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There are crackles midway up both lung fields and 2+ pitting edema midway up his legs discount uroxatral 10 mg on-line. Administer oxygen via non-rebreather buy uroxatral 10 mg overnight delivery, furosemide, nitroglycerin, and consider noninvasive respiratory therapy. Which of the following patients has the lowest clinical probability for the diagnosis of pulmonary embolism? A 55-year-old woman on estrogen replacement therapy who underwent a total hip replacement procedure 3 days ago c. A 39-year-old man who smokes cigarettes occasionally and underwent an uncom- plicated appendectomy 2 months ago d. After 5 minutes of shoveling, he feels short of breath, chest pain, and then passes out. While playing a match of tennis, a 56-year-old man with a medical history significant only for acid reflux disease starts to feel substernal chest pain that radiates into his left arm and shortness of breath. His pain feels better after drinking antacid, but since it is not completely resolved, his partner calls 911. You order a chest radiograph and send his blood work to the laboratory for analysis. Relief of symptoms by antacids essentially rules out a cardiac cause of his chest pain. A 22-year-old college student went to the health clinic complaining of a fever over the last 5 days, fatigue, myalgias, and a bout of vomiting and diarrhea. The clinic doctor diagnosed him with acute gastroenteritis and told him to drink more fluids. She is admitted to the hospital and diagnostic testing reveals min- imal coronary atherosclerotic disease. Which of the following is the most appropriate medication to treat this patient’s condition? Prior to pass- ing out, she describes feeling lightheaded and dizzy and next remembers being in the ambulance. While discussing a case presentation with a medical student, a nearby patient who just returned from getting an ankle radiograph done yells out in pain. Physical examination reveals crackles mid- way up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. The patient does not have hypertension or diabetes mellitus and takes no prescription medications. A friend states that the patient just dropped to the ground shortly after scoring a basket on a fast-break. On examination, you note a prominent systolic ejection murmur along the left sternal border and at the apex. You suspect the diagnosis and ask the patient to perform the Valsalva maneuver while you auscultate his heart. Which of the following is most likely to occur to the intensity of the murmur with this maneuver? The patient complains of acute onset right-sided chest pain that is sharp in character and worse with inspiration. A 57-year-old man complains of chest palpitations and lightheaded- ness for the past hour. Five years ago he underwent a cardiac catheterization with coronary artery stent placement. Which of the following is the most appropriate medication to treat this dysrhythmia? In the past, he experienced chest discomfort after walking 20 minutes that resolved with rest. The episodes of chest pain this morning occurred while he was reading the newspaper. His wife states that he was well until she found him suddenly slump- ing in the chair and losing consciousness for a minute. The patient recalls having some chest discomfort and shortness of breath prior to the episode.

Yes No No Yes Non-pharmacological Non-pharmacological methods/ methods/ behavioural behavioural therapies therapies No No Severe Severe and/or and/or disabling? Yes Yes First line First line Benzodiazepine Benzodiazepine Alternative (elderly) Second line (where sedation Clomethiazole is to be avoided) Buspirone Second line Zopiclone uroxatral 10 mg without prescription, zolpidem cheap uroxatral 10 mg amex, zaleplon Figure 18. Much chronic insomnia is due to dependence on hypnotic • Drugs of other types may be needed when insomnia drugs. In addition, external factors such as noise, snoring part- complicates psychiatric illness. Shortened sleep time is common in the elderly, and Antipsychotics, such as chlorpromazine, may help to patients with dementia often have a very disturbed sleep pattern. They should be used for short • Hypnotics should not be routinely given to hospital periods (two to four weeks at most) and, if possible, taken patients or in any other situation, except where intermittently. On withdrawal the dose and frequency of specifically indicated and for short-term use only. There is currently no evidence people experience sleepiness after a warm bath and/or of superiority for the newer ‘non-benzodiazepine’ sexual activity. A milk-based drink before bed can promote hypnotics that act nonetheless on benzodiazepine sleep, but may cause nocturia and, in the long run, weight receptors (see below). Increased explanation from the outset that these will not be continued daytime exercise improves sleep at night. It also causes dehydration (gueule de bois) and other unpleasant manifestations of hangover. It is due to mismatching of the body clock with his life quite significantly, so that he feels tired most (circadian dysrhythmia) against a new time environment with of the day and is having difficulty holding down his job as its own time cues (Zeitgebers). Thus, one should but says that he will only give it for a maximum of a month, rest in a dark room at night, even if not tired, and eat, work and as he does not want his patient to become addicted. Sufferers should not allow themselves Question 1 to sleep during the day (easier said than done! However, short-acting benzodiazepines may be Answer 1 effective if taken before going to bed for two or three nights. Although the benzodiazepine might help in the short Melatonin is of uncertain usefulness but may help sleep term, it does not provide the patient with a long-term solu- patterns, and improves daytime well-being if taken in the tion, and does not tackle the root cause of his insomnia. A better strategy is to allow the subject to have a short, non-drug-induced sleep during the night shift. Pathological This improves efficiency towards the end of the night shift and anxiety is fear that is sufficiently severe as to be disabling. Episodes of paroxys- The use of hypnotics in children is not recommended, except mal severe anxiety associated with severe autonomic symptoms in unusual situations (e. Hypnotics are sometimes attacks and often accompany a generalized anxiety disorder. Children are, however, prone to experi- ence paradoxical excitement with these drugs. Hypnotics relaxation techniques and simple psychotherapy and increase the risk of falls and nocturnal confusion. In the treatment of insomnia, when short-term treatment • In severely anxious patients who are given anxiolytic drugs, with drugs is considered necessary, short-acting hypnotics these are only administered for a short period (up to two should be used in preference to long-acting drugs but with to four weeks) because of the risk of dependence. Early short-lived high peak blood levels are • Benzodiazepines are the anxiolytics normally used where accompanied by anterograde amnesia. Buspirone is as effective as and less hypnotic than the benzodiazepines, Cautions but has slower onset. Adverse effects • Monoamine oxidase inhibitors (used only by specialists) • drowsiness; can be useful for treating anxiety with depression, phobic • confusion; anxiety, recurrent panic attacks and obsessive-compulsive • paradoxical disinhibition and aggression. Compounds with a short half-life tend to be used as hyp- arisen even after limited drug exposure. Pharmacological evi- notics, because they cause less ‘hangover’ effects; longer half-life dence of tolerance may develop within three to 14 days. The drugs tend to be used as anxiolytics, since a longer duration of full withdrawal picture can manifest within hours of the last action is generally desirable in this setting. Benzodiazepines dose for the shorter-acting drugs, or may develop over up to are used for the short-term alleviation of anxiety, but should three weeks with the longer-duration benzodiazepines.

The reaction of two radicals eliminates both cheap uroxatral 10 mg, but reactions between radicals and non-radicals produces a further radical order uroxatral 10mg free shipping. Reactivity is indiscriminate, so that although their lifespan lasts only microseconds, chain reactions may be thousands of events long (Davidson & Boom 1995) causing the autocatalysis underlying most critical illnesses. Oxygen radicals are particularly destructive, with oxidation modifying proteins (Hipkiss 1989), including cell membrane phospholipid. Free oxygen radicals are released with hyperoxia (Davidson & Boom 1995), so that prolonged high FiO2 (above 0. Intensive care nursing 240 Hypoxic vascular epithelium releases endogenous nitric oxide (see Chapter 28); widespread tissue hypoxia (shock) therefore causes widespread nitric oxide release and systemic vasodilation. Cells surviving initial injury exist in grossly disordered internal environments; anaerobic metabolism causes peripheral accumulation of metabolic acids, free radicals, oxidative enzymes (e. Reperfusion injury can result from toxic products being flushed into the central cardiovascular system during recovery, potentially causing secondary (reperfusion) damage. Calcification Necrosis leads to microscopic calcium deposits; accumulation through persistent injury causes progressive tissue damage and rigidity, especially in renal, pulmonary, cardiovascular and gastric cells (Nowak & Handford 1996). Implications for practice ■ most critical pathologies originate at microcellular rather than macro-system level; understanding these processes enables nurses to understand the pathologies and treatments covered in many of the other chapters (e. Treatments should therefore focus on underlying mechanisms of disease rather than more easily observed effects. Understanding these microscopic mechanisms enables nurses to monitor and assess effects of treatments. This chapter has outlined the main mechanisms of cell dysfunction as a basis for understanding pathophysiologies described in the remainder of this section. Cellular pathology 241 Further reading Revision of normal cell physiology from a recent and appropriate anatomy text, such as Marieb (1995) or Guyton and Hall (1997), can provide a useful basis for understanding pathophysiology; Abbas et al. Mechanisms of key pathological processes can be complex, but some recent specialist articles usefully describe aspects such as free radicals (Davidson & Boom 1995) and treatments (Wardle 1997). On endotracheal suction his sputum is thick mucopurulant and arterial blood gases indicate hypoxia, hypercapnia and severe respiratory acidosis. His blood results include abnormalities in differential white blood cell count: Q. Include structures (and make brief notes on their functions) such as nucleus, cytoplasm, cytoskeleton, microtubules, endoplasmic reticulum, Golgi complex, ribosomes, mitochondria, lysosmomes, cell surface (or surface membrane) with its various structures and components (e. Review the cellular processes which caused this from his acute asthmatic attack (e. Cardiac disease may persist for years; when myocardial oxygen supply becomes inadequate, the myocardium infarcts. This chapter identifies the underlying pathophysiology and treatments (especially thrombolysis). Myocardial oxygen supply Five per cent of cardiac output enters the two coronary arteries (right and left) from the aorta. The left artery divides into the left anterior descending and circumflex (see Figure 24. At rest, myocardium normally extracts 70–80 per cent of available oxygen (Ganong 1995). Having more mitochondria than skeletal muscle, the myocardium relies on aerobic respiration (Clancy & McVicar 1995). Ischaemia is transient; if reversed (reducing oxygen demand, increasing oxygen supply, or both), the myocardium recovers; unreversed ischaemia will progress to infarction. Coronary artery disease begins in childhood and is well advanced in many by the age of 30 (Herbert 1991); symptoms usually only occur when coronary arteries are three- quarters occluded (Carleton & Boldt 1992). This leaves little physiological reserve between the onset of symptoms and ischaemic tissue death. About one-half of acute myocardial infarctions are due to occlusion of the left anterior descending artery, with a significant minority caused by right coronary artery perfusion, circumflex artery occlusion being a far less frequent cause of infarctions (Rowlands 1996a). The tunica intima becomes penetrable to lipids, especially cholesterol and low density lipoproteins, altering the integrity of vasculature (Todd 1997); as fats, fibrin, cholesterol and calcium are deposited (Wilson 1983), lipids are covered by fibrous caps of tissue from proliferating cells in the intima (Todd 1997) which enables platelet adhesion to prominences in arterial walls (Wilson 1983).

Ask the patient if he/she knows about the medication and why the med- ication is being administered discount uroxatral 10mg with mastercard. The patient’s response provides insight into knowledge the patient has about his/her condition and treatment purchase 10 mg uroxatral free shipping. This gives the nurse a perfect opportunity to educate the patient about his/her condition, treatment and medication. Stop immediately if the patient doesn’t recognize the medication as the drug the patient received previously. The dose may have changed, a different medication was substituted, or there is an error in the medication. Make sure you have baseline vital signs, labs, and other patient data before administering the medication. To determine the patient’s reaction to the drug, the baseline can be compared to vital signs, labs, and other patient data taken after the patient receives the medication. Instruct the patient about side effects of the medication and take pre- cautions to assure the patient’s safety such as raising the side rails and instructing the patient to remain in bed until the side effects subside. Properly dispose of the medication and supplies used to administer the medication. Don’t leave the medication at the patient’s bedside unless required by the medication order. You can minimize this adverse effect by giving the patient ice chips prior to administering the medication. The patient is left with the taste of the pleasant tasting medication in his/her mouth. Use the liquid form of the medication where possible because patients find it easier to ingest a liq- uid. Administer medication to a patient who needs extra assistance taking the medication after you give medication to your other patients. In this way, you can devote the necessary time to assist this patient without being pressured to admin- ister medication to your other patients. It is therefore critical that the nurse avoid situations that frequently result in med- ication errors. If an error occurs, assess the patient and notify the nurse in charge and the physician. For example, the patient can use specially marked containers for each day of the week. Evaluating the Patient After Administering Medication The nurse must assess the patient after the patient is given medication to determine if the medication has had the desired therapeutic effect. To do this, the nurse compares the patient’s current vital signs, labs, and other pertinent patient data with baseline information. The patient should also be assessed after the medication has reached its onset and peak time. The nurse must suspend administering further doses of the medication if the patient shows the signs and symptoms indicating an adverse reaction to the medi- cation. The nurse must also note any side effect of the medication experienced by the patient and how well the patient tolerates the side effect. If the patient has a low tolerance to the side effect, then the nurse needs to notify the prescriber. The pre- scriber might substitute a different medication or prescribe other medication to alleviate the side effect. The nurse must determine if the patient is receiving the therapeutic effect from the medication. Patients who are very thin or obese may be receiving too much or too little medication. Prescribers are also con- cerned about patients developing tolerance to or dependency on pain medication and may underprescribe the dose or how often it may be given. If the nurse accu- rately assesses the patient’s response to the drug, the dose or frequency may be adjusted to provide appropriate relief from pain. Controlling Narcotics Special precautions are necessary for storing and handling narcotics because the manufacture, sale, and use of narcotics are controlled by federal legislation. The amount of the drug available is compared with the numbers that have been used for patients and signed for on the narcotics form.