the merciful
Pendahuluan
TUJUAN ILMU KESEHATAN ANAK :
Tujuan utama IKA adalah membentuk seorang anak seutuhnya dg.kualitas sesuai potensi genetiknya melalui perawatan tumbuh kembang anak secara terus menerus dan terpadu sejak pembuahan sampai kematangan yang optimal
=
4 KHoppu 7.3.2007
Children are in a constant state of growth and development which creates particular needs and demands which are of a different order from those affecting adult patients.
Prof Sir Ian Kennedy
The Report of the Public Health Inquiry into Childrens Heart Surgery at the Bristol Royal Infirmary 1984-1995
Pertumbuhan : bertambah besar dlm aspek fisik akibat multifikasi sel dan bertambahnya jumlah zat interseluler ( dpt diukur) Perkembangan : bertambahnya ketrampilan dan fungsi yg kompleks = maturasi dan diferensiasi
Measure: Weight
normal 2.5 3.99kg
Length
normal 48 52cm
90th percentile
PRETERM
31 33 35 37
TERM
39 42
POST-TERM
44 45
Gestation (weeks)
LBW-
11
BBLR : < 2500 gram tanpa memandang masa gestasi Bayi Berat Lahir Cukup/ Normal : berat lahir >/= 2500 gram -4000 gram Bayi Berat Lahir Lebih : > 4000 gram Bayi Kurang Bulan (BKB) : masa gestasi < 37 minggu ( < 259 hari) Bayi Cukup Bulan (BCB) : masa gestasi 37 42 mg (259-293 hari) Bayi Lebih Bulan (BLB) : masa gestasi > 42 minggu (294 hari) Bayi Kecil Untuk Masa Kehamilan :Small for gestational age /SGA berat lahir < 10 persentil grafik Lubchenko Bayi Besar Untuk masa kehamilan: Large for gestational age/LGA berat lahi > 10 persentil grafik Lubchenko
Term :completed 37 weeks gestation till 42 week Premature; less than 37 weeks gestation
Definition
Incidence
: < 2500 g
: 30% neonates
17
Importance
LBW babies account for 25% neonatal deaths and 50% infant deaths. LBW babies are more prone to : - malnutrition. - recurrent infections. - neurodevelopmental delay.
19
Causation : Prematurity
Low maternal weight, teenage pregnancy, multiple pregnancy. Previous preterm baby, cervical incompetence. Antepartum hemorrhage, acute systemic disease. Induced premature delivery. Majority unknown.
Preterm
Teaching Aids: NNF LBW-
Term
26
LBW-
27
LBW-
28
Preterm
Term
LBW-
29
Preterm
Teaching Aids: NNF LBW-
Term
30
Pendahuluan
All gestational age newborns at risk of losing heat soon after birth
Pendahuluan . . . .
Neonatal hypothermia induced cold stress and result in:
Metabolic rate, leading to O2 consumption Caloric consumption and glycogen stores
Fakta . . .
Hypothermia significantly occurred in the vulnerable group of newborns on neonatal admission. The vulnerable group of sick babies included premature (~38%), LBW (~65%), suffering hypoglycaemia since birth or birth asphyxia.
The vulnerable group of babies with C/S birth in OT were more easily prone to hypothermia.
WHO:
Definition of hypothermia (C)
36.4c 36c
35.9c 32c Below 32c
Mild hypothermia
Moderate hypothermia Severe hypothermia WHO, 1997
Four ways a newborn may lose heat to the environment. Most cooling of the newborn occurs during the first minutes after birth.
Pencegahan
Warm Chain: Is a set of ten interlinked procedures carried out at birth and during the following hours and days which will minimize the likelihood of hypothermia in all newborns.
Pencegahan
THE WARM CHAIN 1. Warm delivery room. 2. Immediate drying. 3. Skin-to-skin contact. 4. Breast-feeding. 5. Bathing and weighing postponed. 6. Appropriate clothing and bedding. 7. Mother and baby together. 8. Warm transportation. 9. Warm resuscitation. 10. Training/awareness raising.
What is Normal?
Defining a normal glucose level remains controversial
50 110 mg/dl (Karlsen, 2006) > 40 mg/dl (Verklan & Walden, 2004) > 30 term, > 20 preterm (Kenner & Lott, 2004) > 45 mg/dl (Cowett, R. as cited by Barnes-Powell, 2007)
Incidence of Hypoglycemia
Overall Incidence = 1- 5/1000 live births
Normal newborns 10% if feeding is delayed for 3-6 hours after birth At-Risk Infants 30%
LGA 8% Preterm 15% SGA 15% IDM 20%
McGowan, 1999 as cited by Verklan & Walden
Karlsen, 2006
Haney, 2005
Karlsen, 2006
Inadequate Glycogen
Glycogen stores increase rapidly in the last month of the 3rd trimester Preterm infants are born before this occurs. What little glycogen is available is used up rapidly and their supply is depleted.
Karlsen, 2006
Inadequate Glycogen
SGA birth weight < 10 percentile. Chronically stressed infants have higher metabolic demands and use up available glucose for growth and survival. Markedly post-mature infants are at increased risk due to increased metabolic demand.
Karlsen, 2006
Nursing Management
Complete evaluation and review of systems Early breast or bottle feeding within 30 minutes Glucose monitoring within 1 hour Monitor pre-feeding levels thereafter
Monitoring
Serum glucose level is the gold standard Bedside glucose levels are for screening Monitor at least hourly until glucose level has stabilized Know your hospital policy for monitoring infants at risk for hypoglycemia
Kenner, 1998
Treatment
Oral feedings as tolerated If glucose is very low or the infant is not able to feed orally:
2ml/kg of D10W IV bolus Follow up screenings within 30 minutes Repeat bolus if glucose is < 50 mg/dl If unable to stabilize glucose consider increasing IV rate or glucose concentration
Karlsen, 2006
Prevention
Increase awareness of conditions that predispose an infant to hypoglycemia Early screening of at-risk infants Early and frequent feedings Maintain temperature
Methods
We used an 8-item structured, anonymitytype questionnaire to survey the needs and expectations of medical students with their medical ethics class. The survey population consisted of firstyear students in a medical school who had been taking a medical ethics course for approximately three months.
The Questionnaire 1
* How much value does the medical ethics
class have? * How much time should be spared for this subject? * What kind of person would be fit to teach a course on medical ethics? * Should the class be conscious of the National Examination for Physicians or not?
The Questionnaire 2
* What are purposes expected of the class? * What is a suitable form of the class? * What is a suitable form of the evaluation examination? * In which grade should the class be offered?
Results
Seventy-two of the 85 first-year students (response rate, 84.7%) in fiscal year 2000 and 47 of the 85 first-year students (response rate, 55.3%) in fiscal year 2001 participated in this survey. Below, the set of first-year students in fiscal year 2000 is designated as 'Student-2000', and the other set as 'Student-2001'.
Recognition regarding
16 0 0 1 2 24 1
11 6 0 2 11 16 0
Clinician
Biomedical researcher
23
17
Session styles
Student-2000
Primarily Lectures 6 (8.5) Primarily Discussions 15 (21.1) Lectures + Discussions 50 (70.4)
Student-2001
1 (2.5) 11 (26.8) 29 (70.7)
Discussion 1
Some previous researches included surveys on students attitudes. Although the authors asked the students what lecture themes they preferred (issues of brain death and organ transplants, cloning humans, assisted reproduction, or dying with dignity), no inquiry into the fundamental nature of these courses was actually executed. Before selecting themes for lectures, we tried to discover the attitudes and needs of the students from a fundamental viewpoint of course construction as a whole.
Discussion 2
It is impossible to assume that all medical students could possibly share a single opinion. We can assume that their responses may vary widely depending on circumstances such as the university, school year, and the form and nature of the previous courses they have taken. As far as this survey is concerned, however, the students from two different school years gave considerably similar responses
Discussion 3
Many of the students who participated in the survey seem to be in favor of starting a medical ethics course from the first year. This probably indicates they are aware that a lack of detailed knowledge in medicine as a natural science would not be a major obstacle to taking a medical ethics course.
Discussion 4
Many medical students do not seem to wish to be given (at least not by a teacher) knowledge that can be answered in yes-orno questions.
Discussion 5-1
What underclassmen in medical schools really want to know seems to be 1) the reality of a clinical setting, 2) what ethical issues physicians face, 3) what decisions they make, 4) what actions they take with regard to their decisions, and 5) how they can acquire the ability to see things from a number of different perspectives.
Discussion 5-2
This is not to imply that they necessarily want to swallow whatever experienced doctors judge and practice. Rather, it seems that they want to review and examine what they are told and what is considered to be medical ethics. They seems to have intuition that clinicians talk and belief can be close to simple dogmatism.
Discussion 6
A patient and a medical worker seldom share the exact same values or views of life. It is very important for students to learn to be more receptive to divergent views and values that other people may have, to be able to accept different values as they are, and to carry out a continuous and thorough consideration at all times. Medical ethics teachers are here to show the way.
It seems appropriate to remark that the cooperation between clinicians and philosophers and ethicists is a basic necessity for a medical ethics classes. Second, such a course should be offered in an introspective format with lively discussions. And, thirdly, the professors should maintain an attitude of acceptance in order to ensure the expression of divergent perspectives.
In conclusion
Students who are weak in communication skills are not hard to find. The essential task for a medical ethics teacher is to provide a relative evaluation of the opinions and values of each of his/her students, to make sure that these students are fully aware of their own ethical positions, and to urge reviews that include serious self-examination.