Q. Miguel. University of Texas Medical Branch.
The acceptance of passive euthanasia may prove to be the ‘slippery slope’ to greater (involuntary) extermination (Randall 1997) buy cipro online antibiotic neomycin. The Roman Catholic theology distinguishes ordinary from extraordinary interventions (Rachels 1986): ordinary interventions (‘natural’ or ‘God-given’) must be preserved order cheap cipro line do they give antibiotics for sinus infection, but extraordinary interventions (those created by humans, thus unnatural) may be withdrawn. Ventilators replace breathing, a natural function, and so may be ‘ordinary’, whereas drugs (e. The House of Lords (1993) ruled that a nasogastric tube was ‘extraordinary’, and so removal from a patient in a persistent vegetative state (where brainstem function remains, but higher function is absent) would not lead to prosecution; the tube was removed, so that the patient effectively died of starvation. This—the apparent absurdity of nasogastric tubes being extraordinary while ventilators are ordinary—can make decisions difficult. Decisions should therefore be made by team consensus—and the individual team members have each to live with their own conscience. How would you feel about removing equipment in the extraordinary list from a terminal patient? If patients’ wishes can be ascertained, advocating for patients should be beneficent. If relieving pain is good, but killing is harmful, morphine can both do good (relieve pain) and harm (kill). Intensive care nursing 142 Justice Justice carries connotations of ■ retribution/punishment ■ fairness. However, fairness is a subjective concept— those denied access usually consider injustice has been performed. Hence, the nurses’ duty of care may conflict with their own values about fairness. Ethical theories Duty Duty-based theory (deontology) develops Kant’s belief that people are an end in themselves, not the means to an end. These values are reflected in nursing by respect for individuals and duty of care. These apparently laudable aims can create dilemmas: ■ nursing is learnt though clinical practice, so patient care (means) is a learning experience (end) for the nurse ■ nurses caring for two patients (e. Refusing admission because beds are unavailable means denying care ■ whether or not nurses who have not completed care (e. Rationing services can be justified if they do not meet the needs of the majority. The right of one person necessarily imposes a duty on another person, and so nurse advocacy may be a consequential duty of patients’ rights. Problems with rights include ■ conflict between rights of different people (should there be a Nurses’ Charter? The ethical principles and theories outlined in this chapter provide frameworks for considering dilemmas raised in later chapters or through practice. Various dilemmas have been briefly raised; each can be pursued through the wide range of texts and articles on ethics. Readers are therefore encouraged to consider and discuss ethical dilemmas with colleagues. Intensive care nursing 144 Further reading Beauchamp and Childress (1994) is a major biomedical text, much material being applicable to nursing. Downie and Calman (1994) develop profound and well-supported issues with especial emphasis on rights. There are many nursing-specific texts; Rumbold (1999) is highly approachable, with clear, well-written discussion. There are nursing and medical journals devoted to ethical issues, but other journals frequently include ethics. Purcell (1997) gives a particularly sensitive analysis of withdrawing treatment from a child, while Cook et al. Investigations revealed severe left ventricular failure, an ejection fraction of 20 per cent with very poor medical prognosis. Consider effective strategies which facilitate patient involvement in the planning and delivery of care (e. The first chapter describes various means of respiratory monitoring; additional aspects of ventilatory and airway monitoring were covered in Chapters 4 and 5. Carriage of gases, particularly the oxygen saturation curve and the relationship between arterial oxygen tensions and peripheral saturation of oxygen, is illustrated in Chapter 18; blood gas analysis is then explored in Chapter 19. The final chapter describes neurological monitoring, with especial reference to intracranial pressure monitoring and treatment of intracranial hypertension. This chapter assumes familiarity with simpler respiratory observations (including spirometry); more frequently used ventilator settings are discussed in Chapter 4 and arterial blood gas analysis in Chapter 19. This chapter mainly describes technological monitoring used by nurses, especially pulse oximetry. The information gained should be interpreted holistically, focusing on patients rather than monitors, and trends rather than absolute figures. Burroughs and Hoffbrand (1990) found inaccurate nursing records from following previously charted observations rather than what is actually observed; nurses should have confidence in their observations, noting and reporting significant changes. Visual Observing patients’ colour and appearance is fundamental to all areas of nursing; skin richly supplied with blood (lips, oral membranes, nail beds) gives the best visual indication of perfusion. Good light, preferably daylight, should be used when assessing skin colour; artificial light, especially fluorescent, can cause distortion. In the absence of reliable early visual signs, technology is needed to support respiratory monitoring. Auscultation Breath sounds are created by air turbulence, and so are limited to upper airways (Hough 1996). Chest (and abdominal) sounds can be deceptive, and so should not be relied upon absolutely. Listening for air entry is used to assess: ■ intubation (bilateral air entry) ■ bronchial patency/bronchospasm ■ secretions ■ effect of suction (before and after) The stethoscope diaphragm best transmits lung sounds (especially high pitches, such as wheezes; the bell is better for low pitches (e. Note pitch, intensity, quality and duration of sounds, listening: ■ anteriorly, posteriorly, laterally ■ on both right and left ■ at apices and bases ■ during both inspiration and expiration ■ over any dependent lung areas, where fluid and mucus tend to collect Missing any areas (for example, because difficult to reach) makes assessment incomplete. Normal sounds are: ■ vesicular: most lung fields, especially peripheries; continuous, low pitch and volume, like rustling wind, with short expiratory phase ■ bronchovesicular: lung apices; medium pitched, louder than vesicular ■ bronchial: trachea; high pitched, loud, short inspiration, like blowing through a tube Abnormal sounds include: ■ wheeze (rhonchi): from bronchospasm, continuous Intensive care nursing 148 ■ crackle (rales, crepitations): bubbling, from fluid, exudate or secretions; interrupted ■ pleural rub: grating sound from (abnormal) friction between pleura Sound may be absent with any obstruction (e. Artefactual sounds may be caused by: ■ clothing ■ friction of stethoscope against equipment (e. Inspiration affects, and is affected by, bronchial muscle stretch; thus patients with chronic obstructive pulmonary disease cannot fully dilate bronchi during short inspiratory time. Expiration is passive recoil; the short expiration time of muscle spasm (asthma) causes gas trapping (and distress). Bedside monitors to measure work of breathing enable more accurate titration of pressure support (Banner et al.
There are two parallel procedures purchase generic cipro on-line antibiotic resistance hospital acquired infections, the Examination Procedure buy cipro 750mg line virus 986 m2, which tells the client what to do, and the Scoring Procedure, which tells the clinician how to rate what he or she observes. Examination Procedure Either before or after completing the Examination Procedure, observe the client unobtrusively, at rest (e. If yes, ask him/her to describe and to what extent they currently bother client or interfere with his/her activities. Have client sit in chair with both hands on knees, legs slightly apart, and feet ﬂat on ﬂoor. Ask client to tap thumb with each ﬁnger as rapidly as pos- sible for 10 to 15 seconds; separately with right hand, then with left hand. Scoring Procedure Instructions: Complete examination procedure before making ratings. Code: 0 None 1 Minimal, may be extreme normal 2 Mild 3 Moderate 4 Severe Facial and Oral Movements 1. Severity of abnormal movements: 0 1 2 3 4 (Based on the highest single score on the above items. Incapacitation due to abnormal movements: 0 None, normal 1 Minimal 2 Mild 3 Moderate 4 Severe 10. Client’s awareness of abnormal movements (Rate only client’s report) 0 No awareness 1 Aware, no distress 2 Aware, mild distress 3 Aware, moderate distress 4 Aware, severe distress Dental Status 11. Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Solutions with a pH of 7 are said to be neutral, while those with pH values below 7 are deﬁned as acidic, and those above pH of 7 as being basic. Similarly, the conjugate acid of a strong base is very weak and likewise does not undergo hydrolysis. Acidity is the measure of how easily a compound gives up a proton, and basicity is a measure of how well a compound shares its electrons with a proton. This means that its conjugate base must be weak because it has little afﬁnity for a proton. A weak acid gives up its proton with difﬁculty, indicating that its conjugate base is strong because it has a high afﬁnity for a proton. H Cl + H2O: H O H + Cl− pKa = -7 Strong base H (A conjugate base) Strong acid (A conjugate acid) Weak base pKa = -1. Remember that square brackets are used to indicate concentration in moles/litre ¼ molarity (M). The acid dissociation constant is obtained by multiplying the equilibrium constant (Keq) by the concentration of the solvent in which the reaction 1. For convenience, the strength of an acid is generally indicated by its pKa value rather than its Ka value. The pKa of hydrochloric acid, strong acid, is À7, and the pKa of acetic acid, much weaker acid, is 4. The most important application of acid–base solutions containing a com- mon ion is buffering. Thus, a buffer solution will maintain a relatively constant pH even when acidic or basic solutions are added to it. The most important practical example of a buffered solution is human blood, which can absorb the acids and bases produced by biological reactions without changing its pH. A constant pH for blood is vital, because cells can only survive this narrow pH range around 7. By choosing the appropriate components, a solution can be buffered at virtually any pH. The pH of a buffered solution depends on the ratio of the concentrations of buffering components. When the ratio is least affected by adding acids or bases, the solution is most resistant to a change in pH. The pKa of the weak acid selected for the buffer should be as close as possible to the desired pH, because it follows the following equation: pH ¼ pKa The role of a buffer system in the body is important, because it tends to resist any pH changes as a result of metabolic processes. Titration is also called volumetric analysis, which is a type of quantitative chemical analysis. Generally, the titrant (the known solution) is added from a burette to a known quantity of the analyte (the unknown solution) until the reaction is complete. From the added volume of the titrant, it is possible to determine the concentration of the unknown. Often, an indicator is used to detect the end of the reaction, known as the endpoint. An acid–base titration is a method that allows quantitative analysis of the concentration of an unknown acid or base solution. In an acid–base titration, the base will react with the weak acid and form a solution that contains the weak acid and its conjugate base until the acid is completely neutralized. The following equation is used frequently when trying to ﬁnd the pH of buffer solutions. For the titration of a strong base with a weak acid, the equivalence point is reached when the pH is greater than 7. The half equivalence point is when half of the total amount of base needed to neutralize the acid has been added. In acid–base titrations, a suitable acid–base indicator is used to detect the endpoint from the change of colour of the indicator used. The following table contains the names and the pH range of some commonly used acid–base indicators. Atoms are a collection of various subatomic particles containing negatively charged electrons, positively charged protons and neutral particles called neutrons. Electrons move around the nucleus, and are arranged in shells at increasing distances from the nucleus. These shells represent different energy levels, the outermost shell being the highest energy level. Chemistry for Pharmacy Students Satyajit D Sarker and Lutfun Nahar # 2007 John Wiley & Sons, Ltd. The total number of protons and neutrons in the nucleus of an atom is known as the mass number. For example, a carbon atom containing six protons and six neutrons has a mass number of 12. Mass number (Number of protons + number of neutrons) 12 6C Atomic symbol Atomic number (Number of protons) Elements are substances containing atoms of one type only, e. Compounds are substances formed when atoms of two or more elements join together, e.
It is effective against numerous diseases including histo- plasmosis cheap cipro master card antibiotics for uti with e coli, cryptococcosis safe 250mg cipro antibiotic resistance grants, coccidioidomycosis, aspergillosis, blastomycosis, and candidiasis (system infection), however, it is very toxic. Side effects and adverse reactions include flushing, fever, chills, nausea, vomiting, hypotension, paresthesias, and thrombophlebitis. It is highly toxic, causes nephrotoxicity and electrolyte imbalance, especially hypokalemia (low potassium) and hypomagnesemia (low serum magnesium). Nystatin (Mycostatin) can be given orally or topically to treat candidal infec- tion. It is more commonly used as an oral suspension for candidal infec- tion in the mouth as a swish and swallow. Side effects include anorexia, nausea, vomiting, diarrhea (large doses), stom- ach cramps, rash; vaginal: rash, burning sensation. The Imidazole group is effective against candidiasis (superficial and systemic), coccidioidomycosis, cryptococcosis, histoplasmosis, and paracoccidioidomycosis. Antimalarial Malaria is still one of the most prevalent protozoan diseases in the world. The tissue phase causes no clinical symptoms in the human and the erythrocytic phase invades red blood cells and causes chills, fever, and sweating, In the United States the 1000 cases reported annually are almost all from interna- tional travel. Quinine was the only antimalarial drug from 1820 to the early 1940s when synthetic antimalarial drugs were developed. If drug resistance develops quinine is used in combination with an antibiotic such as tetracycline. Cestodes (tapeworms) (enter via contaminated food [pork (trichinosis), fish, dwarf]) 2. The inflammatory response is the first line of attack bringing white blood cells to the site of the infection in an attempt to stifle the spread of the microbial. Anti-inflammatory medication is administered to patients to reduce the inflam- matory response enabling the patient to return to normal activities. In these cases the patient requires medication to help the body destroy the micro- bial. You learned how they work, how to administer them, their side effects, and when they should not be administered to a patient. In the next chapter you will learn about respiratory diseases and about the medications that are prescribed to treat those diseases. A new infection caused by a bacterium that is resistant to the present antibiotics being given is called a (a) communicable infection. A patient should always be asked if he or she is allergic to any medica- tions, foods, or herbals or who has a family history of allergies to antibi- otics. This is because (a) patients who have a family member who is allergic to an antibiotic might also have an allergy to some antibiotics. Antibiotics fight off bacteria by (a) inhibiting the bacteria’s ability to make protein called protein synthesis. What chemical mediators bring about the inflammatory reaction by vaso- dilatation, relaxing smooth muscles, making capillaries permeable, and sensitizing nerve cells within the affected area to pain? The patient’s white blood count should be studied after the patient is given an antibiotic. Chicken soup is not a drug but it does contain a mucous-thinning amino acid called cysteine and is considered “grandma’s remedy” for the common cold. Actually, time is the best cure and most people feel better in 7 to 10 days with or without chicken soup. The common cold is one of a number of respiratory diseases that can infect our body. However, some respiratory dis- eases—such as emphysema—are debilitating and can slowly choke the life out of a person. In this chapter, we’ll explore the more common respiratory diseases and learn about the medications that are used to either destroy the disease-causing microorganism or to manage the symptoms of the disease. A Brief Look at Respiration Before learning about respiratory diseases and the medications used to treat them, let’s take a few moments to briefly review the anatomy and physiology of the res- piratory tract. The upper respiratory tract contains the nares, nasal cavity, pharynx, and larynx and the lower tract consists of the trachea, bronchi, bronchioles, alveoli, and alveolar- capillary membrane. During respiration, air is inhaled and makes its way through the upper respi- ratory tract and travels to the alveoli capillary membrane in the lower respiratory tract, which is the site of gas exchange. Oxygen from the air attaches to the hemoglobin of the blood while carbon dioxide leaves the blood and is expelled through the lower and upper respiratory tracts during expiration. Perfusion Perfusion is when blood from the pulmonary circulation is sufficient at the alveolar-capillary bed to conduct diffusion. In order for perfusion to occur, the alveolar pressure must be matched by adequate ventilation. The presence of mucosal edema, secretions and bronchospasm increase resistance to the airflow, which results in decreased ventilation. Diffusion Diffusion is the process where oxygen moves into the capillary bed and carbon dioxide leaves the capillary bed. Compliance is the ability of the lungs to be distended and is expressed as a change in volume per unit change in pressure. These are the connective tis- sue that consists of collagen and elastin and surface tension in the alveoli, which is controlled by surfactant. Surfactant is a substance that lowers surface tension in the alveoli, thereby preventing interstitial fluid from entering the alveoli. That is, the lungs become stiff requiring more-than-normal pressure to expand the lungs. This is typically caused by an increase in connective tissue or an increase in surface tension in the alveoli. Throughout the body chemoreceptors sense the concentration of oxygen, car- bon, and carbon dioxide and then send a message to the central chemoreceptors located in the medulla near the respiratory center of the brain and through cere- brospinal fluid to respond to changes. When an increase in carbon dioxide is detected and there is an increase in hydrogen ions, the message goes out to increase ventilation. Once the oxygen pressure falls below <60 mmHg, the peripheral chemoreceptors send a message to the respiratory center in the medulla to increase ventilation. The tracheobronchial tube is a fibrous spiral of smooth muscles that become more closely spaced as they near the terminal bronchioles. The size of the air- way can be increased or decreased by relaxing or contracting the bronchial smooth muscle. This is controlled by the parasympathetic nervous system—par- ticularly the vagus nerve. The vagus nerve releases acetylcholine when it is stimulated, which causes the tracheobronchial tube to contract.
A plan for continuing care or for assistance during stress- ful life experiences is mutually established by the nurse and client discount 250mg cipro overnight delivery xylitol antibiotic. Through these interactions buy cipro discount best antibiotics for sinus infection doxycycline, the client learns that it is acceptable to un- dergo these feelings at a time of separation. Through this knowledge, the client experiences growth during the pro- cess of termination. Note: When the client feels sadness and loss, behaviors to delay termination may become evident. If the nurse experi- ences the same feelings, he or she may allow the client’s behaviors to delay termination. For therapeutic closure, the nurse must establish the reality of the separation and resist being manipulated into repeated delays by the client. Giving Allows the client to “What would you like to broad take the initiative talk about today? Placing the Clariﬁes the relation- “What seemed to lead event in ship of events in up to...? Helps the “What was your client recognize life response the last experiences that tend time this situation to recur as well as occurred? Perhaps you especially well with and I can discuss it a client who is mov- together. This technique is not therapeutic, how- ever, with the client who is very anxious. Exploring Delving further into a “Please explain that subject, idea, experi- situation in more ence, or relation- detail. Especially “Tell me more about helpful with clients that particular who tend to remain situation. However, if the client chooses not to disclose further in- formation, the nurse should refrain from pushing or prob- ing in an area that obviously creates discomfort. Seeking Striving to explain “I’m not sure that I un- clariﬁca- that which is vague derstand. Voicing Expressing uncer- “I ﬁnd that hard to doubt tainty as to the believe (or accept). Verbal- Putting into words Cl: “It’s a waste of time izing the what the client has to be here. Attempting When feelings are Cl: “I’m way out in the to trans- expressed indirectly, ocean. This may cause Better to say: “Let’s the client to discontin- look at that a little ue interaction with the closer. Disagreement implies inaccuracy, provoking the need for defensiveness on the part of the client. Pushing for mother abused answers to issues the you when you client does not wish to were a child. This causes the “Tell me how you client to feel used and feel toward your valued only for what is mother now that shared with the nurse, she is dead. Defending Attempting to protect “No one here would someone or something lie to you. Defending does will try to answer not change the client’s your questions feelings and may cause and clarify some the client to think the issues regarding nurse is taking sides your treatment. Tell me what When one is experienc- you are feeling ing discomfort, it is right now. The nurse has not been prepared to perform this technique and, in attempting to do so, may endanger other nursing roles with the client. The group is founded in a speciﬁc theo- retical framework, with the goal being to encourage improve- ment in interpersonal functioning. Nurses often lead “therapeutic groups,” which are based to a lesser degree in theory. The focus of therapeutic groups is more on group relations, interactions among group members, and the consideration of a selected issue. Types of groups include task groups, in which the function is to accomplish a speciﬁc outcome or task; teaching groups, in which knowledge or information is conveyed to a number of individuals; supportive-therapeutic groups, which help prevent future upsets by teaching participants effective ways of dealing with emotional stress arising from situational or developmental crises; and self-help groups of individuals with similar problems who meet to help each other with emotional distress associated with those problems. Yalom (2005) identiﬁed 11 curative factors that individu- als can achieve through interpersonal interactions within the group. Universality (individuals come to understand that they are not alone in the problems they experience) 3. The group leader is called the director, group members are the audience, and the set, or stage, may be specially designed or may just be any room or part of a room selected for this purpose. Ac- tors are members from the audience who agree to take part in the “drama” by role-playing a situation about which they have been informed by the director. Usually the situation is an issue with which one individual client has been struggling. In this role, the client is able to express true feelings toward in- dividuals (represented by group members) with whom he or she has unresolved conﬂicts. In some instances, the group leader may ask for a client to volunteer to be the protagonist for that session. The client may choose a situation he or she wishes to enact and select the audi- ence members to portray the roles of others in the life situation. The psychodrama setting provides the client with a safer and less threatening atmosphere than the real situation in which to express true feelings. When the drama has been completed, group members from the audience discuss the situation they have observed, offer feed- back, express their feelings, and relate their own similar experi- ences. In this way, all group members beneﬁt from the session, either directly or indirectly. Leaders of psychodrama have graduate degrees in psychology, social work, nursing, or medicine with additional training in group therapy and specialty preparation to become a psychodramatist. Areas of assessment include communication, manner of self- concept reinforcement, family members’ expectations, handling differences, family interaction patterns, and the “climate” of the family (a blend of feelings and experiences that are the result of sharing and interacting). The systems approach to fam- ily therapy is composed of eight major concepts: (1) differentia- tion of self, (2) triangles, (3) nuclear family emotional process, (4) family projection process, (5) multigenerational transmission process, (6) sibling position proﬁles, (7) emotional cutoff, and (8) societal regression. The goal is to increase the level of dif- ferentiation of self, while remaining in touch with the family system. The Structural Model In this model, the family is viewed as a social system within which the individual lives and to which the individual must adapt. Major concepts include systems, subsystems, trans- actional patterns, and boundaries. The therapist does this by joining the family, evaluating the family system, and restruc- turing the family. Functional families are open systems where clear and precise messages, congruent with the situation, are sent and received.