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By N. Gembak. Barrington University. 2018.

This reflex can be initiated by oral endotracheal tubes and suction catheters proven prevacid 15mg gastritis gas, causing discomfort (antitussive drugs purchase prevacid 15mg amex gastritis medical definition, such as codeine phosphate, can suppress gag reflexes). Many critically ill patients have impaired gag reflexes, causing possible aspiration (including past low-pressure endotracheal cuffs). Impaired cough and swallowing reflexes may cause aspiration of saliva and gastric secretions. Seals are usually incomplete; cuffs often develop slow leaks, usually from external valves, but sometimes from cuff permeability to gases or chemicals. If excessive cuff volumes or pressures are needed, the tube probably needs replacing. While cuff pressure should be sufficient to minimise risks from aspiration, excessive pressure on tracheal epithelium may occlude capillary perfusion causing tracheal ulcers; unlike pressure sores on skin, these are not directly visible. Assessing cuff pressures by squeezing the external balloon is unreliable, but commercially available manometers are available and reliable, and so nurses should, as part of their individual accountability, check cuff pressures at least once each shift, and whenever cuff volume is changed. Nasal intubation and tracheostomy prevent hypersalivation, but tracheal secretions may still accumulate. Like cuff pressure sores (above), pressure from tubes can damage any surrounding tissue (lips, gums, nostril). Sympathetic nervous stimulation from intubation and suction initiates stress responses (see Chapter 3); suction-induced stress responses can cause intracranial hypertension (Brucia & Rudy 1996). Direct vagal nerve stimulation (anatomically close to the trachea) can cause bradycardic dysrhythmias and blocks, especially during intubation. Patients’ inability to speak due to intubation through their vocal cords should be explained. Humidification Nasal epithelium has a rich venous supply covering the nasal conchae; air turbulence maximises exposure for heat and moisture exchange, inspired air normally reaching body temperature just below the carina (Jackson 1996); thus the human airway (a) warms, (b) moistens, and (c) filters inspired air. Endotracheal intubation bypasses these normal physiological mechanisms, necessitating artificial replacement. Hot air transports more water vapour than cold air and so fully saturated room air/gas (100 per cent relative humidity) will not be fully saturated once warmed to body temperature. Gas not fully saturated absorbs moisture from airway surfaces, causing dehydration, making mucus more viscid. Viscid mucus increases: ■ risk of chest infection ■ risk of airway encrustation/obstruction ■ airway resistance and work of breathing ■ surfactant dysfunction Gas should therefore be heated and fully saturated exogenously; tracheal gas temperature should be 32–36°C. Heated water baths provide an ideal medium for bacterial incubation, particularly pseudomonas. Water bath humidifiers may cause overhumidification, mucosal burns, hyperthermia and water intoxification (Jackson 1996). Where exogenous heat is used, temperature of inspired air should be continuously monitored. Current dilemmas between humidification and infection control lack an ideal solution. Saline lavage to remove encrusted secretions can cause various problems (discussed below). However pulmonary oedema from increased capillary permeability may limit hydration of critically ill patients. Airway management 43 Suction Intubation bypasses non-specific mucus and cilial defences, while impaired cough reflexes from critical illness, antitussives and sedation, enable accumulation of lower respiratory tract secretions, reducing/obstructing airway patency (increasing work of breathing) and providing media for bacterial growth. Endotracheal suction can remove accumulated secretions, but can also cause: ■ infection ■ trauma ■ hypoxia ■ atelectasis Post-discharge surveys consistently identify patient anxiety and discomfort from suction (e. Puntillo 1990), and so it should never be a ‘routine’ procedure (Ashurst 1997); nurses should evaluate benefits against dangers. The changes made in endotracheal suction practice in the 1980s necessitate caution when reading older literature.

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While law enforcement initially adopted fngerprints as a means of crim- inal identifcation discount prevacid 30mg without a prescription gastritis icd 9 code, their use for victim identifcation also became important generic prevacid 30 mg otc gastritis diet gastritis symptoms. Eventually, the use of fngerprints for human iden- tifcation evolved into one of the primary tools used today by law enforce- ment, medicolegal professionals, and disaster mortuary response teams for personal identifcation. Tis arrangement of the friction ridge skin is permanent due to the underlying structure of the skin and unique because of complex physiological events, both genetic and environmental, that occur during fetal development. Friction ridge skin is present on the palmar and plantar surfaces of the hands and feet. As such, impressions from the fngers and palms of the hands as well as the toes and soles of the feet can all be used for personal identifcation purposes. Te friction ridge skin found on the hands and feet difers from the rela- tively smooth skin that covers the rest of the human body. Tis corrugated skin, consisting of raised ridges and recessed furrows, assists individuals with grasping objects and gaining traction. Friction skin is composed of two main layers, an outer layer called the epidermis and an inner layer called the dermis. Te epidermis has fve diferent cell layers, whereas the dermis is one large layer consisting mainly of connective tissue and blood vessels. Te epidermal ridges are supported by double rows of papillae pegs on the dermis, which can play an instrumental role in the recovery of fngerprints from deteriorating bodies. Detailed examination of the friction ridge skin also reveals that ridge path, in most instances, is not continuous across the entire surface of a fnger. Some ridges, called ending ridges, will fow and abruptly come to an end, while other ridges, called dividing ridges or bifurcations, will fow and separate into two separate and distinct ridges. Additionally, some ridges are as long as they are wide and are called dots (Figure 6. Tese ridge events are commonly referred to as characteristics or minutiae, and their spatial relationship to one another in a friction ridge impression is the basis for fngerprint comparison and identifcation. Other features existing in a fngerprint called formations are ridge path deviations involving the combination of one or more ridge characteristics. Further examination of the friction ridge skin also reveals irregular ridge contours and sweat pores. Structural and dimensional ele- ments of ridges and pores, when clarity permits, can be used in conjunction with ridge characteristics for comparing and identifying fngerprints. Friction ridge arrangement at the ends of the fngers generally forms pattern types referred to as loops, arches, and whorls (Figure 6. Approximately 65% of all fngerprint patterns are loops, 30% are whorls, and 5% are arches. In a loop, the friction ridges enter from one side of the pattern, recurve, and pass out or tend to pass out the same side the ridges entered. An arch has ridges that enter from one side of the pattern, make a wave in the middle, and pass out the opposite side from which they entered. It is important for an examiner to note the ridge fow of a print for orientation purposes and the recognition of focal areas that will ultimately assist in the identifcation process. While pattern confguration alone cannot be used for individualization, it can be used for exclusionary decisions made by an examiner. A latent fngerprint is the two-dimensional reproduction of the friction ridges of the fnger on an object by means of perspiration, oils, or other contami- nants that coat the surface of the ridges when a fnger touches an item. Tese types of prints generally must be made visible through the use of forensic technology such as alternate light sources, chemical techniques, or fnger- print powders. In some instances, latent prints can be visualized without the use of any fngerprint processing techniques and are called patent prints.

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Drinking is therefore not simply seen as an unwanted behaviour that should stop but as a behaviour which serves a function in the alcoholic’s life discount prevacid 15mg visa chronic gastritis no h pylori. Such approaches include: s Assessing the drinking behaviour both in terms of the degree of the problem (e discount prevacid 30mg atrophic gastritis symptoms mayo. Multi-perspective approaches are often regarded as skills training approaches as they encourage individuals to develop the relevant skills needed to change their behaviour. Lichtenstein and Glasgow (1992) reviewed the literature on self-help quitting and reported that success rates tend to be about 10–20 per cent at one-year follow-up and 3–5 per cent for continued cessation. The literature suggests that lighter smokers are more likely to be successful at self-quitting than heavy smokers and that minimal interventions, such as follow-up telephone calls, can improve this success. Research also suggests that smokers are more likely to quit if they receive support from their partners and if their partners also stop smoking (Cohen and Lichtenstein 1990) and that partner support is particularly relevant for women trying to give up smoking during pregnancy (e. However, although many ex- smokers report that ‘I did it on my own’, it is important not to discount their exposure to the multitude of health education messages received via television, radio or leaflets. Public health interventions: promoting cessation in populations Public health interventions aim to promote behaviour change in populations and have become increasingly popular over recent years. For smoking cessation, they take the form of doctor’s advice, worksite interventions, community-wide approaches, government interventions. For drinking behaviour, most public health interventions take the form of government interventions. Research suggests that the recommendation from a doctor, who is considered a credible source of information, can be quite successful in promoting smoking cessation. Research also suggests that the effectiveness of doctor’s advice may be increased if they are trained in patient-centred counselling techniques (Wilson et al. Over the past decade there has been an increasing interest in developing worksite-based smoking cessation interventions. These take the form of either a company adopting a no-smoking policy and/or establishing work-based health promotion programmes. Worksite interventions have the benefit of reaching many individuals who would not consider attending a hospital or a university-based clinic. In addition, the large number of people involved presents the opportunity for group motivation and social support. Furthermore, they may have implications for reducing passive smoking at work, which may be a risk factor for coronary heart disease (He et al. Research into the effectiveness of no-smoking policies has produced conflicting results with some studies reporting an overall reduction in the number of cigarettes smoked for up to 12 months (e. In two Australian studies, public service workers were surveyed following smoking bans in 44 government office buildings about their attitudes to the ban immediately after the ban and after six months. The results suggested that although immediately after the ban many smokers felt inconvenienced, these attitudes improved at six months with both smokers and non-smokers recognizing the benefits of the ban. Although work- site interventions may be a successful means to access many smokers, this potential does not yet appear to have been fully realized. Large community-based programmes have been established as a means of promoting smoking cessation within large groups of individuals. Such programmes aim to reach those who would not attend clinics and to use the group motivation and social support in a similar way to worksite interventions. Early community-based programmes were part of the drive to reduce coronary heart disease. In the Stanford Five City Project, the experimental groups received intensive face-to-face instruction on how to stop smoking and in addition were exposed to media information regarding smoking cessation. The results showed a 13 per cent reduction in smoking rates compared with the control group (Farquhar et al. In the North Karelia Project, individuals in the target community received an intensive educational campaign and were compared with those in a neighbouring community who were not exposed to the campaign.


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