By K. Garik. Franklin College. 2018.
They are 1 The person is viewed as a holistic being: integrated by their cognitive abilities purchase roxithromycin 150mg visa, the wealth of “The experience of wholeness is the foundation previous experiences discount roxithromycin 150 mg on line, the ability to deﬁne relation- of all human enterprises” (Levine cheap roxithromycin 150 mg line, 1991 150 mg roxithromycin with visa, p. Table 9–1 Use of the Nursing Process According to Levine Process Application of the Process Assessment Collection of provocative facts through observation and interview of challenges to the internal and external environments. The nurse observes the patient for organismic responses to illness, reads medical reports, evaluates results of diagnostic studies, and talks with patients and their families (support per- sons) about their needs for assistance. The nurse assesses for physiological and pathophysiologi- cal challenges to the internal environment and the factors in the perceptual, operational, and conceptual levels of the external environment that challenge the individual. The nurse arranges the provocative facts in a way that provides meaning to the patient’s predicament. Nurses seek validation of the patients’ problems with the patients or support persons. The nurses then propose hypotheses about the problems and the solutions, such as: Eight glasses of water a day will improve bowel evacuation. Interventions are designed based on the conservation principles: conservation of energy, structural integrity, per- son integrity, and social integrity. The expectation is that this approach will maintain wholeness and promote adaptation. The outcome of hypothesis testing is evaluated by assessing for organismic response that means the hypotheses are supported or not supported. Consequences of care are either therapeutic or supportive: therapeutic measures improve the sense of well-being; supportive measures pro- vide comfort when the downward course of illness cannot be inﬂuenced. If the hypotheses are not supported, the plan is revised and new hypotheses are proposed. The scientiﬁc process is used to make observations and select relevant data to form hypothetical statements about the patients’ predica- ments (Schaefer, 1991a). These decisions are not the role pletely to every alteration in his or her life of the health-care providers or families (Levine, pattern. Atheoryofnursing must recognize 6 “Persons who require the intensive inter- the importance of unique detail of care for a ventions of critical care units enter with a con- single patient within an empiric framework tract of trust. The model’s universality is supported by the 8 The nurse is responsible for recognizing the model’s use in a variety of situations and patients’ state of altered health and the patient’s organis- conditions across the life span. Swavely, Rothenberger, Hess, & Willistin, 1996), emergency room (Pond & Taney, 1991), primary Values care (Pond, 1991), in the operating room (Crawford-Gamble, 1986), long-term/extended 1 All nursing actions are moral actions. This model has been used with a variety of pa- 3 Ethical behavior “is the day-to-day expres- tients across the life span, including the neonate sion of one’s commitment to other persons and (Mefford, 1999; Tribotti, 1990), infant (Newport, the ways in which human beings relate to one 1984; Savage & Culbert, 1989), young child (Dever, another in their daily interactions” (Levine, 1991), pregnant woman (Roberts, Fleming, & 1977, p. Clark (1992) provides examples of the use of tients (Cox, 1991; Foreman, 1991, 1996; Hirschfeld, the conservation principles with the individual, 1976), including the frail elderly patient (Happ, family, and community as a testament to the personal communication, January 31, 1995; model’s ﬂexibility/universality. The approach to community begins with the The model has been used as a framework for collection of facts and a thorough community as- wound care (Cooper, 1990), managing respiratory sessment (provocative facts). The internal environ- illness (Dow & Mest, 1997; Roberts, Brittin, Cook, ment assessment directs the nurse to examine the & deClifford, 1994), managing sleep in the patient patterns of health and disease among the people of with a myocardial infarction (Littrell & Schumann, the community and their use of programs available 1989), developing nursing diagnoses (MacLean, to promote a healthy community. The assessment 1989; Taylor, 1989), practicing enterostomal ther- of the external environment directs the nurse to ex- apy (Neswick, 1997), assessing for changes in amine the perceptual, operational, and conceptual bladder function in posthysterectomy women levels of the environment in which the people live. It has also been used for devel- The perceptual environment incorporates those oping plans of care for women with chronic illness factors that are processed by the senses. On a com- (Schaefer, 2002), care of intravenous sites (Dibble, munity basis these factors might include an assess- Bostrom-Ezrati, & Rizzuto, 1991), skin care (Burd ment of: et al. The operational environment would encourage Current work on the model is in process in the a more detailed assessment of the factors in the en- areas of community health. The following is a brief vironment that affect the individual’s health but are summary of beginning clariﬁcation of the model’s not perceived by the people. This discussion focuses on ment on the ethnic and cultural patterns in the community-based care using Levine’s Conserva- community. An assessment of types of houses of tion Model to provide a foundation for the future worship and health-care settings might be included. Using Levine’s Conservation Model, conservation principles to guide continued assess- community was initially deﬁned as “a group of peo- ment to assure a thorough understanding of the ple living together within a larger society, sharing community. Levine (1973) maintained that research Assessment of personal integrity might include: is critical to the development of a scientiﬁcally 1.
The strength of a drug action is determined by how much of the drug is given cheap roxithromycin 150 mg without a prescription, (the dose) and how often the drug is given (the frequency) buy 150mg roxithromycin mastercard. For example buy 150 mg roxithromycin with visa, a patient who has a sore throat can be given a large dose of an antibiotic—a loading dose— on the first day of treatment and a normal or maintenance dose for the next five days buy 150 mg roxithromycin free shipping. These are: • Pharmaceutic Phase: This phase occurs after the drug is given and involves disintegration and dissolution of the dosage form. The inactive ingredient, called excipient, is the substance that has no pharmaceutical response but helps in the delivery of the drug. The coating around tiny particles of a capsule that causes a timed-release action of the drug is an inactive ingredient. The time necessary for the drug to disintegrate and dissolve so it can be absorbed is called the rate limiting time. A drug has a higher rate limiting time (Table 2-1) if it is absorbed in acidic fluids rather than alkaline fluids. Some drugs are more effective if absorbed in the small intestine rather than the stomach. Therefore, pharmaceutical manufacturers place an enteric coating around the drug that resists disintegration in the stomach. Enteric coating is also used to delay the onset of the pharmaceutical response and to prevent food in the stomach from interfering with the dissolution and absorption of the drug. Tip: Never crush a capsule that contains enteric release beads or is coated for timed-release. Drug molecules move to the intended site of action in the plasma but sometimes this journey can be limited because they have to get into the interior of a cell or body compartment through cell membranes. These membranes could be in the skin, the intestinal tract, or the intended site of action. Drug particles then attach themselves to receptor sites resulting in its therapeutic effect. These are: Passive Diffusion Passive diffusion is the flow of drug particles from a high concentration to a low concentration—similar to how water flows downstream. There is no energy expended in passive diffusion because drug particles are moving along the natural flow. Active Diffusion Active diffusion is how drug particles swim upstream against the natural flow when there is a higher concentration of plasma than there is of drug particles. Drug particles don’t have enough energy to go against the natural flow without help. Help comes from an enzyme or protein carrier that transports drug parti- cles upstream across the membrane and into the plasma. Pinocytosis Pinocytosis is the process of engulfing the drug particle and pulling it across the membrane. This is similar to how you eat an ice pop by engulfing a piece of it in with your mouth and swallowing it. How long the drug will be effective and how much drug is needed depends on the route of administration, the dose of the drug, and the dosage form (tablet, capsule, or liquid). The absorption rate of a drug is influenced by a number of factors that might increase or decrease the rate, This is similar to how more gasoline is used to drive at faster speeds. Absorption is affected by many factors that include pain, stress, hunger, fasting, food, and pH. Hot, solid, fatty foods can slow absorption such as eating a Big Mac before taking medication. During exercise, circulation to the stomach is diverted to other areas of the body and drug absorption is decreased. Circulation Blood flow to the site of administration of the drug will help increase the rate of absorption. An area that has a lot of blood vessels and good circulation will help absorb the drug quickly and circulate it to the intended site.
Although they may decrease pain buy roxithromycin 150mg online, they also promote hypoventila- tion leading to atelectasis and pneumonia buy discount roxithromycin 150mg on-line. The progressive accumulation of air under pressure in the pleural cavity may lead to a shift of the mediastinum to the contralateral hemithorax roxithromycin 150 mg visa. The physical examination may reveal decreased or absent breath sounds over the involved side generic 150 mg roxithromycin, as well as subcutaneous emphysema. The preferred site for insertion is the fourth or fifth intercostal space at the anterior or mid- axillary line. The tube should be positioned posteriorly and toward the apex so that it can effectively remove both air and fluid. It is more likely to occur after a penetrating trauma to the chest rather than a blunt trauma. Patients with this lesion have ipsilateral motor paralysis and contralateral loss of pain and temperature distal to the level of the injury. This syndrome has the best prognosis for recovery of all of the incomplete spinal cord lesions. Patients typically exhibit flaccid paralysis with loss of sensory input, deep tendon reflexes, and urinary bladder tone. Patients often have greater sensorimotor neurologic deficits in the upper extremities compared to the 156 Emergency Medicine lower extremities. Its hallmark is preservation of vibratory sensation and proprioception because of an intact dorsal column. Its presentation may include variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and saddle anesthesia. A score of 14 to 15 is associated with minor head injury, 9 to 13 indicates moderate, and 8 or less is associated with severe head injury. If there is an active scalp bleed, staples can be rapidly placed to limit bleeding until definitive repair can take place. It is administered if there are signs of impending or actual herniation (eg, fixed and dilated pupil). It is one of the most commonly overlooked injuries resulting from blunt chest trauma. Trauma Answers 157 The paradoxical motion of the chest wall is the hallmark of this condition, with the flail segment paradoxically moving inward with inspiration and outward with expiration. Neck trauma is caused by three major mechanisms, including penetrating, blunt, and strangulation, which can affect the airway, digestive tract, vascu- lar, and neurologic systems. Zone I extends superiorly from the sternal notch and clavicles to the cricoid cartilage. Active bleeding sites or wounds with blood clots should not be probed because massive hemorrhage can occur. Blind clamping should be avoided because of the high concentration of neurovascular structures in the neck. The name “hangman’s fracture” was derived from judicial hangings, where the knot of the noose was placed under the chin which caused extreme hyperextension of the head on the neck, resulting in a fracture at C2. However, many hangings resulted in death from strangulation rather than spinal cord damage. Today, the most common cause of a hangman’s fracture is the result of head-on automobile collisions. It is a transverse fracture of the distal radial metaphysis, which is dorsally displaced and angulated. It is one of the most common fractures of the hand and usually occurs from a direct impact to the hand (eg, a punch with a closed fist). However, indirect signs of injury may include visible evidence of bleeding from the fracture into surrounding soft tissue. Ecchymosis around the mastoid bone is often described as Battle sign and periorbital ecchymosis is often described as Trauma Answers 159 “raccoon eyes.
Folate is essential to numerous bodily functions ranging from nucleotide biosynthesis to the remethylation of homocysteine roxithromycin 150mg with mastercard. Children and adults both require folic acid in order to produce healthy red blood cells and prevent anemia cheap 150mg roxithromycin fast delivery. Folate and folic acid derive their names from the Latin word folium (which means "leaf") generic 150mg roxithromycin with amex. Leafy vegetables are a principal source cheap roxithromycin 150 mg with amex, although, in Western diets, fortified cereals and bread may be a larger dietary source. Lake and Spiegel caution that folate is easily inactivated by cooking and processing. Several older studies found that up to 35% of depressed patients are folate deficient. Supplementation of folate deficiencies is recommended by five sources and only disavowed by one, and adjunctive treatment of depression with folate is a promising practice, especially for women, even if blood serum folate levels are not low. Two (implicitly, three) of the sources counsel supplementation even in the absence of folate deficiency. This deficiency may be an understudied risk factor for depression, especially since studies have shown that folate deficiency can significantly reduce the efficacy of prescribed antidepressants. Subjects with low folate levels were more likely to have melancholic depression and were significantly less likely to respond to fluoxetine. The researchers concluded that there was a link between low folate levels and poorer response to antidepressant treatment. They suggested that folate levels be considered in the evaluation of depressed people who do not respond to antidepressant treatment. Both Lake and Spiegel and Brown and Gerbarg emphasize this critical genetic factor. Those found to be positive for the variants can be treated with methylfolate which avoids the need for conversion. The seven subjects with low folate levels had a 43% relapse rate, compared to 3% for the 64 with normal folate levels. Conversely, when people with folate deficiencies received supplementation with methylfolate to counteract low folate levels, a small 1990 study showed an improved treatment response. The dose was 15-30 mg per day of folinic acid, which is metabolized to methylfolate. As to depression, the Natural Standard states only that folic acid deficiency has been found among people with depression and has been linked to poor response to antidepressants. Although the Natural Standard concedes that folate has been used adjunctively, for enhancing treatment response to antidepressants, it does not credit the evidence in its rating. The Natural Standard states that folate is “not effective” as a replacement for antidepressants, but it does not comment on adjunctive use. They suggest that assessment of folate status ought to be included in any comprehensive medical workup for depression and that folate replacement is essential for individuals with conditions leading to folate deficiency, such as alcoholism, metabolic problems, and malabsorption. Even among individuals with normal folate levels, higher folate levels are correlated with less severe depression, higher age at 13 onset,” and improved response to antidepressants. He recommends a comprehensive vitamin and mineral 14 supplementation program, including B6 and B12 as well as folate. No drug interaction has yet been noted by any source between folate and psychotropic medications, and the remaining risk is low. Mischoulon and Rosenbaum recommend methylfolate over folate as less toxic for older people with mild cognitive impairment because it crosses the blood- 17 brain barrier. Lake and Spiegel note that higher folate levels correlate with higher scores on the Mini-Mental State Exam. Berkeley Wellness discusses potential use of folate for prevention and treatment of cognitive impairment and dementia but asserts, as conceded by all of the sources, that studies on the effects of taking folic acid have yielded contradictory findings.