SELAMAT HARI RAYA AIDIL FITRI......

Sungkai on 25th September 2008 Thursday

The sungkai was held as a closing for out last meeting for clinical attachment during the fasting month of Ramadhan....here it goes...

problem solving....hmmm

what happened in the morning? lecturesssss

busy woman!!

babu raja...got stuffed after big meal.....

lots of plate...yum yumm chomp chomp

zalin smiling...haha

sungkai!! eat shahrin, eat....hehe

with cikgu zaleha..

eat dametzz while u still can...

Pic testing...

here is a production, well testing actually.. of using a subject on aperture mode...i honestly love this style of taking pictures as i love the blurry effect of the background thus making the main subject stands out....

1, 2, 3....learning slowly

My Pic Post.....edited

beautiful me...yuck!! hahah

my outing with my outside friends in bukit shahbandar...posing time guysss.. (nizam is wearing shirt from Linea and Sony is wearing shirt brought by Calvin Klien, the other three are miscellaneous designers)

3 in 1 lectures for the day of Sept 13th 2008...

OK guys .....last Saturday lectures...we encounter three lectures in all which covers ethics and clinical managements....all about paeds....

okay guysss....here is the promised summary for the lectures presented...

first day in the morning..lecture from the court council regarding law on children..the presentation was done by the staffs from the court council itself and basically ..

children for as long as they are a child...hm mm forgot the age group are protected under the law as not to do harm when we (nurses) are treating them. consent from parents should be obtained and their attendance during examination should be considered..

i think we already know this but we just don't know that there are laws that actually mentioned about children in Brunei....mm i know i don't!

About 10.30am...another lecture by Dr. Wilson Chong from the AED regarding Paed resuscitation...you should look;

1.Resp rate (more than 60/min is abnormal)
2.Spo2 (90% below is abnormal)
3.HR (85-190/min) for child below 2 years...and gets even less as they grow..
4.BP (mind the cuff!!, in AE the cuff mostly are for adults and u know adult cuff affect BP result in child!!)
5.Urine output (very common in children as they easily get UTIs...and other illnesses)

the BP measurement differs in children (payah kan xplain! hehe) ok for urine output.. 1.5m-2 ml/kg/hour for child infants and younger child.

older child and adolescent 1ml/kg/hour.

p/s resp arrest = cardiac arrest in children!

the 3rd lecture was presented by Dr.Suresh from the paed team....his lecture was very interesting but to consider its application in AE setting, it can be futile.

there u go guys....

Blood Donation on 16th Septemebr 2008 at 8pm in RIPAS Blood Bank

People!!!! Ok blood donation Hari Selasa anie....8pm onwards in RIPAS...got the invitation from the medical unit team...so who's coming??? i wana donate!!!!

Case Queries??

Okay guys simple one....wat u do??? ACLS!!!!!!!!!!!!!

Case Queries??

What is abnormal in this ECG? Posted few days ago and someone answer, hyperkalemia...yes indeed it is. Noted esp. V1 V2 and V3 shows a high peak T wave which is not supposed to as the one is usu. the R wave...it is expected R wave to be in its highest at V1 to V3 and goes down by V4 to V6. So what are the possibilities of pt to have hyperkalemia? what drug to consider? what 'nurses' play our role here?

Reply - Sept 11th, 2008... ok the same person stated the Rx for this pt. Included Resonium 15 mg, 10 units of Humulin R in 50 cc of 50% Dextrose, 10% of Calcium Gluconate....put the pt on cardiac monitoring....as for Mx in AED, 2nd biochemist analysis not always initiated and usu. done when the pt is in medical ward. But hey, u did mentioned it and mostly its what has been done so far...well done!

hmmm....does these pt does not eat anything? so u just ask the pt to eat wateva he/she wants? not listed...diet on low potassium....tall peak T wave caused by high potassium...medical/nurses intervention will not improve if pt is 'babal' on his/her diet...u see..as people says..'you are what you eat'...i know its not easy to tell pts to restrict their diet but then ...i always remind meself...pt has every right and yes so does US (nurses)...they refuse us, let it be. Kejam kah tu? hehe ok sooner i would end this conversation...i would post another queries for this blog...

Obstetric - Cord Prolapse by Dr. Ohn Htwe

Woahhh people why so many gynae and obstetric lecture nowadays ah? one lecture after another....anyway, this is very useful for ER nurses when encountering such case. Bare in mind, most obstetric case, labour, etc are only handle by female health care members. So, its a bit hard for male staffs to think about such management, but we watch videos and hope to witness such cases one day..(amin!)

What do you know about cord prolapse(CP)? so far i only know 'Rectal Prolapse'...prolapse suggest that the descending of wat eva into an opening, hence its name. In CP, the cord lead the way ahead of the baby (The Cleveland Clinic Foundation, 2008(2)) Effect, is upon the baby, he/she can get strangulated leading to death, asphyxiation and eventually death.

From our lecture, CP is when the cord descend through the cervix alongside (occult) or past the presenting part (overt) in the presence of rupture membrane(adapted 2008 new definition also from the US). For as long as u see the cord coming through the vagina during labour, always suspect CP.

CP occurs 0.1-0.6% in every birth, aproximately, it happens 1 in every 300 birth(The Cleveland Clinic Foundation, 2008). This also tops 1% in breech delivery. CP causes death(25%-50%from asphyxiation)...banyak to beb!! so why death? ..

1. Due to mechanical compression between the presenting part and bony pelvis.
2. Cause the spasm of the cord vessel (restricted blood supply to the baby).
Also, causes hypoxic ischemic encephalopathy and cerebral palsy.

Management of CP, u can insert 500 cc of normal saline into the bladder via foley's catheter which is describe as to create effect of compression as to prevent the baby from coming out further. Another way, placing two fingers into the vagina and pushing back the baby inwards, the other hand might be needed to put pressure on the suprapubic area. This has to be done until the mother reaches Operating Room or until the obstetrician has arrived to the ED(depends).

Assessment includes, feeling the pulse as for the baby...by assessing the cord to feel if there is a pulsating feeling is going on. Supply the mother with sufficient oxygen(first and always a priority). If no pulsating cord felt..proceed by ultrasound or doppler(doppler was not mentioned inthe lecture so this has to be questioned as doppler also serves in the assessment of present HR of the baby).

Additional info might be need or added....feel free to comment

Clinical Presentation of Shoulder Dystorcia by Dr. Indulekha

Tuesday Sept, 9th, 2008. morning. we had lecture on another case in gynaecology (2nd day of women issues labour). lecture starts at 10.30am but AE group only arrived around 11am...lecture we heard was at 11 am....please dont blame us on this...

Shoulder Dystorcia bring fear to doctors and midwives (Weiss, no date) from www.about.com

So, what happens in shoulder dystorcia? it happens when the baby shoulder, per se, got stuck if u see in outer view, it seems that the baby's head is stuck around the labia majora (Correct me!)

This fenomena carries risks; namely for the baby, leads to fracture (e.g. clavicle), distress...

For the mother, it will creates injury to the cervix, vagina and ... add more here please

This happens when the baby is big (macrosomia) and post term pregnancy(which leads to midforceps delivery).

Amazing news! Management of Shoulder Dystorcia has their own algorithm

1. Call for help, inform gynae doctor and paediatricians
2. Traction assisted with the mother expulsive effort
3. Large episiotomy ( normal is around 1 cm or it depends)
3. Adequate analgesia (usu. Pethidine IM)
4. McRobert's manoeuvre (flexion of the thigh and then abduction, requires 2 helps)
5. Suprapubic pressure
6. Woods Corkscrew manoeuvre
7. Delivery of Posterior Shoulder
8. Worst comes worst, Rubin Reverse corkscrew, All Fourrs, Zavanelli, Fracture the Clavicle, Cleidotomy (cutting the clavicle) and Symphysiotomy.

N.b this algorithm comes if each attempt does not work effectively.

Thanx!! Comments encourage...

Gynaecology - Ante-Partum Haemorrhage and Post-Partum Haemorrhage by Dr. On Fei Wen.

After Geriatric Case Management, within the same day (monday 8th sept. 2008), we browse into the world 'down under' (as the aussies always said) haha!! you guy know what i mean....

so APH and PPH....triggers emergency nurses plus the gynae nurses (a.k.a bidanz)....to deal such patients..even though emergency nurses only handle the first what-to-do kinds of stuffs....we measure BP, fetal HR, blood routines plus bleeding time and cross match....we do have to know what exactly happens in the uterus...why bleeding, why so important? YES, we try to save some lives here okay....so here i go again....

The lecture presentation given was a bit on a fast pace...probably some of us were not concentrated during the lecture...REMINDERS FOR STAFFS ALIKE!! NO VE TO BE EXAMINE IN ANY PREGNANT LADY!!!

APH...u think about placental abruption or placental praevia...these two were the most thinkable diagnosis or thoughts we might have to think about when a pregnant lady comes via the AED.

Assessment includes most of the statements i mentioned above...CARE TO ADD MORE IN THE COMMENT AREA..

Worst comes when continuous bleeding will lead the mother to experience blood loss (hypovolaemic shock) so IV hydration needed to be sustained along with blood 'O' negative (which are obtained from the cross match....

P. Previa - occurs when the placenta is in the lower segment of the uterus. Consists of four types. Risk factors include; increase of age, previous history, smoking and cocaine use...

When the mother is in the 3rd trimester, this case should be a concern but before that is not a worry (as mentioned by the lecturer).

Danger for mom, haemorrhage, sepsis and placenta accreta (p.accreta describe as abnormal attachment of the placenta in the myometrium-mid layer of the uterus wall) which leads to further bleeding worse is death...happens in 1:2500 birth (wikipedia,2008).

Danger for fetus, preterm birth, groth restriction, malformation....what do u expect if the baby was delivered for the expected delivery date (EDD)?

P.Abruption - from wikipedia 2008 stated that, this is when the placenta is detached from the uterus while the fetus is still inside...this results, of course, bleeding. Lecturer stated that bleeding PV but the placenta is in normal position. Risky moms are with history of hypertension, increase of age, lower socioeconomic status and smoking.

TO NOTE HERE...BOTH RESULTS BLEEDING SO WHEN IT OCCURS IT NEEDS TO BE WITHHOLD OR STOP

Mx is to save the life of the mother first (gynae issue)....

So, if not settled? mother will experience, Shock, Disseminated Intravascular Coagulation (DIC) and PPH.

POST PARTUM HAEMORRHAGE

Blood loss of +- 500 ml after delivery and continuous for more than 24 hrs.

2 types, first and second....1. occurs in delivery and the first 24hr. 2. bleeding continues upto 6 weeks post partum.

Causes? No contraction of uterus, Haematoma, Vaccum effect, remnants of placenta

Who will be at risk? For emergency C-section, Elective admission mothers, Big baby, Haemophilia, Von Willebrand's disease (jarang di brunei).

Rx? Blood transfusion O negative, FFP (i think Frozen Fresh PLasma-check again ok)
They did include medications but i dont dare to state it here ..do add kan for me in the comment area......to suggest syntocinon, carboprost, oxytocin....to check again if these drugs included ...

okay guys ....arghh wats on my head now???!!

Follow-up Gerentology Case Presentations

Four case management presented on monday lecture 8th september 2008 back in our class. all four cases seemed to be the most occuring event while you guys are at work in the department.

Cases management presented;

1. Group 1 (Diana, Shahrin and Jack) - Elders in case of Malnutrition...comments needed...what do u think in older people with malnutrition issues? is it common? does this case comes alone without secondary illness?

2. Group 2 (Zalin, Ida and Seri) - This group presented with LCD presentation on issue about physical abuse...is it common in Brunei? Facts!! Every year, between 500,000 to five million of elders in America are physically abuse (Breaux, 2002) Link - http://www.nygec.org/

Back to Brunei, so do u think it happens? Few years ago, an old woman was being dumped by ?daughter or maybe daughter in-law? It was an alarming for ORANG MELAYU BRUNEI. Being malay does not mean we can't be abusive even to our parents! So make comments....

3. Group 3 (Eddy, Sofy and Nizam) - Presented with Half LCD as that time there was an electrical malfunction, hehe....so ..this group presents a case of COPD or Chronic Obstructive Pulmonary Disease....combination of two powerful yet very sickening disease; namely chronic bronchitis and emphysema....look out in Wikipedia for further infomation.

Yes, COPD is a very common illness esp. among the elderly why? Due to old age, obviously! old people don't have the energy...some old people yes.. but some not...face the fact of life....its very distressing as these COPD patients always visits the department with the same problem...so need anymore to explain?.....please do...

4. Group 4 (Raliza, Halinah and Amal) - Presented verbally with issue of fall among elders....stated by ?RIPAS in Brunei (i think!)...four to five cases in a week involves fall among elders in the emergency department...so what are the 'commons' of fracture tends to occur??? this is fun....so aside of degenerative process...osteoporosis...it is not surprising elderly will have such incident.

So people.....post comments on these topics....discussion here are appreciated!!!

Gerontology Nursing Case Presentation.

Four case presentation of this section will be discuss next week ..... very interesting yet sometime needs more good heart and strong will within us.... am enjoying this!!!

In AE context....how we will manage such people?

Bowling on August 30th 2008...

Insya Allah nanti ketani buat gathering cemani lagi ok.............