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The results showed that although patients did not show particularly raised levels of anxiety and depression whilst still in hospital discount 10 mg atorlip-10 with visa, those who did not receive counselling showed an increase in these factors following discharge trusted atorlip-10 10mg. In contrast to the patients, the partners did show very high levels of anxiety and depression whilst the patients were still in hospital. Bury (1982) argued that illness can be seen as a form of biographical disruption which requires people to question ‘what is going on here? This need occurs against a backdrop of a family and friends who are worried about their health and often results in the ill person persistently acting in a ‘healthy way’ as a means to communicate that things are ‘back to normal’. This approach finds reflection in theories of coping and the re-establishment of equilibrium described in Chapter 3. The consequences of disease have also be explored in the context of impairment, disability and handicap which is discussed in Focus on research 15. The aim of the model was to clarify terminology and to present a structure for understanding disease that went beyond a simple medical perspective. The model proposed a sequence of consequences of disease which suggested that disease resulted either in impairment, then disability, then handicap or in a direct path from impairment to handicap. Impairment is the loss or abnormality of structure or function and often operates at the level of the organ rather than the individual. Lung cancer may cause impairment to the lungs and heart disease results in impairment of the cardiovascular system. Disability refers to the restriction or lack of ability to perform activities and operates at the level of the indi- vidual. For example, lung cancer and heart disease may both result in the inability to climb stairs. Finally, handicap refers to disadvantage and role limitation and operates as the level of the individual as they exist within their social context. Lung cancer and heart disease may prevent an individual from bringing in an income and being financially independent. Methodology Design The study used cross-sectional and longitudinal designs with three patients groups. They were interviewed on admission and 1 week, 2 months, 6 months and 12 months after discharge. Stroke patients: 68 men and women were recruited within 20 days of admission for stroke. Disabled patients: 101 male and female disabled adults were selected from a primary care data base. These were the Orgogozo Neurological Index for the stroke patients (Orgogozo et al. Disability and handicap: All patients completed the Sickness Impact Profile (Bergner et al. Stroke patients also completed the Barthel index (Mahoney and Barthel 1965) which was complemented with the Observer Assessed disability (Partridge et al. The psychometric properties of these new scales were then assessed for reliability and validity. Data analysis Data was analysed to assess whether the three concepts could be considered separate and then to examine any causal relationships between them. This analysis showed that impairment did not predict disability and handicap suggesting that there is not a simple causal progression between the different consequences of disease. The authors argue that the transition between impairment, disability and handicap may involve a multitude of other variables not described by the model. In particular, they suggest that the transition from initial impairment through to being limited in social functioning may relate to psychological factors. The authors argue that this is also the case for people with some form of impairment, it is just that their impairment may influence these psychological factors. There is much variability in the ways in which people experience and manage their illness. Psychological factors may be a better explanation of this variation than a simple transition through a series of stages. In addition, stopping smoking can halve the risk of another heart attack in those who have already had one. It has been suggested that the 20 per cent of a population with the highest cholesterol levels are three times more likely to die of heart disease than the 20 per cent with the lowest levels. Cholesterol levels may be determined by the amount of saturated fat consumed (derived mainly from animal fats). Cholesterol reduction can be achieved through a reduction in total fats and saturated fats, an increase in polyunsaturated fats and an increase in dietary fibre. It has been suggested that a 10 mmHg decrease in a population’s average blood pressure could reduce the mortality attri- butable to heart disease by 30 per cent.

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A full forensic documentation of the bite should be made as detailed in Chapter 4 atorlip-10 10mg mastercard. Note if there are clinical signs of infection discount atorlip-10 10mg amex, such as erythema, edema, cellulitis, purulent discharge, or regional lymphadenopathy. Wound closure is not generally recom- mended because data suggest that it may increase the risk of infection. This is particularly relevant for nonfacial wounds, deep puncture wounds, bites to the hand, clinically infected wounds, and wounds occurring more than 6–12 hours before presentation. Head and neck wounds in cosmetically important areas may be closed if less than 12 hours old and not obviously infected. Viruses • Dog bites—outside of the United Kingdom, Australia, and New Zealand, rabies should be considered. In the United States, domestic dogs are mostly Infectious Diseases 265 vaccinated against rabies (57), and police dogs have to be vaccinated, so the most common source is from racoons, skunks, and bats. Antibiotic Prophylaxis Antibiotics are not generally needed if the wound is more than 2 days old and there is no sign of infection or in superficial noninfected wounds evalu- ated early that can be left open to heal by secondary intention in compliant people with no significant comorbidity (58). Antibiotics should be considered with high-risk wounds that involve the hands, feet, face, tendons, ligaments, joints, or suspected fractures or for any penetrating bite injury in a person with diabetes, asplenia, or cirrhosis or who is immunosuppressed. Coamoxiclav (amoxycillin and clavulanic acid) is the first-line treatment for mild–moderate dog or human bites resulting in infections managed in pri- mary care. For adults, the recommended dose is 500/125 mg three times daily and for children the recommended does is 40 mg/kg three times daily (based on amoxycillin component). It is also the first-line drug for prophylaxis when the same dose regimen should be prescribed for 5–7 days. If the individual is known or suspected to be aller- gic to penicillin, a tetracycline (e. In the United Kingdom, doxycycline use is restricted to those older than 12 years and in the United States to those older than 8 years old. Anyone with severe infection or who is clinically unwell should be referred to the hospital. Tetanus vaccine should be given if the primary course or last booster was more than 10 years ago. If the person has never been immunized or is unsure of his or her tetanus status, a full three-dose course, spaced at least 1 month apart, should be given. General Information Respiratory tract infections are common, usually mild, and self-limit- ing, although they may require symptomatic treatment with paracetamol or a nonsteroidal antiinflammatory. These include the common cold (80% rhi- noviruses and 20% coronaviruses), adenoviruses, influenza, parainfluenza, and, during the summer and early autumn, enteroviruses. Special attention should be given to detainees with asthma or the who are immunocompromised, because infection in these people may be more serious particularly if the lower respiratory tract is involved. The following section includes respiratory pathogens of special note because they may pose a risk to both the detainee and/or staff who come into close contact. General Information and Epidemiology There are five serogroups of Neisseria meningitidis: A, B, C, W135, and Y. In the United Kingdom, most cases of meningitis are sporadic, with less than 5% occurring as clusters (outbreaks) amongst school children. Between 1996 and 2000, 59% of cases were group B, 36% were group C, and W135 and A accounted for 5%. There is a seasonal variation, with a high level of cases in winter and a low level in the summer. The greatest risk group are the under 5 year olds, with a peak incidence under 1 year old. In Sub-Saharan Africa, the dis- ease is more prevalent in the dry season, but in many countries, there is back- ground endemicity year-round. Routine vaccination against group C was introduced in the United King- dom November 1999 for everybody up to the age of 18 years old and to all first- year university students. As a result of the introduction of the vaccination pro- gram, there has been a 90% reduction of group C cases in those younger than under 18 years and an 82% reduction in those under 1 year old (60,61). An outbreak of serogroup W135 meningitis occurred among pilgrims on the Hajj in 2000. Symptoms After an incubation period of 3–5 days (63,64), disease onset may be either insidious with mild prodromal symptoms or florid. The rash may be petechial or purpuric and characteristically does not blanche under pressure. Meningitis in infants is more likely to be insidious in onset and lack the classical signs. Even with prompt antibiotic treatment, the case fatality rate is 3–5% in meningitis and 15–20% in those with septicemia.

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The arithmetic average safe 10 mg atorlip-10, or arithmetic mean best atorlip-10 10 mg, is the most commonly used measure of central tendency. It is computed by calculating the sum of all the scores of the variable and dividing this sum by the number of participants in the distribution (denoted by the letter N). This occurs when there are one or more extreme scores (known as outliers) at one end of the distribution. The single very extreme income has a disproportionate impact on the mean, resulting in a value that does not well represent the central tendency. The median is used as an alternative measure of central tendency when distributions are not symmetrical. The median is the score in the center of the distribution, meaning that 50% of the scores are greater than the median and 50% of the scores are less than the median. In our case, the median household income ($73,000) is a much better indication of central tendency than is the mean household income ($223,960). In this case the median or the mode is a better indicator of central tendency than is the mean. A final measure of central tendency, known as the mode, represents the value that occurs most frequently in the distribution. In addition to summarizing the central tendency of a distribution, descriptive statistics convey information about how the scores of the variable are spread around the central tendency. Dispersion refers to the extent to which the scores are all tightly clustered around the central tendency, like this: Attributed to Charles Stangor Saylor. The standard deviation, symbolized as s, is the most commonly used measure of dispersion. An advantage of descriptive research is that it attempts to capture the complexity of everyday behavior. Case studies provide detailed information about a single person or a small group of people, surveys capture the thoughts or reported behaviors of a large population of people, and naturalistic observation objectively records the behavior of people or animals as it occurs naturally. Thus descriptive research is used to provide a relatively complete understanding of what is currently happening. Despite these advantages, descriptive research has a distinct disadvantage in that, although it allows us to get an idea of what is currently happening, it is usually limited to static pictures. Although descriptions of particular experiences may be interesting, they are not always transferable to other individuals in other situations, nor do they tell us exactly why specific behaviors or events occurred. For instance, descriptions of individuals who have suffered a stressful event, such as a war or an earthquake, can be used to understand the individuals’ reactions to the event but cannot tell us anything about the long-term effects of the stress. And because there is no comparison group that did not experience the stressful situation, we cannot know what these individuals would be like if they hadn’t had the stressful experience. Correlational Research: Seeking Relationships Among Variables In contrast to descriptive research, which is designed primarily to provide static pictures, correlational research involves the measurement of two or more relevant variables and an assessment of the relationship between or among those variables. For instance, the variables of height and weight are systematically related (correlated) because taller people generally weigh more than shorter people. In the same way, study time and memory errors are also related, because the more time a person is given to study a list of words, the fewer errors he or she will Attributed to Charles Stangor Saylor. When there are two variables in the research design, one of them is called the predictor variable and the other the outcome variable. The research design can be visualized like this, where the curved arrow represents the expected correlation between the two variables: Figure 2. A point is plotted for each individual at the intersection of his or her scores for the two variables. When the association between the variables on the scatter plot can be easily approximated with a straight line, as in parts (a) and (b) of Figure 2. When the straight line indicates that individuals who have above-average values for one variable also tend to have above-average values for the other variable, as in part (a), the relationship is said to be positive linear. Examples of positive linear relationships include those between height and weight, between education and income, and between age and mathematical abilities in children. In each case people who score higher on one of the variables also tend to score higher on the other variable. Negative linear relationships, in contrast, as shown in part (b), occur when above-average values for one variable tend to be associated with below-average values for the other variable. Examples of negative linear relationships include those between the age of a child and the number of diapers the child uses, and between practice on and errors made on a learning Attributed to Charles Stangor Saylor. In these cases people who score higher on one of the variables tend to score lower on the other variable. Relationships between variables that cannot be described with a straight line are known as nonlinear relationships. In this case there is no relationship at all between the two variables, and they are said to be independent.

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Circuits can safely run at 250–300 ml/min buy 10 mg atorlip-10 with mastercard, which may prolong filter life and/or reduce anticoagulation requirements buy atorlip-10 10mg low cost. Volumes below 300 ml per hour in circuits without countercurrent dialysate (haemofiltration) or below 180 ml per hour with diafiltration provide ineffective solute clearance, consuming nursing time without benefit to patients, and so should be discontinued. Outflow volumetric pumps prevent ultrafiltrate volumes falling, but as functional filtration area decreases, transmembrane pressure will increase. Recommended afferent pump speed varies between systems (readers should check the manufacturers’ recommendations and local protocols), but should be commenced slowly (e. If stable, speeds should usually be increased to a minimum 150 ml/min within 10 minutes. Concern about drug clearance by haemofiltration is justified, but factors are complex, requiring advice from unit pharmacists. All drugs (except some colloidal fluids) used in clinical practice are smaller than filter pore size, and so potentially may be filtered. Studies of drug clearance may refer to Intensive care nursing 352 peritoneal dialysis, haemodialysis, haemofiltration or haemodiafiltration. Clearance may also differ between animal or healthy human volunteers and critically ill patients. Kaplan (1998) identifies four main factors affecting drug clearance: ■ molecular weight (5–10 kDa readily cleared by haemofiltration) ■ degree of protein binding ■ drugs’ volume of distribution (water solubility/lipid affinity) ■ drugs’ endogenous clearance (hepatic) Drugs are usually only active if unbound, so that binding is normally weak, with volatile shifts between bound and unbound drug molecules. Protein binding alone is affected by ■ acidity (pH) of blood ■ molar drug concentrations ■ bilirubin levels ■ uraemic inhibitors ■ presence of heparin ■ numbers of free fatty acids ■ other (displacing) drugs Predilution increases transfer (and so clearance) of protein-bound urea (and other molecules) into plasma (Kaplan 1998). Large ultrafiltrate volumes are often smaller than human glomerular filtrate so that drug clearance by filters may be no higher than the Bowman’s capsule. Drug prescriptions may therefore need increasing or decreasing during haemofiltration. Where drugs are titrated to therapeutic effects such as measured laboratory levels (e. Many colloids in clinical use are below filter pore size; volume replacement should either use cheaper crystalloids or large molecule colloids (e. Anecdotal reports suggest filters and circuits can function considerably longer, but circuits are highly invasive and so major sources for infection; nurses contravening (and managers condoning) the manufacturer’s instructions may be legally liable for harm. Plasmapheresis Plasmapheresis (‘extracorporeal purification’) resembles haemofiltration, usually with smaller filter pores. Intermittent treatments, usually spread over several days, enables removal of ■ drugs (e. At present, it is unclear whether removing mediators improves patient outcome (Kirby & Davenport 1996), but Ronco et al. While technology has made circuits and machines safer, haemofiltration is highly invasive, exposing patients to various complications and dangers. Nurses unfamiliar with using haemofiltration are encouraged to find out how to use it in practice before having to care on their own for patients receiving haemofiltration. Some useful articles have appeared in specialist journals; Kirby and Davenport (1996) offer a useful recent overview; despite their age, articles by Miller et al. He developed rhabdomyolysis and acute renal failure from compression injury as a result of collapsing, lying on the floor for over 18 hours and ingesting nephrotoxic medication. Identify and explain any differences in equipment and patient application between haemofiltration and haemodiafiltration (e. Describe and explain the observational assessment of Mr Sinclair’s coagulation status. Chapter 36 Gastrointestinal bleeds Fundamental knowledge Gastrointestinal anatomy Introduction The importance of gastrointestinal failure to critical care pathophysiology has been increasingly recognised; major gastrointestinal bleeding poses more obvious threats to survival. Most clotting factors are produced by the liver, and so hepatic dysfunction disrupts haemostasis. Oesophageal varices can haemorrhage so rapidly and profusely that one-half of patients die from their first bleed (Schoenfield & Butler 1998). Variceal bleeding The portal vein carries blood (and nutrients) from the stomach to the liver; portal hypertension can be caused by portal vein thrombosis or (more often) cirrhosis (McCaffrey 1991). Alcoholic liver disease, the main cause of cirrhosis (Quinn 1995), is often complicated by malnourishment and gastric ulceration. Pressures exceeding 15 mmHg can cause rupture (Lisicka 1997); obstruction may create pressures exceeding 30 mmHg (McCaffrey 1991), Rupture of varices can cause massive haemorrhage, with 30–50 per cent mortality (Sung et al. Urgent treatment should: ■ stop the haemorrhage ■ provide fluid resuscitation ■ replace clotting factors Haemorrhage is usually stopped by: Intensive care nursing 356 ■ balloon tamponade ■ sclerosis ■ stents Medical treatments Direct pressure to bleeding points is possible using balloon tamponade (Sengstaken, Sengstaken-Blakemore, Minnesota tubes; see Figure 36. Tubes usually have four ports: ■ oesophageal balloon (to stop bleeding) ■ oesophageal aspiration port (omitted on 3-port tubes) ■ gastric balloon (to anchor tubes) ■ gastric aspiration port Balloon tamponade controls 85–92 per cent of bleeds, but re-bleeds are common (Boyer & Henderson 1996), so that balloon tamponade is often only a temporary (emergency) treatment. Tubes are large and relatively difficult to introduce, especially during major haemorrhaging.