment, and they will release toxic mediators, like reactive oxygen species and proteases, which will damage the lungs even more.

You’ll need to know that the main site of injury is the alveolar-capillary membrane, which becomes more permeable, causing fluid to move into the alveoli resulting in pulmonary edema. This fluid can impair gas exchange, leading to hypoxemia.

Furthermore, the edema can also wash away the surfactant coating the alveoli to the point where it can’t reduce surface tension anymore, and as a result, the alveoli collapse.

And finally, dead cells and protein-rich fluid start to pile up in the alveolar space and, over time, it forms these waxy hyaline membranes which look like a layer of glassy material.

Individuals with ARDS present with serious symptoms and signs that require urgent investigation. The inflammation process and impaired gas exchange lead to fever, shortness of breath, tachypnea, chest pain, hypotension, hypoxia, and cyanosis. More often than not, ARDS will lead to shock due to hypotension.

The excess fluid in the lungs can cause a crackling sound called rales during auscultation, which is the sound of collapsed alveoli popping open with inspiration.

Keep in mind additional symptoms might provide clues to the underlying cause.

For example, epigastric abdominal pain radiating to the back along with a history of gallstones indicate acute pancreatitis. Diagnosis of ARDS is typically made when the individual presents all of the next four criteria, which you should definitely remember for your exams. First, the symptoms have to be “acute” meaning an onset of one week or less.

Second, and particularly high yield, a chest X-Ray or CT scan shows opacities or “white out” in both lungs, which is due to pulmonary edema.

The third is what’s called the PF ratio. It’s the partial pressure of oxygen in the arterial blood divided by the percent of oxygen in the inspired air, also called the fraction of inspired oxygen.

In ARDS, gas exchange is defective so the PF ratio is below 300 mmHg, and the lower this ratio gets, the more severe the condition.

Fourth, the respiratory distress must not be due to cardiac causes, like heart failure.

Often this is assessed by using an echocardiogram to look for evidence of heart failure, like an ejection fraction below 55% in systolic heart failure, and abnormal relaxation of the myocardium in diastolic heart failure.

Another clue is the pulmonary capillary wedge pressure, which is measured by inserting a catheter into a small pulmonary arterial branch.

In heart failure, this is elevated because more blood remains in the left side of the heart and it prevents pulmonary venous return.

The blood backs up into the pulmonary vessels, and the increase in pressure pushes fluid into the interstitial space of the lungs, resulting in edema.

In ARDS, the pressure is normal since the edema is caused by leaky capillaries instead of increased pressure.

Treatment of ARDS ultimately comes down to treating the condition that triggered it. However, the most important initial step is supportive care, like supplemental oxygen or mechanical ventilation.

A high yield fact to remember is that it’s vital to maintain positive end-expiratory pressure, which is where the pressure in the lungs is kept slightly above atmospheric pressure, even after exhalation, because this prevents the alveoli from collapsing. It’s also good to have low tidal volumes to prevent over-inflation of the damaged alveoli. Another important thing to watch out for is positive pressure ventilation can cause compression of pulmonary vessels which leads to pulmonary hypertension decreased pulmonary venous return.

This will reduce cardiac output and hypotension might worsen.

 Respiratory distress syndrome Read More »

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