By F. Domenik. Benedictine University.
Survivors often develop congestive cardiac failure discount priligy 30 mg amex, necessitating cardiac surgery priligy 30mg lowest price. Since this large increase in blood vessel capacity is not being matched by increased volume discount 30 mg priligy fast delivery, central pres-sure (and perfusion) falls buy priligy 30 mg cheap. Bradycardia from excessive and uncountered vagal tone further reduces blood pressure. Failure of autonomic response makes inotropes ineffective, but volume replacement may compensate for increased blood vessel capacity. Unresponsive sudden hypotension usually indicates a stroke; with a critically ill patient this often proves terminal so that medical assistance should be summoned urgently. Histamine is released following an antigen-antibody reaction and is a potent systemic vasodilator, greatly increasing total blood vessel capacity. Being part of specific immunity, it is released on a second or subsequent exposure to antigens. Anaphylactic shock can be an emergency, and is treated with adrenaline to restore circulating blood pressure and antihistamines (steroids). Slow bleeding (usually spontaneous) may be tolerated until 2 litres accumulate (Cockroft 1997); rapid tamponade (usually from cardiac surgery or trauma) is an emergency, usually causing imminent cardiac arrest once compensatory tachycardia and vasoconstriction fail. Blood is then aspirated, needles usually remaining (capped off) in case further blood accumulates. Blood clots cannot be aspirated through spinal needles, but once coagulation begins, bleeding has probably ceased. This gross extension of normal homeostasis causes, rather than results from, the problem. Sepsis Sepsis rates increased by 137 per cent between 1984–94 (Bone 1994), largely due to escalating risks from: ■ increasingly invasive techniques ■ improved survival from simpler pathologies increasing immunocompromise ■ ageing populations (immunity is impaired with age) ■ greater use of immunosuppressive therapy (including steroids) ■ more resistant organisms. Mortality The 1909 mortality rate from sepsis of 41 per cent remains essentially unchanged today (Ellis 1995), a stark (if alarmist) reminder of the problems and limits facing medicine. Shock 259 Pathology Bacteria initiate sepsis, but shock is a problem of inflammatory response rather than bacterial invasion so that treatment should limit excessive inflammatory responses (Deitch 1995). Cell membrane damage (from microorganisms and inflammation) release vasoactive mediators (e. As inflammation becomes systemic, inflammatory responses throughout the body cause ■ total body vasodilation ■ grossly increased intravascular space ■ increased capillary permeability with extravasation of plasma into tissues, oedema formation, hypovolaemia, hypoperfusion and generalised tissue hypoxia. Many chemical mediators also depress myocardial function, further reducing systemic blood pressure. Local vasoconstrictive mediators unsuccessfully attempt to compensate, making peripheries cold and cyanosed. Fluid resuscitation with colloids (see Chapter 33) should therefore restore colloid osmotic and perfusion pressures, without compounding interstitial oedema. Exogenous albumin only temporarily increases serum albumin, so that endogenous production (through adequate nutrition) should be promoted. Shoemaker and Beez (1996) suggest that mortality correlates with oxygen debt, and so treatment to reverse oxygen debt improves survival prospects. Oxygen debt, the difference between oxygen demand and oxygen delivery, cannot be measured directly, but Shoemaker et al. Phospholipidase is activated by endotoxin, which then triggers the platelet activating factor (Clarke 1997). Implications for practice ■ severe shock necessitates close haemodynamic monitoring and observation Shock 261 ■ where possible, underlying causes of shock should be removed (e. Reviews of particular types of shock, such as Visser and Purday’s (1998) article on cardiogenic shock, appear periodically. Clinical scenario Brian Geller is a 62-year-old man, who was originally admitted to hospital with severe abdominal pain from ruptured gastric and duodenal ulcers. He admits to smoking more than 20 cigarettes and drinking over half a bottle of spirits per day. Surgery was performed and Mr Geller was recovering when he developed a chest infection. Review treatment goals and justify choice of: Invasive ventilation (mode, rates, volumes, etc. The syndrome is largely a creation of the success of intensive care: within living memory single failure of a major organ was usually terminal. The treatment and support of each organ and system follow those described in previous chapters, and so are not repeated here. Instead, this chapter provides a synthesis of progressive pathology, prognosis and issues specific to the syndrome as a whole, rather than the individual parts discussed elsewhere. The syndrome extends problems originating at cellular level, complex interactions of mediators creating a range of (sometimes contradictory) effects. Lack of consensus about both terms and interpretation hinders comparison; for example, prognosis is considerably better for failure of two rather than four major organs. However caused, gross ischaemia causes hypoxia, anaerobic metabolism and failure of most or all organs. Cytokines (especially tumour necrosis factor and interleukin 1) trigger hyperglycaemia and extreme protein catabolism (‘autocannibalism’) (Beal & Cerra 1994). As mitochondria develop abnormalities, energy production is severely impaired (Tan & Oh 1997b), leading to cell failure. Widespread cell failure impairs healing, exposing patients to further nosocomial infection (Tan & Oh 1997b). The liver, being especially rich in xanthine oxidase (Davidson & Boom 1995), is particularly prone to ischaemic damage. Systemic hypotension and hypoperfusion leads to hepatic and respiratory failure and renal failure, often (but not always) in that order. The lack of support for Shoemaker’s use of supranormal treatments is discussed in Chapter 25. Infection rates from central lines are far higher than from peripheral lines; sicker patients have more central lines, and so the risk to critically ill patients may not reflect the much cited sevenfold from peripheral versus ninetyfold from central lines. However, the transfer of drugs that can be given peripherally may enable removal of a central line, or the removal of an unused peripheral line, which may significantly reduce infection risks. Critically ill patients have low antioxidant levels (especially vitamins C and E) (Davidson & Boom 1995). Giving vitamin E, the most important intracellular chain-breaking antioxidant (Davidson & Boom 1995), appears particularly beneficial. Other antioxidants that may Multiorgan dysfunction syndrome 265 prove useful include intracellular glutathione (Davidson & Boom 1995) and enzymes such as cytosolic superoxide dismutase (which includes zinc, long used for skin healing). Reperfusion of ischaemic tissues which have survived through anaerobic metabolism flushes toxic oxygen metabolites and radicals into the cardiovascular system. These can trigger a further cascade of vasoactive and other endogenous chemicals (see Chapter 23). Apparent recovery can therefore be reversed with one or more vital organs failing for a second time. High incidence and paucity of curative (rather than supportive) treatments has encouraged a search for novel solutions.
Sanctity of life is trivial generic priligy 30 mg fast delivery, some dramatic—leaves its mark forever on manifested in everyone buy generic priligy 30mg online. The goal is accomplished Levine’s (1968a cheap priligy 30 mg without a prescription, 1968b discount priligy 30 mg online, 1973) discussion of the through the use of the conservation principles: en- person includes recognition that the person is de- ergy, structure, personal, and social. Yet a person is affected by the vironment to maintain the balance of energy supply presence of another relative to his or her personal and demand. Admittedly, some of this is de- dependent on an intact defense system (immune ﬁned based on cultural ethos, yet what is it about system) that supports healing and repair to preserve the “bubble” that results in a speciﬁc organismic re- the structure and function of the whole being. It may be that the energy involved in the The conservation of personal integrity acknowl- interaction is not clearly deﬁned. Scientists are edges the individual as one who strives for recogni- challenged to examine this. Levine encouraged cre- tion, respect, self-awareness, humanness, self-hood, ativity such as therapeutic touch but rejected activ- and self-determination. The internal environment is recognized, but it is also recognized that the indi- combines the physiological and pathophysiological vidual resides within a family, a community, a reli- aspects of the individual and is constantly chal- gious group, an ethnic group, a political system, lenged by the external environment. The external environment includes those factors The outcome of nursing involves the assessment that impinge on and challenge the individual. The nurse is responsible environment as described by Levine (1973) was for responding to a request for health care and for adapted from the following three levels of environ- recognizing altered health and the patient’s organ- ment identiﬁed by Bates (1967). An organismic The perceptual environment includes aspects of response is a change in behavior or change in the the world that individuals are able to seize or inter- level of functioning during an attempt to adapt to pret through the senses. The organismic responses are lects, and tests information from the environment intended to maintain the patient’s integrity. It is the physiological that may physically affect individuals but are not and behavioral readiness to respond to a sudden directly perceived by them, such as radiation, mi- and unexpected environmental change; it is an in- croorganisms, and pollution. This is the second level patterns characterized by spiritual existence and me- of response intended to provide for structural diated by language, thought, and history. Both are that affect behavior—such as norms, values, and be- defenses against noxious stimuli and the initia- liefs—are also part of the conceptual environment. If the experience is pro- Nurses use the scientiﬁc process and creative longed, the stress can lead to damage to the abilities to provide nursing care to the patient systems. This is the fourth level of re- these abilities, thereby improving the care of the sponse. They are 1 The person is viewed as a holistic being: integrated by their cognitive abilities, the wealth of “The experience of wholeness is the foundation previous experiences, the ability to deﬁne relation- of all human enterprises” (Levine, 1991, p. Table 9–1 Use of the Nursing Process According to Levine Process Application of the Process Assessment Collection of provocative facts through observation and interview of challenges to the internal and external environments. The nurse observes the patient for organismic responses to illness, reads medical reports, evaluates results of diagnostic studies, and talks with patients and their families (support per- sons) about their needs for assistance. The nurse assesses for physiological and pathophysiologi- cal challenges to the internal environment and the factors in the perceptual, operational, and conceptual levels of the external environment that challenge the individual. The nurse arranges the provocative facts in a way that provides meaning to the patient’s predicament. Nurses seek validation of the patients’ problems with the patients or support persons. The nurses then propose hypotheses about the problems and the solutions, such as: Eight glasses of water a day will improve bowel evacuation. Interventions are designed based on the conservation principles: conservation of energy, structural integrity, per- son integrity, and social integrity. The expectation is that this approach will maintain wholeness and promote adaptation. The outcome of hypothesis testing is evaluated by assessing for organismic response that means the hypotheses are supported or not supported. Consequences of care are either therapeutic or supportive: therapeutic measures improve the sense of well-being; supportive measures pro- vide comfort when the downward course of illness cannot be inﬂuenced. If the hypotheses are not supported, the plan is revised and new hypotheses are proposed. The scientiﬁc process is used to make observations and select relevant data to form hypothetical statements about the patients’ predica- ments (Schaefer, 1991a). These decisions are not the role pletely to every alteration in his or her life of the health-care providers or families (Levine, pattern. Atheoryofnursing must recognize 6 “Persons who require the intensive inter- the importance of unique detail of care for a ventions of critical care units enter with a con- single patient within an empiric framework tract of trust. The model’s universality is supported by the 8 The nurse is responsible for recognizing the model’s use in a variety of situations and patients’ state of altered health and the patient’s organis- conditions across the life span. Swavely, Rothenberger, Hess, & Willistin, 1996), emergency room (Pond & Taney, 1991), primary Values care (Pond, 1991), in the operating room (Crawford-Gamble, 1986), long-term/extended 1 All nursing actions are moral actions. This model has been used with a variety of pa- 3 Ethical behavior “is the day-to-day expres- tients across the life span, including the neonate sion of one’s commitment to other persons and (Mefford, 1999; Tribotti, 1990), infant (Newport, the ways in which human beings relate to one 1984; Savage & Culbert, 1989), young child (Dever, another in their daily interactions” (Levine, 1991), pregnant woman (Roberts, Fleming, & 1977, p. Clark (1992) provides examples of the use of tients (Cox, 1991; Foreman, 1991, 1996; Hirschfeld, the conservation principles with the individual, 1976), including the frail elderly patient (Happ, family, and community as a testament to the personal communication, January 31, 1995; model’s ﬂexibility/universality. The approach to community begins with the The model has been used as a framework for collection of facts and a thorough community as- wound care (Cooper, 1990), managing respiratory sessment (provocative facts). The internal environ- illness (Dow & Mest, 1997; Roberts, Brittin, Cook, ment assessment directs the nurse to examine the & deClifford, 1994), managing sleep in the patient patterns of health and disease among the people of with a myocardial infarction (Littrell & Schumann, the community and their use of programs available 1989), developing nursing diagnoses (MacLean, to promote a healthy community. The assessment 1989; Taylor, 1989), practicing enterostomal ther- of the external environment directs the nurse to ex- apy (Neswick, 1997), assessing for changes in amine the perceptual, operational, and conceptual bladder function in posthysterectomy women levels of the environment in which the people live. It has also been used for devel- The perceptual environment incorporates those oping plans of care for women with chronic illness factors that are processed by the senses. On a com- (Schaefer, 2002), care of intravenous sites (Dibble, munity basis these factors might include an assess- Bostrom-Ezrati, & Rizzuto, 1991), skin care (Burd ment of: et al. The operational environment would encourage Current work on the model is in process in the a more detailed assessment of the factors in the en- areas of community health. The following is a brief vironment that affect the individual’s health but are summary of beginning clariﬁcation of the model’s not perceived by the people. This discussion focuses on ment on the ethnic and cultural patterns in the community-based care using Levine’s Conserva- community. An assessment of types of houses of tion Model to provide a foundation for the future worship and health-care settings might be included. Using Levine’s Conservation Model, conservation principles to guide continued assess- community was initially deﬁned as “a group of peo- ment to assure a thorough understanding of the ple living together within a larger society, sharing community. Levine (1973) maintained that research Assessment of personal integrity might include: is critical to the development of a scientiﬁcally 1. Political environment to nursing that is scientiﬁc, research oriented, and universal in practice.
Cardiac surgery 303 Early mobilisation should be supported 30 mg priligy sale, musculoskeletal complications and pulmonary emboli being the main causes of delayed discharge (Johnson & McMahan 1997) proven priligy 30mg. Transplantation issues The severing of the sympathetic and parasympathetic pathways causes loss of vagal tone generic 30mg priligy fast delivery, resulting in resting rates of about 100 beats/minute (Adam & Osborne 1997) buy priligy 30mg with amex. Denervation also (usually) prevents angina, increasing risk of silent infarction (12 per cent of patients do experience pain (Tsui & Large 1998)). A loss of sympathetic tone impairs cardiac response to increased metabolic demands, making atropine ineffective (Adam & Osborne 1997). Surgery preserves recipients’ right atrium, resulting in two P waves (one intrinsic, one graft) (Adam & Osborne 1997). Although not pathologically significant, the reasons for the presence of two P waves should be explained to patients, families and junior nurses. Many possible postoperative complications result from the necessities of intraoperative procedures; increasing percutaneous surgery may significantly reduce numbers of open heart operations. Clinical scenario Peter Da Silver is a 48-year-old man with a history of angina, hypertension and insulin dependent diabetes. Review causative factors for this complication and propose a plan of care to stabilise sternum, promote healing and recovery (evaluate various treatment approaches, pharmacological/surgical interventions, equipment used to stabilise sternum, appropriate nutrition). Haemostasis has four phases: ■ smooth muscle contraction (vasoconstriction; myogenic reflex) ■ formation of platelet plugs ■ formation of fibrin clot (blood clotting/coagulation), followed by retraction of fibrin clots ■ fibrinolysis. The most effective diagnostic tests are D-dimer tests, platelet counts, anti-thrombin-3 levels and fibrin monomers (Jørgensen et al. Proteolysis stimulates further coagulation and fibrinolysis, causing disseminated generation of thrombin and plasmin. Excessive fibrin production and deposition consume clotting factors (hence ‘consumptive coagulopathy’) and cause inappropriate clotting. Consumption of clotting factors leaves insufficient supply for homeostasis so that patients bleed readily (typically from invasive cannulae and trauma, such as endotracheal suction). As coagulopathy progresses, patients bleed from multiple sites, clotting at bleeding sites taking progressively longer. Skin symptoms are easily visible; subdermal haemorrhages cause purpura, the skin may appear cyanotic, mottled or cool, and in latter stages gangrene may develop. Bleeding may occur from traumatic endotracheal suction, further complicating respiratory function. The gastrointestinal tract is especially susceptible to haemorrhage, and so gastric drainage/aspirate and stools should be assessed for blood (including occult and melaena). Intensive care nursing 308 If patients are not being fed enterally, stomach decompression (free nasogastric drainage) reduces stomach stretch and acid accumulation, thus helping to prevent haemorrhage. Early beliefs that heparin would release clotting factors from microthrombi for normal homeostasis proved unfounded. Since hypovolaemia is a common complication, fluid replacement with whole blood and plasma substitutes is likely (see Chapter 33). Symptoms typically include purpura, neurological deficits, multifocal neuropsychiatrie disturbances and renal failure. Heparin stimulates heparin-dependent anti-platelet antibodies, causing intravascular platelet aggregation, thrombocytopenia and arterial and venous stenosis (Cavanagh & Colvin 1997). Many nursing interventions may provoke haemorrhage: ■ endotracheal suction ■ turning ■ cuff blood pressure measurement ■ rectal temperature ■ enemas ■ rectal/vaginal examinations ■ plasters and tape ■ shaving ■ mouthcare Some interventions may be necessary, although alternative approaches should be considered. For example, wet shaves are likely to cause bleeding; electric shavers may be safely used (staff may need to ask families to bring electric razors in, as electric shavers are usually unavailable in hospitals for infection control reasons). Invasive cannulae and procedures should be minimised to reduce risks of haemorrhage. The sight of blood can cause many people great distress, often out of all proportion to the amount of volume lost. The loss of 5 ml of blood is physiologically unimportant, but Intensive care nursing 310 can cause a large enough stain on bedding to create distress, and possible fainting. Visitors should be warned about the possible sight of blood, escorted to the bedside, and observed until staff are satisfied about their safety. Relatives experiencing stress may transmit their fears to patients; apart from humanitarian reasons for reducing stress, it may increases fibrinolytic activity (Thelan et al. Early treatments with anticoagulants have been largely superseded by more conservative (temporary) approaches of replacing clotting factors and treating symptoms to buy time while the underlying pathology is treated. Nursing care should focus on avoiding complications of trauma, while minimising anxiety to both patients and relatives. Of journal articles, Kesteven & Saunders (1993) and Rutherford (1996) give useful overviews. Kelly’s haematological investigations included: Kelly’s results Normal Prothrombin time 22 sec 1–15 sec Partial thromboplastin time 60secs 39–48 sec Thrombin time 15 sec 10–13 sec Fibrinogen levels 0. With reference to physiology, explain why Kelly developed coagulation disorder from hyperthermia and hypermetabolic state. Outline the rationale for this treatment and the nursing approaches which can maximise their therapeutic benefits (e. Reflect on how such a discussion should be managed, appraise the feasibility of organ donation (e. When patients with pre-existing chronic renal failure are admitted, renal management usually continues previous care (e. Distinctions between acute and chronic renal failure are arbitrary (often 100 days), but imply differences between potentially recoverable and incurable conditions. Acute renal failure is therefore potentially reversible; treatment aims to replace renal function while optimising recovery of renal tissue. Acute renal failure can be classified as: ■ prerenal ■ intrarenal (intrinsic) ■ postrenal In this chapter, some treatments for renal failure are discussed, while haemofiltration is covered in Chapter 35. This chapter also describes some renal hormones (renin, atrial natriuretic factor and insulin-like growth factor) and rhabdomylolysis. Renal failure is failure of the kidneys to perform normal metabolic functions (see Table 32. Renal failure indicates widespread (about three-quarters) non-function of nephrons. Endstage renal failure occurs when 90 per cent of nephrons fail, leaving a relatively narrow margin between recoverable and terminal failure. As more patients survive primary patholo-gies, and the population becomes older, secondary renal failure is likely to increase. Provided chronic failure is prevented, recovery of renal tissue (unlike other major organs) is usually complete. Two easily measured metabolites (urea 60 kDa, creatinine 133 kDa) are useful markers of healthy renal function, but with critical illness become progressively unreliable (Stark 1998). Nitrogen balance is restored by hepatic metabolism of ammonia to urea, which is excreted renally. Glomerular filtration of urea is influenced by many factors, such as tubular reabsorption of urea, metabolic rate, diet and drugs. Creatinine, a waste product of muscle metabolism, varies with muscle mass; those with less muscle (children, older adults) usually produce less creatinine. In health, creatinine clearance reflects glomerular filtration rate, normal serum levels being 50–120 micromol/l.
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