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By I. Zuben. Mercyhurst College.
Prolonged malnourishment (especially with alcoholism) buy calan 240mg with amex blood pressure medication best time to take, vomiting and nasogastric drainage may compound hypokalaemia, while dehydration (e. Electrolyte imbalances have varied systemic effects, including dysrhythmias from hypokalaemia and oedema formation from hyponatraemia. Hepatic failure 381 Metabolic acidosis may occur from ■ hypoperfusion (anaerobic metabolism) ■ renal impairment ■ gastric acid loss (vomiting, aspiration) (Adam & Osborne 1997) Impaired toxin metabolism and clearance increases sensitivity to, and effects of, many drugs and metabolites. With chronic failure, hepatocellular necrosis prevents glycogenolysis, which causes potential hypoglycaemia (Lockhart-Wood 1996), necessitating frequent blood sugar monitoring and probably glucose supplements. Artificial livers The development of artificial livers has been slow and problematic, but shortage of donor livers prompted experiments with xenoperfusion. Cadaver and baboon livers have achieved extracorporeal support for up to 75 days (Conlin 1995), although immunologie intolerance makes xenoperfusion impractical (Sussman 1996). Temporary support is possible from hepatocytes grafted onto semipermeable hollow-fibre devices (visually similar to those used for haemofiltration), which provide support until transplantation (Fristoe et al. Nurses should encourage families to express their needs Intensive care nursing 382 and emotions, but it may be necessary to involve counselling or other services. Liver function affects many other organs and systems, and so the care of patients with liver dysfunction requires a range of knowledge and skills. Intracranial hypertension, a major complication of hepatic failure, is discussed further in Chapter 22. Further reading Hawker is a leading authority on hepatic failure; her chapter (1997a) is an accessible and useful source. Langley and Pain (1994) discuss some of the options for medical treatment, while Stanley et al. Artnal and Wilkinson (1998) give a case study of fulminant failure from paracetamol. Clinical scenario Fabio Galvani is a 26-year-old male who has recently completed a six-month backpacking trip to southeast Asia. Since his return he has been feeling increasingly unwell with nausea, vomiting, fever with influenza-like symptoms. He was admitted to hospital for investigations after behaving in a confused and agitated manner. Doctors made a diagnosis of fulminating hepatic failure and grade 3 hepatic encephalopathy. Review your understanding of hepatitis B virus: • Likely route (portal of entry) and mode of transmission • Incubation period • Survival outside host cells (how long virus can live outside body) • Infectious risk to friends, family and health care workers. Specify proactive nursing strategies, which can minimise potential complications (prioritising care, type of psychological support, nutrition, health promotion, use of specialists). Immunity Classifications of immunity derive from historical schools of immunology, which increasingly recognised that different modes of immunity existed concurrently. Nonspecific immunity is any defence mechanism not targeting specific microorganisms. Specific immunity is necessarily acquired through exposure to various organisms or antibody vaccination. Cell-mediated immunity causes T-lymphocytes to respond to (nonspecific) protein by producing various lymphokines; humoral immunity is mediated by antibodies (B-lymphocytes) in the blood, and is antigen-specific. Nonspecific immunity Many body systems include defence mechanisms against foreign material, all potentially compromised by critical illness and treatments (e. Specific immunity Specific immunity is achieved through two types of lymphocytes: T and B. T-lymphocytes T-lymphocyte precursors originate in bone marrow, migrating to and maturing in the thymus gland (Abbas et al. Antigen recognition by T-lymphocytes causes enlargement and differentiation into (Johnson 1994): ■ killer cells (cytolytic) attach to invading cells, then secrete • lymphotoxins (kill invading cells) • lymphokines (attract lymphocytes and macrophages) • interferon (inhibits viral replication, enhances action of killer cells) ■ helper cells assist B-lymphocytes increase antibody production (Johnson 1994). Intensive care nursing 386 B-lymphocytes B-lymphocytes, produced in the bone marrow, respond to foreign antigens by becoming antibody producing cells (Abbas et al. Three (IgA, IgG, IgM) primarily neutralise toxins and viral activity, promoting bacterial lysis and phagocytosis.
Through sections on the cur- and Economic Constraints of rent context of health-care organizations trusted 240 mg calan hypertensive urgency guidelines, review of Nursing Practice the literature related to the political and economic constraints of nursing practice, economic caring Economic Implications of Bureau- research, political and economic implications of cratic Caring Theory: Research in bureaucratic caring, and visions for the future, we Current Atmosphere of Health-Care learn how the Theory of Bureaucratic Caring Reform applies. Economic/Political Implications Current Context of of Bureaucratic Caring Health-Care Organizations Summary In the wake of the controversial health-care reform References process that is currently being debated in the United States, the central thesis in today’s economic health-care milieu in both the for-profit and not- for-profit sectors is managed care (Williams & Ray (1989, p. Managed care is an economic con- tion of America and other health care systems to cept based on the premise that purchasers of care, corporate enterprises emphasizing competitive both public and private, are unwilling to tolerate management and economic gain seriously chal- the substantial growth of the last several years in lenges nursing’s humanistic philosophies and theo- health-care costs. Managed care involves managed ries, and nursing’s administrative and clinical competition and is based on the assumption that policies. Within traditional complex health-care or- nursing services to the bed rate for patients ganizations, community or public health agencies, (Shaffer, 1985). This new form of health-care fi- trators who must determine how these resource nancing, based on the ratio of benefits over costs or dollars will be allocated within their respective the “highest quality services at the lowest available institutions. When professional nursing salary outcomes are paramount to health-care organiza- dollars are viewed as an economic liability that tional survival and the economic viability of pro- limits the potential profit margins of organiza- fessional nursing practice. From an economic per- executives attribute these workforce reductions to spective, health-care organizations are a business. It is imperative to the future of is becoming stronger, cost controls are becoming professional nursing practice that the economic tighter, and reimbursement is declining. However, value of caring be studied and documented, so human caring is not subsumed by the economics of The human dimension of health care is health care. Review of the Literature: the human dimension of health care is missing from the economic discussion. Political and Economic In the economic debate, the belief in caring for Constraints of Nursing Practice the patients as the goal of health-care organizations has been lost. Ray (1989) questioned how eco- In order to use the economic dimension of the nomic caring decisions are made related to patient Theory of Bureaucratic Caring to guide research, care in order to enhance the human perspective nursing administration, and clinical practice, it is within a corporate culture. When patients are hos- necessary to understand both the way in which pitalized, it is the caring and compassion of the reg- health care has been financed and the current reim- istered nurse that the patients perceive as quality bursement system. Nurses, who understand the care and making a difference in their recovery economics of health-care organizations, will be (Turkel, 1997). The concerns of patients themselves able to synthesize this knowledge into a framework are not about costs or health-care finance. Yet, in a for practice that integrates the dimensions of climate increasingly focused on economics, it has economics and human caring. Consequently, newer cost systems, such work and charitable religious organizations as managed care, do not look at human caring (Dolan, 1985). Prior to the establishment of or the nurse-patient relationship when allocating Medicare and Medicaid in 1965, the health-care resource dollars for reimbursement. Nursing Historically, nursing care delivery has not been students subsidized hospitals, and hospital-based financed or costed out in terms of reimbursement nursing care was not considered a reimbursable as a single entity. As nursing education As a result of the prospective payment system, moved away from the hospital setting to universi- hospital administrators were pressured to increase ties in the late 1950s and as the role of the student efficiency, reduce costs, and maintain quality. Research was con- the retrospective reimbursement of Medicare ducted in order to examine the costs associated and Medicaid in 1965 allowed for hospital prof- with nursing (Bargagliotti & Smith, 1985; Curtin, itability and the issue of nursing care costs was not 1983; McCormick, 1986; Walker, 1983). Hospital administrators were under process did not include the humanistic, caring considerable pressure to control costs. It Foshay (1988) investigated 20 registered nurses’ was assumed that the rising costs of health care perceptions of caring activities and the ability of were due to nurses’ salaries and the number of reg- patient classification systems to measure these car- istered nurses (Walker, 1983). Findings from this study revealed that a percent of hospital charges could not be identi- patient classification systems could not address the fied, because historically they had been tied to the emotional needs of patients, the needs of the eld- room rate. Specific car- care costs continued to rise and did not follow ing behaviors that could not be measured included traditional economic patterns. Cost-based reim- giving a reassuring presence, attentive listening, and bursement altered the forces of supply and de- providing information. In the traditional economic marketplace, Other research of this time period focused on when the price of a product or service goes up, the the cost and outcomes of all registered nurse demand decreases and consumers seek alternatives staffing patterns (Dahlen & Gregor, 1985; Glandon, at lower prices (Mansfield, 1991). However, in the Colbert, & Thomasma, 1989; Halloran, 1983; health-care marketplace, consumers did not seek Minyard, Wall, & Turner, 1986). These studies an alternative as the price of hospital-based care showed that nursing units staffed with more regis- continued to rise (DiVestea, 1985). This imbalance tered nurses had decreased costs per nursing diag- of the supply-and-demand curve occurred because nosis, increased patient satisfaction, and decreased consumers paid little out-of-pocket expense for length of stay.
In some laboratories media are prepared by individual measurement of ingredients and then mixing the same buy calan 240mg with visa blood pressure young living. Hence the method of preparation is given likewise: 375 Nutrient broth Meat extract 10. Dissolve the agar in nutrient broth and sterilize by autoclaving at 121°C for 15 minutes. Glucose broth Nutrientbroth 900ml Glucose (10% solution) 100 ml • Dissolve 9 gm glucose in distilled water and sterilize by tyndallisation. Blood agar Nutrient agar 100 ml Sheep blood (defibrinated) 10 ml • Melt the sterile nutrient agar by steaming, cool to 45°C. Loeffler serum medium Nutrientbroth 100ml Serum(sheeporhorseorox) 300ml Glucose 1. Distribute in 100 ml quantities in a bottle and autoclave at 121°C for 15 minutes. Glycerolated blood tellurite mixture Sterile defibrinated sheep blood 14 ml Sterileglycerol 6 ml Sterile potassium tellurite solution (1% in water) 4 ml • Sterilize the glycerol in hot air oven at 160°C for 60 minutes and the tellurite solution by autoclaving at • 115°C for 20 minutes. One per cent solution of • good quality tellurite is sufficient but 2% of some batches may be required. Preparation of complete medium Glycerolated blood tellurite mixture 24 ml Agar base 100 ml 380 Melt the agar, cool to 45°C, add blood and tellurite and pour in sterile petri dishes. A-1 Medium Tryptone 20 g Lactose 5 g NaCl 5 g *Triton X-100 (Rohm & Haas) 1 ml Salicin 0. Dispense 10 ml portions of single strength broth into 18 x 150 mm tubes containing inverted fermentation vials. For double strength broth, use 22 x 175 mm tubes containing inverted fermentation vials. Dispense 15 ml into 20 x 150-mm screw-cap tubes and sterilize by autoclaving for 15 min at 121°C. Alkaline Peptone Agar Peptone 10 g NaCl 20 g Agar 15 g Distilled water 1 liter Boil to dissolve ingredients. Alkaline Peptone Water Peptone 10 g NaCl 10 g Distilled water l liter 383 Adjust pH so that value after sterilization is 8. Medium must be reduced before inoculation by 24 h anaerobic incubation in anaerobic glove box or GasPak jar. Anaerobic Egg Yolk Agar Agar base Yeast extract 5 g 384 Tryptone 5 g Proteose peptone 20 g NaCl 5 g Agar 20 g Distilled water 1 liter Autoclave 15 min at 121°C. To 1 liter melted medium (48-50°C) add 80 ml yolk-saline mixture (available from Difco as Bacto Egg Yolk Enrichment 50%), and mix. Bile Esculin Agar Beef extract 3 g Peptone 5 g Esculin 1 g Oxgall 40 g Ferric citrate 0. Suspend precipitate by gentle agitation, and pour 20 ml portions into sterile 15 x 100 mm petri dishes. Blood Agar Tryptone 15 g Phytone or soytone 5 g NaCl 5 g Agar 15 g Distilled water 1 liter Heat with agitation to dissolve agar. Tryptic soy agar, tryptic soy 388 agar blood base, or trypticase soy agar [soybean-casein digest agar (M152)] may be used as the basal medium. Blood Agar Base (Infusion Agar) Heart muscle, infusion from 375 g Thiotone 10 g NaCl 5 g Agar 15 g Distilled water 1 liter Heat gently to dissolve. Suspend ingredients of Medium 2 in distilled water and boil for 1 min to completely dissolve. Brilliant Green Lactose Bile Broth Peptone 10 g Lactose 10 g Oxgall 20 g Brilliant green 0. Dispense into 391 fermentation tubes, making certain that fluid level covers inverted vials. Bromcresol Purple Broth Base Peptone 10 g Beef extract 3 g NaCl 5 g Bromcresol purple 0. Sterilize stock solutions of carbohydrates (50% w/v) separately by autoclaving or, preferably, by filtration (0. Place yolks in sterile container and mix aseptically with equal volume of sterile 0. For heart infusion agar, add 15 g agar/L and boil to dissolve before dispensing and sterilizing. Kligler Iron Agar Polypeptone peptone 20 g Lactose 20 g Dextrose 1 g NaCl 5 g Ferric ammonium citrate 0.
New York calan 240mg amex blood pressure normal in pregnancy, the head has been injured in some way, a tremendous Basic Books, 1969, 1973, 1980. Lon- often have detrimental effects on brain cells, including don, Routledge, 1993. Recent medical advances have uncovered some drugs and treat- ments that can offset this after-effect of trauma, and physicians now know that brain cells can be replaced in Brain disorders adults, a procedure that was thought impossible only a decade ago. Doctors now have the ability to procure ac- Any of the various disorders associated with the curate images of the brain from magnetic resonance human brain, including stroke, trauma, and tu- mors. It has recently been reported that neurology, the The incidence of brain tumors has increased in re- study of the brain, is the fastest growing specialty in the cent years, although it is not certain if this trend is sim- life sciences. Nonetheless, treatments devised thus far have of the more prevalent brain disorders. Researchers have found varieties of brain disorders that affect humans, including that certain genes inside tumors are capable of creating Alzheimer’s disease, Parkinson’s disease, epilepsy, resistance to drugs being used to destroy the tumor. The four principal Developmental neurologic disorders of the brain in- sections of the human brain are the brain stem, the dien- clude well-known brain diseases such as Alzheimer’s, cephalon, the cerebrum, and the cerebellum. Most of these disorders are now known to be inheritable, passed from one generation to another genetically. Re- The brain stem cent research has isolated the gene that causes strains of The brain stem connects the brain with the spinal Alzheimer’s, Huntington’s disease, and several other cord. Cerebral palsy, a devastating devel- brain and spinal cord pass through the medulla—a part opmental neurologic disorder involving severe muscle of the brain stem—via fibers. The fibers on the right side and coordination deterioration, has been attributed to of the medulla cross to the left and those on the left cross stroke in newborn infants. The medulla also controls spent the following studying brain disorders: the heartbeat, the rate of breathing, and the diameter of Alzheimer’s disease, $305 million; stroke, $116 million; the blood vessels and helps to coordinate swallowing, multiple sclerosis, $80 million; Parkinson’s disease, $72 vomiting, hiccupping, coughing, and sneezing. Another million; epilepsy, $55 million; and head injury, $51 mil- component of the brain stem is the pons (meaning lion. Conveying impulses between the cerebral Further Reading cortex, the pons, and the spinal cord is a section of the “Cognitive Impairment to Dementia. The diencephalon The diencephalon lies above the brain stem and em- bodies the thalamus and hypothalamus. The thalamus Brain is an important relay station for sensory information, in- Part of the central nervous system located in the terpreting sensations of sound, smell, taste, pain, pres- skull. Controls mental and physical actions of the sure, temperature, and touch; the thalamus also regulates organism. The hypothalamus con- trols a number of body functions, such as heartbeat rate The brain, with the spinal cord and network of and digestion, and helps regulate the endocrine system nerves, controls information flow throughout the body, and normal body temperature. The hypothalamus inter- voluntary actions, such as walking, reading, and talking, prets hunger and thirst, and it helps regulate sleep, and involuntary reactions, such as breathing and heart- anger, and aggression. Encased within the skull, The cerebrum the brain of an average adult weight about 3 lb (1. For example, spoken and written language are three-layer membrane called the meninges. Earthworm brain Deutocerebrum Cerebrum Protocerebrum Stomatogastric system Infundibulum Pituitary gland Ventral Cerebellum nerve cord Midbrain Pons Brain Tritocerebrum Thoracic ganglia Medulla stem Subesophageal oblongata ganglion Spinal cord B. Bird brain Comparison of the brains of an earthworm, an insect, a bird, and a human. Motor areas of the pus callosum had been destroyed, scientists realized that cerebrum control muscle movements. Broca’s area trans- differences existed between the left and right sides of the lates thoughts into speech, and coordinates the muscles cerebral cortex. The right direct hand muscles for writing and eye muscles for side of the brain, on the other hand, is more concerned physical movement necessary for reading. In gen- eral, the left half of the brain controls the right side of The cerebrum’s outer layer, the cerebral cortex, is the body, and vice versa.
