Een reptiel als huisdier Algemeen: Hoewel we vaak spreken over reptielen in het algemeen, zijn de verschillende groepen reptielen zeer divers. Er zijn zeer veel diersoorten die onder de reptielen vallen, welke ook nog uit verschillende werelddelen komen of gewoon anders zijn waardoor de huisvesting en de verzorging voor het ene reptiel heel anders kan zijn dan het andere reptiel. Ond
Conversely, injection forms, though being painful and needing help of medical personnel for application, help to quickly achieve necessary concentration of preparation in blood buy antibiotics online Antibiotic is usually chosen in an empiric way (at random). But when choosing one is obligatory guided by definite rules.
Preventingvap_reviewed_7-26-05.pmdAdapted from the CDC Guidelines for Preventing Healthcare-Associated Pneumonia, 2003. Most initiatives for reducing VAP can be readily Avoid the use of antacids and histamine type-2 incorporated into standard care for ventilated patients antagonists — Patients on mechanical ventilation are without incurring significant expenditure of resources.
subject to gastrointestinal hemorrhage (stress ulcers).
Antacids and histamine type-2 antagonists are often Wash hands — Washing hands or the use of alcohol- used protectively. Unfortunately, they also alter the based antiseptic solutions has been shown to reduce acidic environment allowing bacteria to colonize the nosocomial infections. Clean hands between patients, area while increasing gastric volume and distension.
after glove removal, before clean and after dirty tasks.
Regurgitation and subsequent aspiration can cause VAP. Alternatively, sucralfate has been advocated as it Wear gloves and gowns as appropriate — Change neither decreases acidity nor increases gastric volume.
gloves between patients and between contaminated However, more recent studies have had variable results and clean procedures on the same patient. Use sterile gloves when appropriate to protect the patient (e.g.
Use of post-pyloric rather than gastric feeding has suctioning). Gloves and gowns have been shown to beeffective in preventing the spread of Vancomycin- benefits — A gastric feeding tube violates the Resistant Enterococci (VRE) and MRSA.
gastroesophageal (cardiac) sphincter. This can permit gastric reflux which can travel up the esophageal tract Make patient oral hygiene standard practice —Routine to the subglottic space then subsequently aspirated oral decontamination is an effective method for around the cuff. The percutaneous delivery of nutrients reducing VAP by decreasing the microbial load in the into the small bowel (post-pyloric) prevents oropharyngeal cavity. It has been found that the gastroendotracheal delivery-related gastric reflux, incorporation of routine oral hygiene into standard gastric over-distension, and peptic acid alteration, practice reduced VAP by 57.6%. Oral hygiene programs reducing VAP risk. The overall optimal approach for should consist of frequent tooth brushing, oral feeding the ventilated patient is undefined; however, suctioning and swabbing of the mouth with antiseptic post-pyloric feeding is associated with an overall Implement Common Suction Protocol — Standardized Utilize methods for early diagnosis of VAP — Early endotracheal suction protocols, in which everyone recognition of VAP and identification of the causative suctions effectively in the same way, have been shown pathogen(s) insures early use of the appropriate to reduce colonization and the incidence of VAP.
antibiotic regimen reducing outcome severity. Methods Subglottic suction prior to extubation should be of rapid accurate sampling include bronchial alveolar lavage (BAL or mini BAL) performed by the respiratory Use Closed Suction System (CSS) — CSS provides a therapist or other trained caregivers or specimen barrier to separate the contaminated catheter from the retrieved by brush, biopsy, swab or lavage caregiver and other patients as well as reduce the bronchoscopy conducted by a pulmonologist.
environmental exposure of the patient being suctioned.
Write policies, educate staff and monitor compliance — Closed suctioning also permits continuous ventilation Although positioned last in this list, institutionalization of reducing respiratory stress and vulnerability. CSS is recommended by the American Association for accomplished by integrating them into facility policies, Respiratory Care (AARC) as part of an infection control routinely educating staff and monitoring for compliance —absolutely necessary for reduction of VAP.
This brochure was originally developed for Infection Control Week 2004, Minimize Saline Lavage — Research does not Nosocomial pneumonia is the most deadly form of support the routine use of saline lavage. Some hospital-acquired infection. Patients receiving mechanical studies have shown that the practice may be intubated — A cuff that is under-inflated forms ventilation are especially at risk. Intubated patients are detrimental to the patient as bacteria may be creases that can readily allow contaminated secretions approximately 20 times more likely to develop pneumonia dislodged from the catheter and endotracheal tube to migrate past the cuff and aspirate into the lungs. The than non-intubated patients. The endotracheal tube into the lung while simultaneously causing oxygen optimal pressure for all situations has not been interferes with normal patient defenses by blocking conclusively established but is generally held to be 20 mucocilliary ladder, interfering with gag and cough recommend the use of saline sparingly for thick mm/Hg. Cuff pressure should be monitored and reflexes and allowing pathogens direct access to the secretions. It is important to note that this does not recorded routinely. Avoid excessive inflation as too lung. Ventilator-associated pneumonia (VAP) continues to exclude thorough and complete rinsing of CSS after much pressure can prevent adequate perfusion of occur in 8 to 28% of this vulnerable population. VAP suctioning which is necessary to prevent colonization accounts for 60% of all deaths due to hospital-acquired condensate —Warm expired air condenses in endotracheal tube — Manipulation of the tube ventilator tubing. Microbial growth occurs rapidly in creates creases and gaps in the cuff which can allow the pooled condensate. Disconnection of the circuit contaminated secretions to slip through and drop intothe lungs.
Increased hospital charges attributed to nosocomial and manipulation to drain the tubing can cause the pneumonia are approximately $40,000.
contaminated condensate to dump directly into the Remove tube as early as possible, but avoid lungs. Condensation traps permit drainage without re-intubation — Early tube removal has been shown opening the circuit, preventing both microbial dump to reduce VAP. However, if the patient is not ready and and contamination from the external environment.
must be re-intubated, the process will increase VAP risk.
The mortality rate ranges from 24 to 50% and can reach Opening the circuit for other procedures should be Noninvasive ventilation may be more appropriate rather 76% when high risk pathogens are involved. As the avoided. Accumulation of condensate can also be number of days intubated increases, so does the reduced by the use of a heated wire in the expiratory phase tubing or a heat-moisture exchanger (HME).
Prevent cross-contamination with reusable However, care must be taken not to allow patient devices — Use single use devices whenever possible.
secretions to dry, which can cause endotrachael and Reusable items such as resuscitation bags,temperature probes, spirometers, humidification VAP is a bacterial pneumonia. Infections which occur apparatus and endoscopes must be subjected to within 48 to 72 hours after intubation are referred to as Perform subglottic suctioning when necessary sterilization or high level disinfection to prevent cross- “early-onset” and are usually antimicrobial sensitive. Those The endotracheal tube prevents closure of the contamination. Residual disinfectants should be rinsed occurring after 72 hours, referred to as “late-onset”, are epiglottis. Oropharyngeal secretions accumulate off with sterile water, or when this is not possible, rinsed often multi-drug resistant. The causative pathogens above the endotracheal tube cuff, below the glottis.
with tap or 0.2 micron filtered water followed by alcohol usually associated with these time periods are: Microorganisms can grow in this protected environment. Suction removal of these fluids can reduce the risk of aspiration. Suctioning prior to Selective decontamination of the digestive tract is controversial — The use of an antibiotic paste for repositioning or extubation should be standard the mouth and stomach is gaining favor in Europe, but Incline patient’s head whenever possible has not been widely used in the US. This practice has been associated with the emergence of antibiotic- (Reverse Trendelenberg’s position) — The supineposition increases the accumulation of secretions in the subglottic area. Elevating the head 30 to 45° Vaccinate staff — Seasonal influenza vaccinations reduces this pooling and thus the microbial load.
are recommended, as well as the 23-valent vaccine against invasive pneumococcal disease (if indicated), to Methicillin Resistant Staphylococcus aureus (MRSA) possible — Nasotracheal intubation has been protect staff and reduce nosocomial outbreaks.
associated with nosocomial sinusitis and high incidence of VAP. The oropharyngeal route is Copyright 2005, APIC. Limited copies permitted for educational, not-for- profit use. Call 202/789-1890 x2629 for more info. Authored by D. Theron VanHooser M.Ed. RRT, FAARC and Wava Truscott, PhD, and reviewed by RosieFardo, RN, BSN, CIC, & Chris Nightingale, RN, BSN, CIC. 10/16/04
MAOMBI YA KUTAKA PASI YA KENYA KWA AJILI YA MTOTO MWENYE UMRI WA CHINI YA MIAKA 16 APPLICATION FOR A KENYA PASSPORT FOR A CHILD UNDER SIXTEEN YEARS OF AGE Fomu ijazwe na mzazi au mlezi wa halali au ijazwe kwa idhini ya mzazi au mlezi wa halali To be completed by or with the written consent of the legal guardian (Tafadhari soma sana maelezo kabla ya kujaza fomu) (Please read the instructions c