Monthly Archives: September 2017

MANAGEMENT OF DETERIORATING Patient ( RAPID RESPONSE TEAM)

MANAGEMENT OF DETERIORATING Patient ( RAPID RESPONSE TEAM)

Rapid Response Team (RRT) – a formally designated multidisciplinary team that responds to the call of health care providers from inpatient units except MICU, SICU, CCU, SDU and NICU regarding deteriorating patients. Team provides coverage 24 hrs a day, 7 days a week.

Early Warning Signs (EWS) – are medical signs and symptoms which allow staffs to identify and respond to patients who are deteriorating clinically. Scores used are the adult Modified Early Warning Score (MEWS), and the Pediatric Early Warning Scores (PEWS).

  • To provide an integrated approach to the recognition and response to at risk patients, preventing avoidable deterioration.
  • To improve patient outcomes by identifying and acting upon early signs of deterioration in a patient’s condition through the implementation of the EWS system and support of the RRT when activated.
  • To formalize procedures and responsibilities of each members of the team.

All adult and pediatric patients admitted to the hospital (except lCUs and SDU) shall:

  • Have real time vital signs recorded and EWS calculated to provide both the initial baseline and ongoing trends. Documentation shall be done in the MEWS and PEWS Scoring Guide Form.
  • Be managed according to their EWS score and appropriate referral to physician or RRT shall be implemented according to score.

 

Rapid Response Team comprises of:

ADULT Rapid Response Team:

  • On-call Medical Resident
  • ICU Nurse
  • Hospital Nursing Supervisor
  • Respiratory Therapist
  • EMT

PEDIATRIC Rapid Reponses Team:

  • On-call Pediatric Resident
  • NICU Nurse
  • Hospital Nursing Supervisor
  • Respiratory Therapist
  • EMT

The appropriate RRT (Adult or Pediatric), when called, shall manage the care of an unstable patient in all in-patient units except MICU, SICU, CCU, SDU and NICU.

The RRT will be activated whenever the condition of the patient meets the activation criteria.

The allocated RRT per shift will be seen on each specified department duty rota as arranged by the head of the department.

RRT will report to the unit in less than 5 minutes from the time of RRT activation.

The role of RRT is not intended to replace Code Blue activation. Upon activation and arrival of the Rapid Response Team and if patient is in imminent cardiopulmonary failure then the CODE BLUE shall be activated.

The RRT will introduce necessary interventions in the absence of treating physician’s order that address the patient’s emergency condition.

RRT Leader shall request Anesthetist, treating doctor (Most Responsible Physician) or his designee if required.

After every RRT activation, a debriefing of the RRT’s overall response process shall be done where the whole team shall review how the overall response process went through.

Rapid Response Team activities are documented in Rapid Response Team Event Record and shall be completed by all members of the RRT.

ICU/NICU Nurse is responsible to assist and monitor the patient during the event or if patient to be transferred to ICU immediately after the event.

If patient is stable after Rapid Response Team Management and does not require transfer to ICU Doctor will document it in the file and ICU/NICU Nurse will endorse the patient to Unit Nurse.

RRT events shall be discussed and acted upon through the CPR Committee when needed.

Systemic Nasal Decongestants

Nasal decongestants for administration by mouth may not be as effective as preparations for local application but they do not give rise to rebound nasal congestion on withdrawal. Pseudoephedrine is available over the counter; it has few sympathomimetic effects. Systemic decongestants should be used with caution in diabetes, hypertension, hyperthyroidism, susceptibility to angle-closure glaucoma, prostatic hypertrophy, renal impairment, pregnancy, and ischaemic heart disease, and should be avoided in patients taking monoamine oxidase inhibitors.

Pseudoephedrine/Triprolidine:

Indications: Allergic Conjunctivitis, Allergic Rhinitis, Atopic Rhinitis, Cold Symptoms, Nasal Congestion, Rhinorrhea, Seasonal Allergic Rhinitis, Sneezing, And Vasomotor Rhinitis

Contraindications: Acute Asthma Attack, Lactating Mother, Narrow Angle Glaucoma, Severe Coronary Artery Disease, Severe Uncontrolled Hypertension, Benign Prostatic Hypertrophy, Bladder Outflow Obstruction, Chronic Idiopathic Constipation, Diabetes Mellitus, Glaucoma, Stenosing Peptic Ulcer, Urinary Retention

Dose and Administration: each 5ml syrup contain 30mg Pseudoephedrine and 1.25mg Triprolidine. Dose for adults 10ml 3 times daily, for children 6 months up to 2 years 1.25ml three times daily, for children 2-5 years 2.5ml 3 times daily and for children 6-12 years 5ml 3 times daily.

Pseudoephedrine/ Brompheniramine:

Indications: Relief of sneezing, itchy, watery eyes, itchy nose or throat, and runny nose because of hay fever (allergic rhinitis) or other respiratory allergies. also indicated for temporary relief of runny nose and sneezing caused by the common cold; treatment of allergic and nonallergic pruritic symptoms; temporary relief of mild, uncomplicated urticaria and angioedema; amelioration of allergic reactions to blood or plasma loss; adjunctive therapy of anaphylactic reactions.

Contraindications: Newborn or premature infants; nursing mothers; narrow-angle glaucoma; urinary retention; peptic ulcer; during an asthmatic attack; lower respiratory conditions, including asthma; MAOI therapy or for 2 wk after stopping MAOI therapy; allergy to any component of product.

Dose and Administration: each 5ml elixir contains 15mg pseudoephedrine and 1mg Brompheneramine maleate. Children below 6 years 5ml 2-3 times daily. Children 6-12 years 10ml 3 times daily. Adult’s 20ml 3 times daily.

Cetirizine-Pseudoephedrine:

Indications: Relief of nasal and non-nasal symptoms associated with seasonal or perennial allergic rhinitis.

Contraindications: Narrow-angle glaucoma; urinary retention; severe hypertension; severe coronary artery disease; patients receiving MAOIs or within 14 days of stopping such treatment; hypersensitivity to any component of the product, adrenergic agents, or other drugs of similar chemical structure; manifestations of patient idiosyncrasy to adrenergic agents, including arrhythmias, dizziness, insomnia, tremor, or weakness.

Dose and Administration: Adults and children 12 yr of age and older PO One 12-h capsule (cetirizine 5 mg/pseudoephedrine 120 mg) twice daily.

Loratidine-Pseudoephedrine:

Indications: Allergic Conjunctivitis, Allergic Rhinitis, Atopic Rhinitis, Cold Symptoms, Nasal Congestion, Rhinorrhea, Seasonal Allergic Rhinitis, Sneezing, And Vasomotor Rhinitis.

Contraindications: Narrow Angle Glaucoma, Severe Coronary Artery Disease, Severe Uncontrolled Hypertension, And Urinary Retention and Benign Prostatic Hypertrophy, Diabetes Mellitus, Hypertension.

Dose and Administration: for adults one tablet (5mg loratidine and 120mg pseudoephedrine) 2 times daily. For children 6-12 years 5ml (5mg loratidine and 60mg pseudoephedrine) twice daily.

Pseudoephedrine/Paracetamol:

Indications: Nasal Congestion, Rhinorrhea, and Sinus Headache

Contraindications: Acetaminophen Toxicity, Narrow Angle Glaucoma, Severe Coronary Artery Disease, Severe Uncontrolled Hypertension, Urinary Retention, Alcoholism, Benign Prostatic Hypertrophy, Diabetes Mellitus, Disease of Liver, Hypertension

Dose and Administration: each tablet contains paracetamol 500mg and pseudoephedrine 30mg. The regular dose for adults and children over 12 years 2 tablets up to 4 times daily.

Pseudoephedrine/Ibuprofen:

Indications: Nasal Congestion, Rhinorrhea, and Sinus Headache Contraindications: Gastrointestinal Hemorrhage, Narrow Angle Glaucoma, Post-operative from CABG Surgery, Pregnancy, Severe Coronary Artery Disease, Severe Uncontrolled Hypertension, Urinary Retention, Alcoholism, Benign Prostatic Hypertrophy, Blood Coagulation Disorder, Diabetes Mellitus, Disease of Cardiovascular System, Duodenal Ulcer, Gastric Ulcer, Gastrointestinal Ulcer, Hypertension, Increased Cardiovascular Event Risk, Peptic Ulcer, Stomatitis Dose and Administration: each caplet contains 200mg Ibuprofen and 30 mg Pseudoephedrine. The regular adult and children over 12 years dose 1 to 2 caplets every 4 hours.

Pseudoephedrine/Paracetamol/Diphenhydramine:

Indications: relief of symptoms associated with cold and flu including headache, fever, cough, muscle aches, nasal congestion and runny nose.

Contraindications: Gastrointestinal Hemorrhage, Narrow Angle Glaucoma, Post-operative from CABG Surgery, Pregnancy, Severe Coronary Artery Disease, Severe Uncontrolled Hypertension, Urinary Retention, Alcoholism, Benign Prostatic Hypertrophy, Blood Coagulation Disorder, Diabetes Mellitus, Disease of Cardiovascular System, Duodenal Ulcer, Gastric Ulcer, Gastrointestinal Ulcer, Hypertension, Increased Cardiovascular Event Risk, Peptic Ulcer, Stomatitis

Dose and Administration: each tablet contains 500mg Paracetamol, 30mg Pseudoephedrine and 25mg Diphenhydramine. The regular adult and children over 12 years old dose 2 tablets up to 4 times daily.

Pseudoephedrine/Paracetamol/Chlorpheneramine:

Indications: Cold Symptoms, Fever, Flu-Like Symptoms, Headache Disorder, Nasal Congestion, and Rhinorrhea.

Contraindications: Acetaminophen Toxicity, Acute Asthma Attack, Arterial Thrombosis, Myocardial Infarction, Narrow Angle Glaucoma, Severe Uncontrolled Hypertension, Ventricular Tachycardia, Acute Hepatitis, Acute Pancreatitis, Alcoholism, Benign Prostatic Hypertrophy, Bladder Outflow Obstruction, Bradycardia, Chronic Idiopathic Constipation, Coronary Artery Disease, Disease of Liver, Gastrointestinal Obstruction, Hypertension, Hyperthyroidism, Ileus, Incomplete AV Heart Block, Severe Arteriosclerotic Vascular Disease, Urinary Retention

Dose and Administration: each caplet contains 500mg paracetamol, 30mg pseudoephedrine and 2mg chlorpheniramine. The regular adults and children of 12 years and over two caplets up to 4 times daily.

Cough Preparations

Expectorant and demulcent cough preparations

Expectorants are claimed to promote expulsion of bronchial secretions but there is no evidence that any drug can specifically facilitate expectoration. The assumption that sub-emetic doses of expectorants, such as ammonium chloride, ipecacuanha, and squill promote expectoration is a myth. However, a simple expectorant mixture may serve a useful placebo function and has the advantage of being inexpensive.

Demulcent cough preparations contain soothing substances such as syrup or glycerol and some patients believe that such preparations relieve a dry irritating cough. Preparations such as simple linctus have the advantage of being harmless and inexpensive; pediatric simple linctus is particularly useful in children. Compound preparations are on sale to the public for the treatment of cough and colds; the rationale for some is dubious.

GUAIFENESIN:

Indications: Guaifenesin is used to help coughs caused by colds or similar illnesses clear mucus or phlegm (pronounced flem) from the chest. It works by thinning the mucus or phlegm in the lungs. Guaifenesin is used to reduce chest congestion caused by the common cold, infections, or allergies.

Contraindications: There are no adequate studies

Dose and Administration: Adults—200 to 400 milligrams (mg) every four hours. Children 6 to 12 years of age—100 to 200 mg every four hours. Children 4 to 6 years of age—300 mg every twelve hours. Children and infants up to 4 years of age—Use is not recommended.

Guaifenesin and Dextromethorphan:

Indications: The combination of dextromethorphan and guaifenesin is used to treat cough and chest congestion caused by the common cold, infections, or allergies.

Contraindications: if allergic to any ingredient in Guaifenesin DM Elixir, taking or have taken a monoamine oxidase inhibitor (MAOI) within the last 14 days or taking a selective serotonin reuptake inhibitor (SSRI).

Dose and Administration: Each 5ml contains 100mg Guaifenesin and 10mg Dextromethorphan. Children 6 to 12 years of age 5ml every four hours. Adults 10ml every four hours.

Guaifenesin and Theophylline:

Indications: Preventing and treating symptoms and blockage of airway due to asthma or other lung diseases such as emphysema or bronchitis.

Guaifenesin/Theophylline are a combination xanthine derivative and expectorant. The xanthine derivative works by relaxing the smooth muscle surrounding the bronchial tubes (air passages) of the lungs, allowing the tubes to widen, and making breathing easier

Contraindications: if allergic to any ingredient in Guaifenesin/Theophylline.

Dose and Administration: adults 15-30ml 2-3 times daily. Children over 45kg the same dose as adults. Over 8 years old 15ml 2-3 times daily. Under 8 years old 2.5ml per each 4.5kg body weight 2-3 times daily.

Guaifenesin/Dextromethorphan/Pseudoephedrine:

Indications: Relieving congestion, cough, and throat and airway irritation due to colds, flu, or hay fever.

Contraindications: if allergic to any ingredient in Guaifenesin DM Elixir, taking or have taken a monoamine oxidase inhibitor (MAOI) within the last 14 days or taking a selective serotonin reuptake inhibitor (SSRI).

Dose and Administration: Each 5ml contains 100mg Guaifenesin 30mg Pseudoephedrine and 10mg Dextromethorphan. Children 6 to 12 years of age 5ml every four hours. Adults’ 10ml every four hours.

Diphenhydramine/Menthol:

Indications: control of cough and allergy and hay fever and to reduce nasal congestion symptoms.

Contraindications: if allergic to any ingredient

Dose and Administration: children 1 to 6 years 5ml every 6 hours. From 6 to 12 years 10ml every 6 hours.

Diphenhydramine/Ammonium Chloride/Menthol:

Indications: for controlling cough due to colds and allergy and to reduce nasal congestion symptoms.

Contraindications: if allergic to any ingredient

Dose and Administration: each 5ml syrup contains 14mg Diphenhydramine, 135mg Ammonium chloride, and 1.1mg Menthol. Children 1 to 6 years 2.5ml every 6 hours, 6 to 12 years 5ml every 6 hours and for adults 5 to 10ml every 6 hours.

Cough Suppressants

Dextromethorphane:

Indications: Dextromethorphan is a cough suppressant. It works by loosening mucus and lung secretions in the chest and making coughs more productive. Temporarily relieving cough due to the common cold, upper respiratory tract infections, sinus inflammation, sore throat, or bronchitis.

Contraindications: if allergic to any ingredient in Dextromethorphan or taking or have taken a monoamine oxidase (MAO) inhibitor within the last 14 days.

Dose and Administration: each 5ml contains 15mg of Dextromethorphane. Children above 2 years 2.5ml to 5ml up to 4 times daily. Adult’s 5ml to 10ml 4 times daily.

Thyme fluid extract and primula root fluid extract:

Indications: used in cough, bronchitis, bronchial catarrh and mucous obstruction of the bronchi.

Contraindications: in case of allergy to thyme, primula root extract or any of the additives. Also in epileptic patients or liver impairment patients.

Dose and Administration: the usual adult dose is one spoon every 2-3 hours up to 6 times per day. Children half of the adult dose.

Thyme fluid extract:

Indications: used in whooping cough, bronchitis, and bronchial catarrh Contraindications: in case of allergy to thyme or any of the additives. Also in epileptic patients or liver impairment patients.

Dose and Administration: the usual adult dose is two spoons 3 times per day. Children half of the adult dose.

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