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The information gained should be interpreted holistically 250 mg trimox overnight delivery, focusing on patients rather than monitors 250 mg trimox for sale, and trends rather than absolute figures 500mg trimox for sale. Burroughs and Hoffbrand (1990) found inaccurate nursing records from following previously charted observations rather than what is actually observed; nurses should have confidence in their observations, noting and reporting significant changes. Visual Observing patients’ colour and appearance is fundamental to all areas of nursing; skin richly supplied with blood (lips, oral membranes, nail beds) gives the best visual indication of perfusion. Good light, preferably daylight, should be used when assessing skin colour; artificial light, especially fluorescent, can cause distortion. In the absence of reliable early visual signs, technology is needed to support respiratory monitoring. Auscultation Breath sounds are created by air turbulence, and so are limited to upper airways (Hough 1996). Chest (and abdominal) sounds can be deceptive, and so should not be relied upon absolutely. Listening for air entry is used to assess: ■ intubation (bilateral air entry) ■ bronchial patency/bronchospasm ■ secretions ■ effect of suction (before and after) The stethoscope diaphragm best transmits lung sounds (especially high pitches, such as wheezes; the bell is better for low pitches (e. Note pitch, intensity, quality and duration of sounds, listening: ■ anteriorly, posteriorly, laterally ■ on both right and left ■ at apices and bases ■ during both inspiration and expiration ■ over any dependent lung areas, where fluid and mucus tend to collect Missing any areas (for example, because difficult to reach) makes assessment incomplete. Normal sounds are: ■ vesicular: most lung fields, especially peripheries; continuous, low pitch and volume, like rustling wind, with short expiratory phase ■ bronchovesicular: lung apices; medium pitched, louder than vesicular ■ bronchial: trachea; high pitched, loud, short inspiration, like blowing through a tube Abnormal sounds include: ■ wheeze (rhonchi): from bronchospasm, continuous Intensive care nursing 148 ■ crackle (rales, crepitations): bubbling, from fluid, exudate or secretions; interrupted ■ pleural rub: grating sound from (abnormal) friction between pleura Sound may be absent with any obstruction (e. Artefactual sounds may be caused by: ■ clothing ■ friction of stethoscope against equipment (e. Inspiration affects, and is affected by, bronchial muscle stretch; thus patients with chronic obstructive pulmonary disease cannot fully dilate bronchi during short inspiratory time. Expiration is passive recoil; the short expiration time of muscle spasm (asthma) causes gas trapping (and distress). Bedside monitors to measure work of breathing enable more accurate titration of pressure support (Banner et al. Peripheral saturation is within 2 per cent of arterial blood gas saturations (Jones, A. Signals measure (usually) over five pulses (Harrahill 1991), causing slight delay when commencing monitoring. Arteriole emptying during diastole enables differentiation of infrared light absorption by bone, vein and skin pigmentation from absorption by blood. Blood only absorbs two per cent of total infrared light, so poor signal to noise ratios (= poor flow, ‘noisy signal’) frequently occur (Glutton-Brock 1997). Waveform display, rather than just a bar, usefully indicates vasoconstriction and vasodilation, and reliability of readings. Oximetry is the most widely used means of respiratory monitoring, but limitations include ■ oxygen availability to tissues and SpO2 are not identical as • relationship between SaO2 to PaO2 is complex (oxygen dissociation curve—see Chapter 18) • reduced erythrocyte counts reduces oxygen carriage but not SaO2. Inhaled carbon monoxide affects readings four hours after a cigarette (Dobson 1993), so oximetry is unreliable if carbon monoxide poisoning is suspected. Thus oximetry alone is unreliable with chronic obstructive pulmonary disease (Stoneham et al. Most finger probes include light shields, but ear probes may detect overhead lighting. However, if SpO2 falls below 90 per cent, arterial blood gas analysis is advisable. Oximetry probes can be very uncomfortable; by testing probes on yourself you can gauge what patients are experiencing. Uncomfortable probes may need more frequent changes of position, or replacement with less uncomfortable models. Many units change probe positions every hour or two; some anecdotal reports suggest changing every half-hour. Changes should be individually assessed rather than ritualized, depending on ■ heat from probes (assess by trying probes on yourself) ■ perfusion Respiratory monitoring 151 ■ visual observation of probe sites ■ nursing records. Transcutaneous gas analysis Transcutaneous gas analysis is noninvasive, but more useful for neonates than adults, being affected by ■ thickness (Gibbons 1997) ■ poor capillary flow (Gibbons 1997). Transcutaneous carbon dioxide tensions are higher than arterial, but do show useful trends (Rithalia et al.

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Useful contact The Guillain Barré helpline: 0800 374803 Further reading Useful medical articles on Guillain Barré syndrome include Desforges (1992) and Fulgham & Wijdicks (1997) literature reviews purchase trimox 500 mg with mastercard, Hund et al buy cheap trimox 500 mg on line. Finocchiaro and Herzfeld (1990) provide almost the only easily accessible nursing article on autonomic dysreflexia; Keely (1998) gives a useful critical care update cheap trimox 500 mg visa. Some have been published in nursing and medical journals, but can be difficult to obtain. Clinical scenario Duncan Munro, 46 years old, presented with tachypneoa (over 40 breaths/min), tachycardia (110 beats/min), hypertension (170/110 mmHg), difficulty swallowing, general fatigue with numbness in both legs and feet. During the previous three weeks, he had been travelling abroad on business and recovering from an upper respiratory tract infection. Duncan’s respiratory and motor function deteriorated a tracheotomy was performed Neurological pathologies 375 and invasive positive pressure ventilation initiated. The liver has more functions, and a wider range of functions, than any other major organ, so that hepatic failure causes many problems. Liver function tests indicate the degree of liver failure; if severe, referral to specialist centres may be necessary. The term fulminant hepatic failure (liver disease together with encephalopathy occurring within 8 weeks of onset) is still used, but it is increasingly being replaced by ■ hyperacute (0–7 days) ■ acute (8–28 days) ■ subacute (29 days-12 weeks). Although scientifically questionable (drugs are chemicals), this apparently arbitrary division is clinically useful. Symptoms of acute failure are similar from all causes, but are included here in the section on paracetamol. Many other therapeutic drugs (such as chlorpromazine) can also provoke failure (Hawker 1997a). Hepatic failure 377 Hepatic failure may be caused by hepatitis and many other viruses (e. Hepatocyte recovery is good following acute hepatic failure, and so treatment is largely a matter of system support to minimise complications (especially cerebral oedema and cardiac failure) and allow hepatocyte recovery. Progression to chronic failure usually causes ■ hyperdynamic circulation ■ portal hypertension ■ oesophageal varices and bleeding. Survivors of these complications usually progress to end-stage failure, necessitating transplantation (see Chapter 44). Most of the complications identified here occur with acute failure, but some complications of chronic failure are also specifically identified. Plasma paracetamol levels exceeding 250 mg/litre after 4 hours or 50 mg/litre at 12 hours usually result in hepatic damage (Weekes 1997), although severe symptoms may be delayed for 2–3 days, appearing only after significant, possibly fatal, damage. Human transmission is only through faeces (not blood or other body fluids), infection being endemic where sanitation is poor (Pratt 1995). Transmission can be ■ parenteral (most body fluids) ■ sexual ■ (possibly) through insect bites (Pratt 1995). Chronic carriers rarely develop infection (Raeside 1996), but can spread infection (Pratt 1995). Hepatitis C usually recurs following transplantation, but most patients remain asymptomatic. Hepatitis D complicates hepatitis B infection, making fulminant hepatic failure more likely. In Europe and North America, hepatitis D is primarily transmitted through drug injection; elsewhere infection is usually sexual (Pratt 1995). Hepatic failure 379 Complications Liver dysfunction affects most other major systems of the body. The description below is reductionist, and specific management of other systems is covered in other chapters. Cerebral oedema provokes intracranial hypertension, impairing cerebral perfusion pressure (see Chapter 22). Prolonged effects from exogenous sedation may delay recovery and make assessment difficult; debate continues on whether to avoid sedating patients with hepatic failure. Whichever medical practice is followed, nurses should actively assess the level of sedation and effects of drugs. Normal sleeping patterns may be reversed, with patients remaining awake overnight. Treatment should optimise cerebral perfusion pressure by reducing intracranial pressure while maintaining mean arterial pressure (see Chapter 22). Persistent intracranial hypertension (above 25 mmHg) may be reversed with mannitol.

Nasolachrymal drainage plays a key role in the systemic Consequently purchase 500mg trimox with mastercard, even though the dose administered as eye drops is absorption of drugs administered to the eye buy trimox 250mg with amex, and drugs much smaller than the usual dose of the same drug (e cheap 250 mg trimox overnight delivery. Thus ocular drugs such as β-adrenergic antagonists can nonetheless lead to unwanted systemic effects. Agents that dilate the and flows from the posterior chamber through the pupil into the pupil may abruptly increase the intra-ocular pressure in anterior chamber. Around 80–95% of it exits via the trabecular closed-angle glaucoma by causing obstruction to the outflow meshwork and into the canal of Schlemm and subsequently into tract, and are contraindicated in this condition. Patients the episcleral venous plexus and eventually into the systemic should be asked whether they are driving before having their circulation. Fluid can also flow via the ciliary muscles into the pupils dilated and should be warned not to drive afterwards suprachoroidal space. The geometry of the anterior chamber dif- until their vision has returned to normal. Open-angle glaucoma is usually treated medically in the first instance, by reducing aqueous Tears humour flow and/or production. Closed-angle glaucoma is treated by iridectomy following urgent medical treatment to Conjunctiva reduce the intra-ocular pressure in preparation for surgery. Mannitol can reduce Iris Ciliary body the intra-ocular pressure acutely by its osmotic effect. In add- ition, therapy with a carbonic anhydrase inhibitor (intra- venous acetazolamide or topical dorzolamide) may be Systemic circulation required. The free acid dif- fuses out of the cornea into the aqueous humour and lowers Mannitol (Chapter 36) is an osmotic diuretic. It shifts water from intracellular and transcellular com- The main side effects are local irritation with stinging, burning partments (including the eye) into the plasma, and promotes and blurred vision. Punctate keratopathy has occurred, and it loss of fluid by its diuretic action on the kidney. Its major increases the amount of brown pigment in the iris in patients adverse effect is dehydration. It was previously used as Brimonidine is a selective α2-agonist, used for chronic open- a diuretic (see Chapter 36). It decreases aqueous humour production and increases the eye reduces aqueous humour production by the ciliary uveoscleral flow. The major toxicities include local ocular irritation and occasional corneal staining, and sys- Adverse effects temic adverse effects include dry mouth (25% of cases), headache, fatigue, drowsiness and allergic reactions. Acetazolamide is poorly tolerated orally, although a slow- release preparation exists which can be given twice daily and Key points has reduced incidence of side effects. Dorzolamide is a topic- ally applied carbonic anhydrase inhibitor, whose use may Drugs and the pupil reduce the need for systemic acetazolamide therapy (see • Miosis (pupillary constriction) below). Acetazolamide should not be used in patients with – Parasympathetic stimulation: renal failure, renal stones or known hypersensitivity to muscarinic agonists (e. Acute bac- specialist supervision to treat uveitis and scleritis, and some- terial conjunctivitis is usually due to Staphylococcus aureus or times in the post-operative setting. Chloramphenicol, gentamicin, fusidic acid or to treat the undiagnosed ‘red-eye’ which could be due to a one of the fluoroquinolones (e. Furthermore, topical steroids produce or exacerbate glaucoma in genetically pre- disposed individuals (Chapter 14). Several such ophthalmic Topical antihistamines for ophthalmic use include antazoline preparations are available, including diclofenac, flurbiprofen and azelastine. Oxybuprocaine and tetracaine are widely used in the eye as Sodium cromoglicate in particular is very safe and only topical local anaesthetics. Tetracaine causes more profound anaesthesia and is suitable for minor surgical procedures. Lidocaine is also often injected for surgical proced- Pegaptanib and ranibizumab are two newly licensed ures on the globe of the eye. Ocular involvement occurs in up to two- evidence of efficacy and safety; currently, its licensed indica- thirds of patients, of whom approximately one-third suffer tions are metastatic colorectal or breast carcinoma (see permanent visual sequelae.

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