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Volumes below 300 ml per hour in circuits without countercurrent dialysate (haemofiltration) or below 180 ml per hour with diafiltration provide ineffective solute clearance cheap 100mg kamagra overnight delivery erectile dysfunction drugs boots, consuming nursing time without benefit to patients kamagra 50mg discount erectile dysfunction viagra cialis levitra, and so should be discontinued. Outflow volumetric pumps prevent ultrafiltrate volumes falling, but as functional filtration area decreases, transmembrane pressure will increase. Recommended afferent pump speed varies between systems (readers should check the manufacturers’ recommendations and local protocols), but should be commenced slowly (e. If stable, speeds should usually be increased to a minimum 150 ml/min within 10 minutes. Concern about drug clearance by haemofiltration is justified, but factors are complex, requiring advice from unit pharmacists. All drugs (except some colloidal fluids) used in clinical practice are smaller than filter pore size, and so potentially may be filtered. Studies of drug clearance may refer to Intensive care nursing 352 peritoneal dialysis, haemodialysis, haemofiltration or haemodiafiltration. Clearance may also differ between animal or healthy human volunteers and critically ill patients. Kaplan (1998) identifies four main factors affecting drug clearance: ■ molecular weight (5–10 kDa readily cleared by haemofiltration) ■ degree of protein binding ■ drugs’ volume of distribution (water solubility/lipid affinity) ■ drugs’ endogenous clearance (hepatic) Drugs are usually only active if unbound, so that binding is normally weak, with volatile shifts between bound and unbound drug molecules. Protein binding alone is affected by ■ acidity (pH) of blood ■ molar drug concentrations ■ bilirubin levels ■ uraemic inhibitors ■ presence of heparin ■ numbers of free fatty acids ■ other (displacing) drugs Predilution increases transfer (and so clearance) of protein-bound urea (and other molecules) into plasma (Kaplan 1998). Large ultrafiltrate volumes are often smaller than human glomerular filtrate so that drug clearance by filters may be no higher than the Bowman’s capsule. Drug prescriptions may therefore need increasing or decreasing during haemofiltration. Where drugs are titrated to therapeutic effects such as measured laboratory levels (e. Many colloids in clinical use are below filter pore size; volume replacement should either use cheaper crystalloids or large molecule colloids (e. Anecdotal reports suggest filters and circuits can function considerably longer, but circuits are highly invasive and so major sources for infection; nurses contravening (and managers condoning) the manufacturer’s instructions may be legally liable for harm. Plasmapheresis Plasmapheresis (‘extracorporeal purification’) resembles haemofiltration, usually with smaller filter pores. Intermittent treatments, usually spread over several days, enables removal of ■ drugs (e. At present, it is unclear whether removing mediators improves patient outcome (Kirby & Davenport 1996), but Ronco et al. While technology has made circuits and machines safer, haemofiltration is highly invasive, exposing patients to various complications and dangers. Nurses unfamiliar with using haemofiltration are encouraged to find out how to use it in practice before having to care on their own for patients receiving haemofiltration. Some useful articles have appeared in specialist journals; Kirby and Davenport (1996) offer a useful recent overview; despite their age, articles by Miller et al. He developed rhabdomyolysis and acute renal failure from compression injury as a result of collapsing, lying on the floor for over 18 hours and ingesting nephrotoxic medication. Identify and explain any differences in equipment and patient application between haemofiltration and haemodiafiltration (e. Describe and explain the observational assessment of Mr Sinclair’s coagulation status. Chapter 36 Gastrointestinal bleeds Fundamental knowledge Gastrointestinal anatomy Introduction The importance of gastrointestinal failure to critical care pathophysiology has been increasingly recognised; major gastrointestinal bleeding poses more obvious threats to survival. Most clotting factors are produced by the liver, and so hepatic dysfunction disrupts haemostasis. Oesophageal varices can haemorrhage so rapidly and profusely that one-half of patients die from their first bleed (Schoenfield & Butler 1998). Variceal bleeding The portal vein carries blood (and nutrients) from the stomach to the liver; portal hypertension can be caused by portal vein thrombosis or (more often) cirrhosis (McCaffrey 1991). Alcoholic liver disease, the main cause of cirrhosis (Quinn 1995), is often complicated by malnourishment and gastric ulceration. Pressures exceeding 15 mmHg can cause rupture (Lisicka 1997); obstruction may create pressures exceeding 30 mmHg (McCaffrey 1991), Rupture of varices can cause massive haemorrhage, with 30–50 per cent mortality (Sung et al. Urgent treatment should: ■ stop the haemorrhage ■ provide fluid resuscitation ■ replace clotting factors Haemorrhage is usually stopped by: Intensive care nursing 356 ■ balloon tamponade ■ sclerosis ■ stents Medical treatments Direct pressure to bleeding points is possible using balloon tamponade (Sengstaken, Sengstaken-Blakemore, Minnesota tubes; see Figure 36. Tubes usually have four ports: ■ oesophageal balloon (to stop bleeding) ■ oesophageal aspiration port (omitted on 3-port tubes) ■ gastric balloon (to anchor tubes) ■ gastric aspiration port Balloon tamponade controls 85–92 per cent of bleeds, but re-bleeds are common (Boyer & Henderson 1996), so that balloon tamponade is often only a temporary (emergency) treatment.

Medications: Use of anticoagulants before sur- side rails and place bed in low position discount kamagra 50 mg overnight delivery erectile dysfunction wellbutrin xl. Previous surgery: Previous heart or lung surgery ent him/her to the room as necessary purchase 50 mg kamagra visa erectile dysfunction cancer, and allow may necessitate adaptations in the anesthesia family members to remain with the patient after used and in positioning during surgery. Nausea and vomiting: Provide oral hygiene as for meeting his/her psychological needs and needed; avoid strong-smelling foods. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Surgical pain: Assess pain frequently; offer d b f g a e c nonpharmacologic measures to supplement medications. False—Pediculus humanis corpus Intellectual: ability to identify the common psycho- 12. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. The mother the nurse to observe the skin for signs of break- must be educated on the proper method of bathing down. A back rub improves circulation and provides a for good hygiene for her baby, and a bath should means of communication with the patient be demonstrated with a return demonstration. Ventilation: It is wise to air the room when the means to buy the materials necessary for her patient is away for a diagnostic or therapeutic baby’s hygiene (shampoo, oil, powder, diaper rash procedure to remove pathogens and unpleasant ointment, etc. Odors: Odors can be controlled by promptly measures designed to refresh the patient and pre- emptying bedpans, urinals, and emesis basins pare him/her for breakfast. The face and hands and by being careful not to dispose of soiled should be washed and mouth care provided. Morning care: After breakfast, the nurse offers waste receptacle in the patient’s room. Room temperature: Whenever possible, patient care, cosmetics, dressing, and positioning. Lighting and noise: The nurse should reduce assistance with toileting, handwashing, and harsh lighting and noises whenever possible. Hour of sleep care: The nurse again offers assis- diately outside the patient’s room. Gums: Lesions, bleeding, edema, and exudate; acts as a conditioner, relaxes a restless person, pro- loose or missing teeth motes circulation, serves as musculoskeletal exer- d. Tongue: Color, symmetry, movement, texture, cise, stimulates the rate and depth of respirations, and lesions promotes comfort, provides sensory input, improves e. Hard and soft palates: Intactness, color, patches, self-esteem, and strengthens the nurse–patient rela- lesions, and petechiae tionship. Provide the patient with articles for bathing and a appearance; presence of lesions, nodules, basin of water that is at a comfortable temperature; redness, swelling, crusting, flaking, excessive place these items conveniently for the patient. Ear: Position, alignment, and general Place cosmetics in a convenient place with a mir- appearance; buildup of wax; dryness, crusting, ror and light, and supply hot water and a razor for discharge, or foreign body; and hearing acuity a patient who wishes to shave. Nose: Position and general appearance; patency cannot bathe themselves completely. A towel bath can be accomplished with little edema, bleeding, and discharge or secretions fatigue to the patient. The towel remains warm during the short the outer canthus using a wet, warm washcloth; procedure. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Delamordo’s daughter ger, instructing patient never to insert objects should be taught the proper techniques for caring into the ear for cleaning purposes. Delamordo demonstrates washing suctioning may be indicated), remove crusted areas of her body that she can reach. What intellectual, technical, interpersonal, and/or gently grasping the lens near the lower edge ethical/legal competencies are most likely to bring and lifting it from eye. Technical: ability to adapt hygiene care measures to Ask the patient how he/she cleans the eye area meet the needs of an older adult with right-sided (usually flushed with normal saline before paralysis. Hearing aids: Batteries should be checked their caregivers, as appropriate, in learning new self- routinely and earpieces cleaned daily with mild care measures related to hygiene.

The Nursing Times 1993 series of articles (since collected together in book form) also outlines many therapies generic kamagra 50mg with amex erectile dysfunction young age causes. The journal Complementary Therapies in Nursing and Midwifery includes many useful articles order kamagra 100 mg otc erectile dysfunction treatment vacuum device. He has become increasingly withdrawn and depressed, has difficulty sleeping and discomfort from paraesthesia in lower limbs. Nursing values may conflict with norms and values of other groups, and changes are not always successful, but planning helps achieve success. Asking basic questions helps to clarify issues and motives, and so this chapter adopts a what? Include changes on your own unit, within the hospital, and wider changes in healthcare. As you read through this chapter, note down, section by section, how you would plan to bring this change about. After reading this chapter, you may have a workable plan which you can discuss with senior staff on your unit. The requirements by managers and courses for introducing change have created some negative structures and outcomes; change should grow from convictions that it is needed. Ideas may be gained from Intensive care nursing 448 courses, study days, reading, discussions with others, experience elsewhere, or (sometimes) out of the blue. Be clear about what you want to change (the exercise above should have crystallised your ideas). Internal stimuli depend on the motivation, ambition and values of the staff involved. Rationales for change probably precede the identification of the precise nature of changes. Having clarified what you intend to do, reconsider your initial motivation, identifying the existing problems and benefits of suggested changes. Changes without clear benefits may not be worth the effort and trauma of introducing them. Everyone is a potential change agent, capable of initiating, and possibly leading, change. Top-down change agents may be members of staff or outsiders; with bottom-up approaches, change agents are necessarily team members. Outsiders are usually authoritarian, although action research (Webb 1989), which has proved popular within nursing, helps people to reflect on and understand change better, and so aids the establishment of a change in practice (Pryjmachuk 1996). Outsiders need to establish either authority (power-coercive) or credibility (rational-empirical); insiders are usually already accepted group members. Ketefian (1978) suggested that change agents should: diagnose need identify and clarify issues develop strategies and tactics establish and maintain working relationships with staff This model recalls the nursing process, but usefully emphasises that interpersonal relationships are as important as the plan itself. Possible strategies include feedback education standards/guidelines/quality control Managing change 449 Ethical approval may be needed, especially if patients are involved in any research. Wright (1998) suggests that most literature on leadership derives from soci-ology, industry or politics, but if nursing really is unique (as it is often claimed) it may need to develop its own unique management models. However, Surman and Wright (1998) follow most nursing literature in citing Bennis et al. Orders should be followed because managers are senior (coercive); no further reason is required, and discussion is usually discouraged. Power-coercion is hierarchical, top-down, autocratic (Keyzer & Wright 1998), achieving strong, cost-effective leadership. Junior staff may not agree with the ideas, but know what those ideas are; change occurs quickly, and the power-base for decision- making is clear. National management of healthcare often adopts power-coercion, whether by government (Department of Health) or professional bodies. Benner’s (1984) novice may be more comfortable with clear power-coercive leadership; more advanced practitioners usually find power-coercion increasingly oppressive, with their own ideas and initiatives being cramped by others. Power coercion is grounded in behaviourism (see Chapter 2), with outward behaviours (action) being valued more than the inner feelings of individuals.

Haemoglobin is therefore not normally lost into interstitial fluid (oedema) or urine buy 100mg kamagra fast delivery erectile dysfunction doctors in atlanta. An average 70 kg adult has about 900 grams of circulating haemoglobin order kamagra 100 mg free shipping erectile dysfunction doctors in orlando, giving ‘normal’ levels of 14–18 g/dl for men and 12–16 g/dl for women (Rowswell 1997). Lower concentrations decrease viscosity, so aid perfusion: 10 g/dl being preferred with critically ill patients. Macrophages metabolise old erythrocytes, releasing iron (for further haemoglobin synthesis) and waste (excreted in bile). Polypeptides of normal adult haemoglobin (HbA) consist of two alpha and two beta chains:. The slight biochemical differences between alpha and beta chains are not significant for clinical nursing, but abnormalities of either chain can cause pathologies. Each erythrocyte contains approximately 640 million haemoglobin molecules (Hoffbrand & Pettit 1993). Adult haemoglobin normally replaces fetal haemoglobin soon after birth, although the latter can (abnormally) persist throughout life, predisposing patients to tissue hypoxia. Haemoglobin levels of 10 g/dl with an average 5-litre circulating volume give a total body haemoglobin of. If all four limbs of the molecule carry oxygen, the haemoglobin is described as fully (100 per cent) saturated. Saturation of total haemoglobin (not single molecules) can be measured through oximetry (e. While haemoglobin is an efficient transport mechanism for oxygen, usually only 20– 25 per cent of available oxygen unloads, leaving normal venous saturations (SvO2) of 70– 75 per cent. This large venous reserve can provide oxygen without any increase in respiration rate or cardiac output so that, while SaO2 indicates oxygen availability, the SaO2-SvO2 gradient indicates tissue uptake (consumption) of oxygen, measured through cardiac output studies (see below). Prussic acid is found in cyanide, one of the degradation products of sodium nitroprusside. Partial pressure of gases Air contains approximately 21 per cent oxygen and 79 per cent nitrogen, with negligible amounts of other gases (carbon dioxide is 0. Thus the partial pressure of each gas is determined by the difference between total barometric pressure and water pressure vapour percentage concentration of gas, which is then divided in proportion to percentage concentration of gases (see Table 18. Alveolar gas tensions are altered by rebreathing ‘dead space’ gas, relatively rich in carbon dioxide and poor in oxygen. Physiological adult dead space is about 150 ml; additional pathological dead space exists when alveoli are not perfused. With artificial ventilation, dead space begins at the inspiratory limb (‘Y’ connector) of ventilator tubing. Cellular respiration The purpose of respiratory function is to supply tissue cells with sufficient oxygen to enable mitochondrial activity and remove carbon dioxide (a waste product of metabolism). Mitochondria are the powerhouses of the cell, so that their failure leads to cellular damage and eventual cell death. Currently, it is not practical to monitor mitochondrial respiration, and cruder parameters (e. However, the end of respiratory function should be remembered when assessing intermediate parameters. Partial pressures of oxygen progressively fall with further stages of internal respiration: capillary pressure of 6. Relative differences in pressures create the concentration gradient that enables diffusion across capillary and cell membranes. However, a fall in alveolar partial pressure (from respiratory failure) reflects proportional reductions in tensions throughout the body, resulting in tissue hypoxia. Similarly, giving oxygen concentrations above 21 per cent increases alveolar tensions, reflected in proportional increases in tensions throughout the body. Oxygen dissociation curve The complex relationship between partial pressures of arterial oxygen (PaO2) and oxygen saturation of haemoglobin (SaO2) are shown in the oxygen saturation curve (Figure 18. Transfer of gasses across capillary membranes is determined by differentials in partial pressure on either side of the membrane. Oxygen content of arterial blood is the sum of the oxygen dissolved in plasma (PaO2) and the oxygen carried by haemoglobin (SaO2). Most oxygen is carried by haemoglobin, but oxygen in solution determines the partial pressure and, thus, tension of gas across the capillary membrane. On the plateau of the curve (SaO2 above 75 per cent) oxygen readily dissociates from haemoglobin, causing marked fluctuations in PaO2 , and making oxygen saturation a relatively insensitive marker of oxygen content (e.