By U. Ketil. Troy State University - Dothan. 2018.

His girlfriend had said that he had shown no signs of unusual mood on the previous day 4 mg cardura overnight delivery arrhythmia cause. He had his end of term examinations in psychology coming up in 1 week and was anx- ious about these but his studies seemed to be going well and there had been no problems with previous examinations order 1mg cardura with amex arteria etmoidal anterior. The first part of the care should be to ensure that he is stable from a cardiac and respiratory point of view. Blood gases should be measured to monitor the oxy- genation and ensure that the carbon dioxide level is not high, suggesting hypoventilation. The family history of diabetes raises the possibility that his problem is related to this. One would expect a slower development with a history of thirst and polyuria over the last day or so. Hypoglycaemia comes on faster but would not occur as a new event in diabetes mellitus. Other metabolic causes of coma such as abnormal levels of sodium or calcium should be checked. A neurological problem such as a subarachnoid haemorrhage is possible as a sudden unexpected event in a young person. Where the level of consciousness is so affected, some localizing signs or subhyaloid haemorrhage in the fundi might be expected. Despite the lack of any warning of intent beforehand, drug overdose is common and the question of avail- ability of any medication should be explored further. If there is any suspicion of this then levels of other drugs which might need treat- ment should be measured, e. The other possibility in somebody brought in unconscious is that they are suffering from carbon monoxide poisoning. The fact that it is winter and he was found in the bathroom where a faulty gas-fired heater might be situated increases this possibility. Patients with carbon monoxide poisoning are usually pale rather than the traditional cherry-red colour associated with carboxyhaemoglobin. Papilloedema can occur in severe carbon monoxide poisoning and might account for the swollen appearance of the optic discs on funduscopy. He was treated with high levels of inspired oxygen and made a slow but full recovery over the next 48 h. Mannitol for cerebral oedema and hyperbaric oxygen are considerations in the management. The problem was traced to a faulty gas water heater which had not been serviced for 4 years. His conscious level is decreased but he is rousable to command and there are no focal neurological signs. He has presented with sudden onset of severe headache, vomiting, confusion, photophobia and neck stiffness. The presence of hypotension, leucocy- tosis and renal impairment suggest acute bacterial infection rather than viral meningitis. The most likely causative bacteria are Neisseria meningitidis, Haemophilus influenzae and Streptococcus pneumonia.

Children at this age will likely sense changes in the atmosphere of the home where a death has occurred order 1mg cardura arteria gastroepiploica dextra. They often react to the emotions of adults by becoming more irritable and crying more generic cardura 4 mg otc arteria poplitea. Preschoolers and kindergartners have some understanding about death but often have difficulty distin- guishing between fantasy and reality. They believe death is reversible, and their thoughts about death may include magical thinking. For example, they may believe that their thoughts or behaviors caused a person to become sick or to die. They become frightened if they feel a threat to themselves or to their loved ones. They are concerned with safety issues and require a great deal of personal reas- surance that they will be protected. Regressive behaviors, such as loss of bladder or bowel control, thumb sucking, and temper tantrums, are not uncommon. They are able to understand a more de- tailed explanation of why or how the person died, although the concept of death is often associated with old age or with accidents. They may believe that death is contagious and avoid association with individuals who have experienced a loss by death. Death is often personified in the form of a “bogey man” or a monster—someone who takes people away or someone whom they can avoid if they try hard enough. Normal grief reactions at this age include regressive and aggressive behaviors, withdrawal, school phobias, somatic symptoms, and clinging behaviors. Preadolescent children are able to understand that death is final and eventually affects everyone, includ- ing themselves. They are interested in the physical aspects of dying and the final disposition of the body. They understand death to be universal and inevitable; however, they have difficulty tolerating the intense feelings associated with the death of a loved one. They may withdraw into themselves or attempt to go about usual activities in an effort to avoid dealing with the pain of the loss. It is often easier for adolescents to discuss their feelings with peers than with their parents or other adults. Some adolescents may show regressive behaviors whereas oth- ers react by trying to take care of their loved ones who are also grieving. Although they understand that their own death is inevitable, the concept is so far-reaching as to be imperceptible. Loss and Bereavement ● 401 Adults The adult’s concept of death is influenced by cultural and reli- gious backgrounds (Murray, Zentner, & Yakimo, 2009). Behaviors associated with grieving in the adult were discussed in the section on “Theoretical Perspectives on Loss and Bereavement. By the time individuals reach their 60s and 70s, they have experienced numerous losses, and mourning has become a life- long process. Those who are most successful at adapting to losses earlier in life will similarly cope better with the losses and grief inherent in aging. Unfortunately, with the aging proc- ess comes a convergence of losses, the timing of which makes it impossible for the aging individual to complete the grief process in response to one loss before another occurs. Because grief is cumulative, this can result in bereavement overload; the person is less able to adapt and reintegrate, and mental and physical health is jeopardized (Halstead, 2005).

It may also occur from vascular pathology buy cardura 4mg with mastercard prehypertension how to treat, such as laceration or thrombosis of the anterior spinal artery order cardura 4 mg on line heart attack remind for you. The syndrome is characterized by different degrees of paralysis and loss of pain and temper- ature sensation below the level of injury. Its hallmark is the preservation of the posterior columns, maintaining position, touch, and vibratory sensation. Central cord syndrome (b) is often seen in patients with degenerative arthritis of the cervical vertebrae, whose necks are subjected to forced hyperextension. This is seen typically in a forward Syndrome Neurologic Deficits Anterior cord B/L paralysis below lesion, loss of pain and tempera- ture, preservation of proprioception and vibratory function Central cord Lower extremity paralysis > upper extremity paralysis, some loss of pain and temperature with upper > lower Brown-Séquard Ipsilateral: paresis, loss of proprioception, and vibratory sensation Contralateral: loss of pain and temperature Cauda equina Variable motor and sensory loss in lower extremities, bowel/bladder dysfunction, saddle anesthesia Trauma Answers 165 fall onto the face in an elderly person. Patients often have greater sensorimo- tor neurologic deficits in the upper extremities compared to the lower extremities. Cauda equina injury (d) causes peripheral nerve injury rather than direct spinal cord damage. Its presentation may include variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dys- function, and saddle anesthesia. Brown-Séquard syndrome (e) results in ipsi- lateral loss of motor strength, vibratory sensation, and proprioception, and contralateral loss of pain and temperature sensation. The simplest and quickest way to establish this is by inserting a 14-gauge catheter into the thoracic cavity in the second intercostal space in the midclavicular line. Needle thoracos- tomy is necessary when a patient’s vital signs are unstable; otherwise, direct insertion of a chest tube is adequate for suspicion of a hemo- or pneumoth- orax. This increased pressure causes the ipsilateral lung to collapse, shifting the mediastinum away from the injured lung, compromising vena caval blood return to the heart. The severely altered preload results in reduced stroke volume, increased cardiac output, and hypotension. As the brain mass decreases in size with age, there is greater stretching and tension of the bridging veins that pass from the brain to the dural sinuses. Geriatric patients are thus more susceptible to the development of hypoxia and respiratory infections following trauma. Fractured pelvic bones bleed briskly and can lacerate surrounding soft tissues and disrupt their extensive arterial and venous networks. Once an abdominal source of bleeding is ruled out as a source of hypoten- sion, the patient should undergo pelvic angiography with embolization of bleeding vessels. Motor vehicle Trauma Answers 167 collisions with another vehicle or with pedestrians are the major causes of blunt abdominal trauma. The spleen is the organ most often injured, and in approximately 66% of these cases, it is the only damaged intraperitoneal organ. The liver (a) is the second-most commonly injured intra-abdominal organ, third is the kidney (c), fourth is the small bowel (d), and fifth is the bladder (e). Anterior ure- thral injuries are most often attributed to falls with straddle injuries or a blunt force to the perineum. Approximately 95% of posterior urethral injuries are secondary to pelvic fractures. Signs and symptoms of urethral injury include perineal pain, inability to void, gross hematuria, blood at the urethral mea- tus, perineal or scrotal swelling or ecchymosis, and an absent, high-riding, or boggy prostate. A retrograde urethrogram is the study of choice when there is suspicion of a urethral injury.

Sympathetic activation: The prolonged production of adrenalin and noradrenalin can result in: s blood clot formation; s increased blood pressure; s increased heart rate; s irregular heart beats; s fat deposits; s plaque formation; and s immuno suppression purchase cardura 4 mg blood pressure 9070. These changes may increase the chances of heart disease trusted 4mg cardura pulse pressure for dengue, kidney disease and leave the body open to infection. These changes may increase the chances of infection, psychiatric problems and losses in memory and concentration. These physiological changes can be further understood in terms of Johnston’s chronic and acute model of the stress illness link (Johnston 2002). This results in ongoing wear and tear and the slower process of atherosclerosis and damage to the cardiovascular system. Acute stress operates primarily through changes in sympathetic activation with changes in heart rate and blood pressure. This can contribute to atherosclerosis and kidney disease but is also related to sudden changes such as heart attacks. So far the behavioural and physiological pathways have been presented as separate and discrete. Stress may cause changes in behaviours such as smoking and diet which impact upon health by changing the individual’s physiology. Likewise, stress may cause physiological changes such as raised blood pressure but this is often most apparent in those that also exhibit particularly unhealthy behaviours (Johnston 1989). Therefore, in reality, stress is linked to illness via a complex interaction between behavioural and physiological factors. Further, Johnston (1989) argued that these factors are multi- plicative, indicating that the more factors that are changed by stress the greater the chance that stress will lead to illness. To some extent this is due to the role of variables such as coping, control, personality and social support which are described in detail later on. However, research indicates that this variability is also due to individual differences in stress reactivity, stress recovery, the allostatic load and stress resistance. Stress reactivity Some individuals show a stronger physiological response to stress than others which is known as their level of ‘cardiovascular reactivity’ or ‘stress reactivity’. This means that when given the same level of stressor and regardless of their self perceived stress some people show greater sympathetic activation than others (e. Research suggests that greater stress reactivity may make people more susceptible to stress-related illnesses. For example, individuals with both hypertension and heart disease have higher levels of stress reactivity (e. However, these studies used a cross sectional design which raises the problem of causality. The results showed that stress and illness were not linked in the children with low reactivity but that those with higher reactivity showed more illness if they had experienced more stress. Everson and col- leagues (1997) also assessed baseline stress reactivity and explored cardiac health using echo cardiography at follow-up. The results showed that higher stress reactivity at base- line was predictive of arteriol deterioration after four years. In addition, stress reactivity has been suggested as the physiological mechanism behind the impact of coronary prone behaviours on the heart (Harbin 1989; Suarez et al. This doesn’t mean that individuals who show greater responses to stress are more likely to become ill. However, some people recover more quickly than others and some research indicates that this rate of recovery may relate to a susceptibility to stress-related illness. This is reflected in Seyle’s (1956) notion of ‘exhaustion’ and the general wear and tear caused by stress.

However buy cheap cardura 1 mg line blood pressure iphone, a more precise measurement is desirable for evidence-based nursing assessment and the search for precision has created various sedation scales discount cardura 1mg on-line hypertension signs and symptoms treatment, most developed in this country, many initially for drugs research. Some scales, such as Bion and Ledingham, are too complex and time-consuming for routine use, and few have been tested for reliability (Olleveant et al. However most lists are relatively simple, if potentially subjective; Shelly (1998) suggests that the choice between tools is less important than using one to ensure regular assessment. Reliable assessment necessitates familiarity and confidence with whatever is used, and so limiting the number of tools used on one unit promotes reliable assessment. However, many scales necessitate inflicting pain and so, for regular assessment, observation- orientated tools may be more appropriate. Many scales are known both by their developer’s names and the place where they were developed. Sedation 53 Paralysis, whether from paralysing agents or pathology, prevents patients expressing awareness so that infusions of any paralysing agents should be stopped long enough before sedation assessment to ensure they will not influence the result. Achieving optimum sedation is a humanitarian necessity; professional autonomy and accountability make each nurse responsible for ensuring their patients are appropriately (i. The only reasonable way to ensure patients are adequately sedated is by objective assessment. The Ramsay scale Originally designed for drugs research rather than clinical use, this scale (see Table 6. Bion suggests that patients should be observed for 10–15 minutes before assessment (Olleveant et al. Intensive care nursing 54 The Cohen and Kelly scale Like the Ramsay scale, this scale (see Table 6. Being based on a tried and trusted neurological assessment tool, it has proved reliable. The scoring system is more complex than Ramsay and Ramsay-like scales, which can make it time-consuming, but makes it more comprehensive. The last two categories (paralysed, asleep) were added to the initial four-point scale following comments by nursing staff; the fourth category (roused by tracheal suction) was also added (see Table 6. However, the subjectivity of Ramsay is replaced by descriptions of each level, enabling greater objectivity (descriptions are omitted from Table 6. They claim this modification is more reliable, although potential researcher bias necessitates further objective measurement to support their claim. The Dutch unit does not normally use sedation, arguing that very sick patients are naturally sedated, and that chemical sedation overpowers useful compensatory mechanisms. Monger’s (1995) article makes passing mention of the use of physical restraints to maintain safety. The choice between chemical (sedation) and physical restraint is an ethical dilemma with no absolute answer. As with Monger’s awake patients, this allows response to both verbal and physical stimuli (Hudak et al. Ensuring amnesia while allowing consciousness implies that this is merely an extension of lighter sedation. While amnesia is arguably beneficial from humanitarian perspectives, nurses should ensure that patients are not exposed to unnecessary pain (physical or psychological), however soon that pain may be forgotten.