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A 1992 consensus conference modified terminology to Acute Respiratory Distress Syndrome (Bernard et al cheap super levitra 80 mg on line. Alveoli being inherently unstable and prone to atelectasis generic super levitra 80mg online, surfactant lack causes high intra-alveolar pressures and barotrauma, accelerating alveolar collapse and pulmonary oedema formation. Terminology again varies, and in practice these two stages are part of a continuum rather than distinct entities; but descriptions are clinically useful to understand disease progression. The early or exudative stage, which begins as endothelial injury causes progressive pulmonary capillary permeability, results in ■ interstitial and alveolar oedema (DiRusso et al. Proliferative/fibrotic stages Early insults to lung tissue cause progression to diffuse problems. Treatment Preventing further ventilator-induced injury and system support are the main-stays of treatment. Conventionally, treatment aimed to normalise blood gases, but the excessive peak airway pressures needed to achieve this accelerate alveolar damage (barotrauma, volotrauma). Current treatment has moved from short-term aims of normalising blood gases to longer-term aims of limiting damage and recruiting alveoli (Artigas et al. Fluid management necessitates balancing adequate perfusion without aggravating pulmonary oedema. Prolonged stays can enable close rapport between families and staff, but can become stressful for everyone; both bedside nurses and nurse managers need to recognise incipient distress. Families may seek hope where little exists, placing excessive trust/reliance/expectations on individual members of staff; as well as being a symptom of denial, this can be particularly stressful for staff. Ventilation Achieving ‘normal’ blood gases with reduced functional alveolar space necessitates forcing larger volumes of gas and/or higher concentrations of oxygen into remaining alveoli. Increased intra-alveolar pressures cause shearing damage (Volotrauma’), while higher concentrations of oxygen may become toxic. Hence, the focus has shifted from normalising blood gases to recruiting alveoli, using smaller tidal volumes and accepting abnormally high arterial carbon dioxide tensions (permissive hypercapnia): Thomsen et al. Permissive hypercapnia should therefore be used cautiously or avoided with: ■ raised intracranial pressure ■ anoxic brain injury (e. Intensive care nursing 270 Pressure limited/controlled ventilation limits peak inflation pressure, and so also limits further volotrauma (Hudson 1995). While preventing or limiting further damage remains the main priority, gas exchange can be optimised by manipulating other aspects of ventilation. Nurses detecting increases in pulmonary pressures (indicative of pulmonary oedema) should alert medical staff. Inverse ratio ventilation increases mean (but not peak) airway pressure (Mulnier & Evans 1995), and prolonged inspiratory phases promote alveolar recruitment, while shorter expiratory phases prevent alveolar collapse. Perfluorocarbon associated gas exchange (liquid ventilation, see Chapter 29) appears to have potential, and is likely to be evaluated rigorously in the near future. However, Lewis and Veldhuizen (1996), while acknowledging that specific dose and intervals remain unknown and the prediction of which patients will benefit remains impossible, argue that exogenous surfactant has proved ineffective because it is given too late. Lung damage occurs in dependent areas, so nursing patients prone for 4 to 8 hours (Brett & Evans 1997) may increase functional residual capacity, improve diaphragmatic motion and help removal of secretions (Mulnier & Evans 1995). Lateral positioning, potentially easier to achieve, also benefits gas exchange (Hinds & Watson 1996). Acute respiratory distress syndrome 271 However, use of the prone position remains controversial (Thomas 1997). Studies consistently show improvements in oxygenation, reduction of shunting, reduced oxygen requirements and reduced mortality (Wong 1998), although available literature may be biased by reluctance to report unsuccessful cases (Ryan & Pelosi 1996). Nursing prone may more usefully prevent potential problems rather than resolve existing ones, and so should be instigated early; too often, like other promising approaches, nursing prone is used once other approaches have failed (Gosheron et al. Recommended duration of prone positioning varies from 30 minutes to 12 hours; Vollman’s (1997) 4–6 hours (drawn from literature review and substantial practice) is recommended until systematic evaluation provides more concrete guidelines. However, a major limitation on prone positioning is staff availability to turn patients. In the absence of suitable equipment (Thomas 1997), some units have experienced significant levels of staff injury from adopting prone positioning. Other nursing complications of prone positioning include access of intravenous lines, positioning of endotracheal and ventilator tubing and aggravation of cardiovascular instability (Thomas 1997).

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Beneath the protective layer purchase 80 mg super levitra, areolar connective tissue containing lymphocytes (which form a thin lymphoid tissue) removes foreign materials super levitra 80mg free shipping. A layer of blood vessels next to the periosteum (the membrane cover- ing the surface of bones) forms a rich plexus (network) that tends to swell when irritated or inflamed, closing the ostia (openings) of the nasal sinuses. Lined with a ciliated columnar epithe- lium (refer to Chapter 4’s tissue discussion), sinuses are cavities in the bone that reduce the skull’s weight and act as resonators for the voice. Each of the sinuses is named for the bone containing it, as follows: Frontal sinuses are located in the front bone behind the eyebrows. Ethmoid and sphenoid sinuses are located in the ethmoid and sphenoid bones in the cranial cavity’s floor. Beyond the sinuses and connected to them are nasal ducts that extend from the medial angle of the eyes to the nasal cavity. These ducts let serous fluid — a biology term referring to any fluid resembling serum — from the eyes’ lacrimal glands (tear ducts) flow into the nasal cavity. The nasal cavity performs several important functions: It drains mucous secretions from the sinuses. Dust and bacteria are caught in the mucous and passed outward from the nasal cavity by the motion of the cilia. Some of that gunk is taken up by lymphatic tissue in the nasal cavity and respiratory tubes for delivery to the lymph nodes, which destroy invading germs. Beyond the nasal cavity is the nasopharynx, which connects — you guessed it — the nasal cavity to the pharynx. With a bit of a refresher on the nasal and sinus passages, do you think you can hit the following practice questions on the nose? Which of the following statements about the mucous membranes of the nasal cavity is not true? Use the terms that follow to identify the structures of the respiratory tract shown in Figure 8-2. The top of the throat con- sists of these key parts: Chapter 8: Oxygenating the Machine: The Respiratory System 135 Pharynx: The pharynx is an oval, fibromuscular sac about 5 inches long and tapering to 1⁄2 inch in diameter at its anteroposterior end, which is a fancy biology term meaning “front to back. On the back wall of the pharynx is a mass of lymphoid tissue called the pharyngeal tonsil, or adenoids. Larynx: Connecting the pharynx with the trachea, this collection of nine carti- lages is what makes a man’s prominent Adam’s apple. Also called the voice box, the larynx looks like a triangular box flattened dorsally and at the sides that becomes narrow and cylindrical toward the base (see Figure 8-3). Ligaments con- nect the cartilages controlled by several muscles; the inside of the larynx is lined with a mucous membrane that continues into the trachea. Three of the larynx’s nine cartilages go solo — the thyroid, the cricoid, and the epiglottis — while three more come in pairs — the arytenoids, the corniculates, and the cuneiforms. The thyroid cartilage (thyroid in Greek means “shield-shaped) is largest and consists of two plates called laminae that are fused just beneath the skin to form a shield-shaped process, the Adam’s apple. Immediately above the Adam’s apple, the laminae are separated by a V-shaped notch called the superior thyroid notch. The ring- shaped cricoid cartilage is smaller but thicker and stronger, with shallow notches at the top of its broad back that connect, or articulate, with the base of the arytenoid car- tilages. The arytenoid cartilages both are shaped like pyramids, with the vocal folds attached at the back and the controlling muscles that move the arytenoids attached at the sides, moving the vocal cords. On top of the arytenoids are the corniculate carti- lages, small conical structures for attachment of muscles regulating tension on the vocal cords. Nestled in front of these and inside the aryepiglottic fold, the cuneiform cartilages stiffen the soft tissues in the vicinity. The epiglottis, sometimes called the lid on the voice box, is a leaf-shaped cartilage that projects upward behind the root of the tongue. Attached at its stem end, the epiglottis opens during respiration and reflex- ively closes during swallowing to keep food and liquids from getting into the respira- tory tract. When talking, the folds stretch for high sounds or slacken for low sounds, causing the opening into the glottis — the opening in the larynx — to form an oval. Just above these folds are the ventricular vocal folds, also known as vestibular or false folds, that don’t produce sounds. Use the terms that follow to identify the structures of the larynx shown in Figure 8-3.

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Although compartment syndrome can occur with blunt and penetrating extremity trauma order 80mg super levitra with mastercard, it is more common in crush injuries or fractures with marked swelling best super levitra 80mg. It may be required, but should be performed in conjunction with and after the establishment of arterial blood flow. Herniation can occur within minutes or up to days after a trau- matic brain injury. Once the signs of herniation are present, mortality approaches 100% without rapid reversal or temporizing measures. Uncal herniation is the most common clinically significant form of traumatic herniation and is often associated with traumatic extracranial bleeding. The classic signs and symptoms are caused by compression of the ipsilateral uncus of the temporal lobe. As herniation progresses, compression of the ipsilateral oculomotor nerve eventually causes ipsilateral pupillary dila- tion and nonreactivity. It can lead to hypovolemic shock and can significantly reduce vital capacity if it is not recognized. Hemorrhage from injured lung parenchyma is the most common cause of hemothorax, but this tends to be self-limiting unless there is a major laceration to the parenchyma. A hemothorax is treated with chest thoracostomy (chest tube) that is generally placed in the fourth or fifth intercostal space at the anterior or midaxillary line, over the superior portion of the rib. The tube should be directed superior and posterior to allow it to drain blood from the dependent portions of the chest. Indications for thoracotomy include: • Initial chest tube drainage of 1000 to 1500 cc of blood (a and b). In general, if the patient remains hemodynamically unstable after 40 cc/kg of crystal- loid administration (approximately 2-3 L), then a blood transfusion should be started. Fully cross-matched blood is preferable; however, this is generally not available in the early resuscitation period. Therefore, type- specific blood (type O, Rh-negative or type O, Rh-positive) is a safe alternative and is usually ready within 5 to 15 minutes. Type O, Rh-negative blood is typically reserved for women in their childbearing years to prevent Rh sensitization. Type O, Rh-positive blood can be given to all men and women beyond their childbearing years. Epinephrine is used if the patient is in cardiopulmonary arrest and no longer has a pulse. If the patient remains hypotensive despite resuscitation, then definitive measures need to take place, such as an exploratory laparo- tomy to stop the hemorrhage. It is important to focus the primary examination on the patient and evaluate the fetus in the secondary examination. Cardiotocographic observation of the viable fetus is recommended for a minimum of 4 hours to detect any intrauterine pathology. The minimum should be extended to 24 hours if, at any time during the first 4 hours, there are more than three uterine contractions per hour, persistent uterine tenderness, a non-reassuring fetal monitor strip, vaginal bleeding, rupture of the membranes, or any serious maternal injury is present. Shielding of the uterus in head and chest scans allows for an acceptable radiation exposure level. The mother with no obvious abdominal injury or even normal laboratory values still requires monitoring. Because of the central location of the disk herniation, symptoms are often bilateral and involve leg pain, saddle anes- thesia, and impaired bowel and bladder function (retention or inconti- nence). On examination, patients may exhibit loss of rectal tone and display other motor and sensory losses in the lower extremities. Patients, however, should not exhibit altered bowel and bladder function, or have decreased rectal tone. If so, the condition is likely cauda equina syndrome and is a neurologic emergency.

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The nurse observes and/or ethical/legal competencies are most that all the medications appeared to have been likely to bring about the desired outcome? Identify pertinent patient data by placing a single underline beneath the objective data in the case study and a double underline beneath 4 super levitra 80mg visa. Complete the Nursing Process Worksheet on page 193 to develop a three-part diagnostic statement and related plan of care for this patient discount super levitra 80mg visa. Read the following patient care study and use your nursing process skills to answer the Patient strengths: questions below. Scenario: Dominic Gianmarco, a 78-year-old retired man with a history of Parkinson’s disease, lives alone in a small home. He was Personal strengths: recently hospitalized for problems with cardiac rhythm, and a pacemaker was installed. The home healthcare nurse visits 1 week after he was discharged to monitor his recovery and 4. Several food items are in various stages of prepa- ration on the kitchen counter, and some appear to have spoiled. He is pleasant and oriented to place and Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. For the purposes of this exercise, develop the one patient goal that demonstrates a direct resolution of the patient problem identified in the nursing diagnosis. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Povidone–iodine or hydrogen peroxide should be used to fight infection in the Circle the letter that corresponds to the best wound. A patient who is being treated for self- wounds because they damage the cells inflicted wounds admits to the nurse that she needed for healing. Total lymphocyte count of 1,500/mm the ulcer moist because it is susceptible to c. A patient with a pressure ulcer on his back it is present, but still maintains a moist should be treated by which of the following environment. The wound should be cleaned with each with a saline or occlusive dressing to dressing change. Which of the following vitamins is needed tract and would be used after incision and for collagen synthesis, capillary formation, drainage of an abscess, in abdominal surgery? It would be categorized as Multiple Response Questions which of the following stages? People who are thin may heal more slowly due to the small amounts of subcutaneous c. Vitamins B and D are essential for re- to the area epithelialization and collagen synthesis. People who are taking corticosteroid drugs greatest risk for developing a pressure ulcer? A patient with cardiovascular disease resulting in increased leukocytes and a de- c. Which of the following statements accurately describe the complications that may occur 10. Dehiscence is present when there is a par- elbows tial or total disruption of wound layers. A large wound with considerable tissue loss these complications owing to a thinner allowed to heal naturally by formation of layer of tissue cells. An increase in the flow of serosanguineous which of the following categories of wound fluid from the wound between postopera- healing? Tertiary intention often the result of delayed healing, com- monly manifested by drainage from an d.

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