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By J. Ur-Gosh. Suffolk University.

Acquiring the fundamental knowledge buy cheap sevelamer 400mg line, as well as cognitive and technical skills necessary to provide safe anesthesia order cheap sevelamer on-line, are essential early on in your training purchase sevelamer. Understand the proper use of laboratory testing and how abnormalities could impact overall anesthetic management. Exam ple Traces • Time delay exists due to length and volume of sample tube as wellas samplingrate (50-500 A. Ph iladelph ia:L ippincottW illiams& W ilkins, correlationwith tympanicandesoph agealtemperatures 2003. A nesth esiology 74:489, 1991 6 M inim um A lveolarC oncentration A lveolarconcentrationofagas atwh ich 50% of subjsubjecectts do ns do notrotrespesponondd ttoo sursurgigiccaalliinncciisisionon M A C & A w areness Im portantPoints • R emarkably consistentacross species. F actors Decreasing M A C A w areness • Drugs decreasingcentralcatech olamines: – Reserpine,-meth yldopa • Very rare – Ch ronicamph etamine abuse • M ostcommonsensationis h earingvoices •• O tO thh ererdrdrugugs:s: – O pioids,benz odiaz epines,barbiturates,2-agonists(clonidine, • M ostly occurs duringinductionoremergence dexmedetomidine),ketamine,lidocaine,lith ium,verapamil,h ydroxyz ine. Cellularandmolecularmech anismsof • Talk to th e patientafterth e case to assess ifth ey h ad any anesth esia. O pioids O pioids M orph ine – Slow peak time (~80% effectat15 minutes,butpeak analgesic F entanyl efefffececttiis ats at~9090 miminnututes)es). The strategies presented here are simply 60 suggestions, something to get you thinking rationally Fentanyl about how and when you use opioids for analgesia. S trategies forO pioid U se R eferences • M eperidine is usually reserved fortreatment/prevention • F ukuda K. Intraoperative H ypertension Treatm entofH ypertension • “L igh t”anesth esia • Temporiz e with fast-onset,sh ort-actingdrugs,but • Pain ultimately diagnose and treatth e underlyingcause. A utonomicnervous system: • DirectandindirectadrenergicstimulationviaN E release ph ysiology and ph armacology. A minosteroids = “-oniums” jjununccttiiononalalrrh yth yth mh m,orarorarrrestest;al;always giways givve 2e 2nd dosedose wiwitthh 00. DifficultIntubation – H istoryofpriordifficulty – H istoryofpriordifficulty DifficultA irw ay A lgorith m – F acialh air – Underlyingpath ology (e. W h enI meth im inppreopp,I was relieved th ath e because I was gettinggastriccontents (you always say th is),th e sursurggeonceoncompompllaiainns abs aboutouta pa pereriiodiodicwh icwh iffffofofa fa fouloulodor Wodor. Post-renal(post-renalobstruction) Parkland F ormula – F oleykinked,clogged,displaced,ordisconnected – Surgicalmanipulationofkidneys,ureters,bladder,orureth ra 3. DurD iing massiivettransfusif ionwhenh fifibrb iinogenllevellnottavaiilbllable HctHct((ststarartt)) <1year 80 4. Hypotherm ia • Diagnosisof ex clusion:firstR /O sepsis,volum eoverload,and • Bloodproductsarestoredcold-useafluidwarmer! Itis a signth atth ey,too,h ave been Duringth e middle ofa straigh tforward case I was sprayed with eith erPropofolorK efz olwh ile tryingto draw ddrawiingupmy ddrugs ffortthh e nexttcase. C entralC ontrol • G eneralanesth esia inh ibits th ermoregulationand • Th ermalinputsare “preprocessed”atnumerouslevelswith inth e spinalcord increases th e interth resh old range ~20-fold,to ~4°C. EfferentR esponses • Beh avioralresponses(sh elter,cloth ing,voluntarymovement,etc)are most importantandare determinedbyskintemperature. C onsequences ofH ypoth erm ia W arm ing S trategies Preventionofh ypoth erm iais m ore effective th antreatm ent! Prom eth az ine,Proch lorperaz ine) – Serotoninreceptorantagonist – Dopamine antagonist – M ore effective atpreventingemesisth annausea – Cancause sedationandextrapramidalside effects – A llagentsequallyeffective – Ph energan12. Scopolam ine) Steroids – Centrallyacting – Ch eapandeffective – Transdermaladministrationrequires2-4 h oursforonset. A factorialtrialofsixinterventionsforth e preventionof • U se propofolforinductionand maintenance of postoperative nauseaandvomiting. H ow much are patientswillingtopaytoavoid • A void N O and/orvolatile anesth etics postoperative nauseaandvomiting? N orm alM etabolicStatus – A dequate mentation(G C S > 13,minimalsedation) • N ormalelectrolytes – H emodynamically stable,onminimalpressors (e. Definition Stage 1 – F ailure to regainconsciousness as expected with in20-30 – SedatSedated,ed iinnttacactltliiddrrefefllexex,ffololllowscowscommanommandsds miminnututeses ofoftthh e ene endd ofofaa sursurggiiccalalpprrococeduredure. R esidualdrugeffects purposefulmovement – A bsolute orrelative overdose – Irregularbreath ing& breath -h olding,dilated& disconjugate pupils, conjunctivalinjection – Potentiationofagentsbypriorintoxication(e. H ypo-/H yperglycemia – M edullarydepression,cardiovascular/respiratorycollapse 51 Delayed Em ergence Diagnosis and Treatm ent Ensure adequate oxygenation,ventilation,and h em odynam ic C auses stability first,th enproceed with : 5. EnEnsursuree ppatatiienenttiissnnorormotmothh erermimicc • Risk factors:A F ib,h ypercoagulable state,intracardiacsh unt • Use BairH ugger • Incidence:0. F aulty O xygenSupply – C rC rossiossinnggofofppiippeleliinneses durduriinnggccononststrrucucttiionon//rrepepaiairrss. Anaphylactoid Sequence of E vents Anaphylaxis • IggE-mediated Typype I h ypypersensitivityy reaction • Sensitiz ation= priorexposure to anantigenwh ich produces antigen-specificIgE antibodies th atbind to F creceptors onmast cells and basoph ils. Ph iladelph ia: • M easurementofserum mastcelltryptase levels can L ippincottW illiams & W ilkins,2006. C ross- reactivityand tolerability ofceph alosporins inpatients with • F ollow upwith anallergistmay be usefulfor immediate h ypersensitivity to penicillins. P rim ary A B C D S urvey S econdary A B C D S urvey F ocus:A dvanced A ssessm ents & Invasive Th erapy. C ellDam age – L eakage ofK +,myoglobin,C K • A llpotentinh alationalagents (butnotN 2O ) • SucS ciinyllhch olliine 5. Increased C ytoplasm icF ree C a2+ – Increased catech olamines -tach ycardia,h ypertension, cutaneous vasoconstriction • M assetermuscle rigidity (trismus) – Increased cardiacoutput-decreased ScvO 2,decreased PaO 2, • Totalbody rigidity metabolicacidosis 3. Treath yperth erm ia – Insulin& glucose (10 units in50 mlD50) – C alcium (10 mg/kgC aC l2,or10-50 mg/kgC a gluconate) – C oolifT > 39˚C ,butD/C ifT < 38˚C. C ounC ounselselppaattiienenttaanndd ffaam im illyy – R Y R 1 mutationscreening • F uture precautions. R eferpatientand fam ily to nearestB iopsy relatives ofknownM H susceptibility,orpatients with C enterforfollow-up. P erioperative Antibiotics • If vancom ycinorafluoroquinoloneisused,it shouldbegivenwithin120m inof incisionto preventantibiotic-associatedreactionsaround thetim eof anesthesiainduction. The *canpotentiateneuromuscularblockers trendtowardhigherratesof infectionforeachhourthatantibioticadministrationwas • Considerre-dosing every6hrs(ex ceptVanc,Zosyn,andCeftriax one) delayedafterthesurgicalincisionwassignificant(z score= 2. O nlyIgE -m ediated ststaphyaphyllococcianococcianddststrrepteptococciococci reaction(typeI,im m ediatehypersensitivityreactions) • Proceduresinvolving bowelanaerobes,G ram neg- aretrueallergic reactions. However,itm aybe • Cardiactransplantpatientswhodevelopcardiacvalvulopathy prudenttogive1m lof theantibiotic firsttoseeif the • BacterialE ndocarditisprophylax is patientwillhaveareaction. I gotlostalongth e way and took a anesth esia attendingand orth o residentmove wrongturnleading to a dead end. I tried to play th e patientto th e O R bed atwh ich pointth e pt itoffth atwe h ad takenth is round aboutway just ch uckles and smiles. U nfortunately, responds,"I justh ad abouta milliondollars desppite th e Versed,,I th ink h e saw riggh tth rouggh worth ofeducationmove me from one bed to th e subterfuge. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty.

A diuretic is a compound that increases urine output and therefore decreases water conservation by the body buy sevelamer cheap. Diuretics are used to treat hypertension discount sevelamer american express, congestive heart failure 800mg sevelamer visa, and fluid retention associated with menstruation. Some ions assist in the transmission of electrical impulses along cell membranes in neurons and muscles. All of the ions in plasma contribute to the osmotic balance that controls the movement of water between cells and their environment. Electrolytes in living systems include sodium, potassium, chloride, bicarbonate, calcium, phosphate, magnesium, copper, zinc, iron, manganese, molybdenum, copper, and chromium. In terms of body functioning, six electrolytes are most important: sodium, potassium, chloride, bicarbonate, calcium, and phosphate. Roles of Electrolytes These six ions aid in nerve excitability, endocrine secretion, membrane permeability, buffering body fluids, and controlling the movement of fluids between compartments. More than 90 percent of the calcium and phosphate that enters the body is incorporated into bones and teeth, with bone serving as a mineral reserve for these ions. In the event that calcium and phosphate are needed for other functions, bone tissue can be broken down to supply the blood and other tissues with these minerals. Phosphate is a normal constituent of nucleic acids; hence, 1260 Chapter 26 | Fluid, Electrolyte, and Acid-Base Balance blood levels of phosphate will increase whenever nucleic acids are broken down. In a clinical setting, sodium, potassium, and chloride are typically analyzed in a routine urine sample. In contrast, calcium and phosphate analysis requires a collection of urine across a 24-hour period, because the output of these ions can vary considerably over the course of a day. Bicarbonate is the one ion that is not normally excreted in urine; instead, it is conserved by the kidneys for use in the body’s buffering systems. It is responsible for one-half of the osmotic pressure gradient that exists between the interior of cells and their surrounding environment. People eating a typical Western diet, which is very high in NaCl, routinely take in 130 to 160 mmol/day of sodium, but humans require only 1 to 2 mmol/day. Sodium is freely filtered through the glomerular capillaries of the kidneys, and although much of the filtered sodium is reabsorbed in the proximal convoluted tubule, some remains in the filtrate and urine, and is normally excreted. Hyponatremia is a lower-than-normal concentration of sodium, usually associated with excess water accumulation in the body, which dilutes the sodium. An absolute loss of sodium may be due to a decreased intake of the ion coupled with its continual excretion in the urine. An abnormal loss of sodium from the body can result from several conditions, including excessive sweating, vomiting, or diarrhea; the use of diuretics; excessive production of urine, which can occur in diabetes; and acidosis, either metabolic acidosis or diabetic ketoacidosis. The excess water causes swelling of the cells; the swelling of red blood cells—decreasing their oxygen-carrying efficiency and making them potentially too large to fit through capillaries—along with the swelling of neurons in the brain can result in brain damage or even death. It can result from water loss from the blood, resulting in the hemoconcentration of all blood constituents. It helps establish the resting membrane potential in neurons and muscle fibers after membrane depolarization and action potentials. Potassium is excreted, both actively and passively, through the renal tubules, especially the distal convoluted tubule and collecting ducts. Potassium participates in the exchange with sodium in the renal tubules under the influence of aldosterone, which also relies on basolateral sodium-potassium pumps. Similar to the situation with hyponatremia, hypokalemia can occur because of either an absolute reduction of potassium in the body or a relative reduction of potassium in the blood due to the redistribution of potassium. Some insulin-dependent diabetic patients experience a relative reduction of potassium in the blood from the redistribution of potassium. Hyperkalemia, an elevated potassium blood level, also can impair the function of skeletal muscles, the nervous system, and the heart. This can result in a partial depolarization (excitation) of the plasma membrane of skeletal muscle fibers, neurons, and cardiac cells of the heart, and can also lead to an inability of cells to repolarize. For the heart, this means that it won’t relax after a contraction, and will effectively “seize” and stop pumping blood, which is fatal within minutes. Because of such effects on the nervous system, a person with hyperkalemia may also exhibit mental confusion, numbness, and weakened respiratory muscles. The paths of secretion and reabsorption of chloride ions in the renal system follow the paths of sodium ions. Hypochloremia, or lower-than-normal blood chloride levels, can occur because of defective renal tubular absorption. Hyperchloremia, or higher-than-normal blood chloride levels, can occur due to dehydration, excessive intake of dietary salt (NaCl) or swallowing of sea water, aspirin intoxication, congestive heart failure, and the hereditary, chronic lung disease, cystic fibrosis. In people who have cystic fibrosis, chloride levels in sweat are two to five times those of normal levels, and analysis of sweat is often used in the diagnosis of the disease. Carbon dioxide is converted into bicarbonate in the cytoplasm of red blood cells through the action of an enzyme called carbonic anhydrase. Calcium About two pounds of calcium in your body are bound up in bone, which provides hardness to the bone and serves as a mineral reserve for calcium and its salts for the rest of the tissues. A little more than one-half of blood calcium is bound to proteins, leaving the rest in its ionized form. In addition, calcium helps to stabilize cell membranes and is essential for the release of neurotransmitters from neurons and of hormones from endocrine glands. A deficiency of vitamin D leads to a decrease in absorbed calcium and, eventually, a depletion of calcium stores from the skeletal system, potentially leading to rickets in children and osteomalacia in adults, contributing to osteoporosis. Hypocalcemia, or abnormally low calcium blood levels, is seen in hypoparathyroidism, which may follow the removal of the thyroid gland, because the four nodules of the parathyroid gland are embedded in it. Hypophosphatemia, or abnormally low phosphate blood levels, occurs with heavy use of antacids, during alcohol withdrawal, and during malnourishment. In the face of phosphate depletion, the kidneys usually conserve phosphate, but during starvation, this conservation is impaired greatly. Hyperphosphatemia, or abnormally increased levels of phosphates in the blood, occurs if there is decreased renal function or in cases of acute lymphocytic leukemia. Regulation of Sodium and Potassium Sodium is reabsorbed from the renal filtrate, and potassium is excreted into the filtrate in the renal collecting tubule. Aldosterone Recall that aldosterone increases the excretion of potassium and the reabsorption of sodium in the distal tubule. Aldosterone is released if blood levels of potassium increase, if blood levels of sodium severely decrease, or if blood pressure decreases. Its net effect is to conserve and increase water levels in the plasma by reducing the excretion of sodium, and thus water, from the kidneys. This action increases the glomerular filtration rate, resulting in more material filtered out of the glomerular capillaries and into Bowman’s capsule.

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Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function discount sevelamer 400mg with mastercard. The changes can worsen prior haemodynamic alterations and this situation poses a special therapeutic problem buy discount sevelamer 400mg on-line. The relevant haemodynamic changes are an increasing heart rate cheapest sevelamer, instability in arterial blood pressure and in systemic and pulmonary resistance, and increased cardiac output. During labour, delivery and the post- partum, these haemodynamic alterations suffer sudden and severe changes that can cause life-threatening complication in these patients. To make a timely decision on the optimal treat- ment for such patients, it is mandatory that the haemodynamic status of the patient be evaluated, and follow-up evaluations be carried out. These patients are at high risk of life-threatening complications during pregnancy and delivery, and in most cases physicians should advise that preg- nancy be avoided. However, given the advances in cardiovascular diagnostic and therapeutic techniques, including percutaneous bal- loon mitral valvotomy and surgical commissurotomy performed during pregnancy, pregnancy could be allowed if the appropriate facilities are available (1–9). Archivos Cardiologia de Mexico, [Mexican Archives of Cardiology,] 2001, 71:S160– S163. Rheumatic fever and rheumatic heart disease: epidemiology, clinical aspects, management and prevention, 1st ed. Arqivos Brasileiros de Cardiologia, [Brazilian Archives of Cardiology,] 2000, 75(3):215–224. The role of mitral valve balloon valvuloplasty in the treatment of rheumatic mitral valve stenosis during pregnancy. Revista Española de Cardiologia, [Spanish Journal of Cardiology,] 2001, 54(5):573– 579. Pregnancy outcomes and cardiac complications in women with mechanical, bioprosthetic and homograft valves. In patients with carditis, a rest period of at least four weeks is recommended (2), although physicians should make this decision on an individual basis. Ambula- tory restrictions may be relaxed when there is no carditis and when arthritis has subsided (1). Patients with chorea must be placed in a protective environment so they do not injure themselves. Antimicrobial therapy Eradication of the pharyngeal streptococcal infection is mandatory to avoid chronic repetitive exposure to streptococcal antigens (2). However, antibiotic therapy is warranted even if the throat cultures are negative. Antibiotic therapy does not alter the course, frequency and severity of cardiac involvement (3). The eradication of pharyngeal streptococci should be followed by long-term secondary prophylaxis to guard against recurrent pharyngeal streptococcal infections. Aspirin, 100mg/kg-day divided into 4–5 doses, is the first line of therapy and is generally adequate for achieving a clinical response. In children, the dose may be increased to 125mg/kg-day, and to 6–8g/day in adults (4). If symptoms of toxicity are present, they may subside after a few days despite continuation of the medication, but salicylate blood levels could be monitored if facilities are available (4, 5). After achieving the desired initial steady-state concentration for two weeks, the dosage can be decreased to 60–70mg/kg-day for an additional 69 3–6 weeks (2, 4, 5). No controlled trials comparing aspirin and nonste- roidal anti-inflammatory agents have been conducted. However, in patients who are intolerant or allergic to aspirin, naproxen (10–20mg/ kg-day) has been used (6). One of the most common errors made by physicians is the early administration of anti-inflammatory therapy before the diagnosis has been finally established. In a recent meta-analysis of salicylates and steroids, no differences were observed in the long-term outcomes of these treatments for decreasing the frequency of late rheumatic valvular disease (7). How- ever, since one large study in the meta-analysis favoured the use of steroids, it remains unclear whether one treatment is superior to the other. Patients with pericarditis or heart failure respond favorably to corticosteroids; corticosteroids are also advisable in patients who do not respond to salicylates and who continue to worsen and develop heart failure despite anti-inflammatory therapy (1). Prednisone (1– 2mg/kg-day, to a maximum of 80mg/day given once daily, or in divided doses) is usually the drug of choice. In life-threatening cir- cumstances, therapy may be initiated with intravenous methyl pred- nisolone (8). After 2–3 weeks of therapy the dosage may be decreased by 20–25% each week (2, 5). While reducing the steroid dosage, a period of overlap with aspirin is recommended to prevent rebound of disease activity (1, 9). Since there is no evidence that aspirin or corticosteroid therapy af- fects the course of carditis or reduces the incidence of subsequent heart disease, the duration of anti-inflammatory therapy is based upon the clinical response to therapy and normalization of acute phase reactants (1, 4, 5). Five per cent of patients continue to demon- strate evidence of rheumatic activity for six months or more, and may require a longer course of anti-inflammatory treatment (4). Infre- quently, laboratory and clinical evidence of a rebound in disease activity may be noticed 2–3 weeks after stopping anti-inflammatory therapy (4). This usually resolves spontaneously and only severe symptoms require reinstitution of therapy (4). Initially, patients should follow a restricted sodium diet and diuretics should be admin- istered. Angiotensin converting enzyme inhibitors and/or digoxin may be introduced if these measures are not effective, particularly in patients with advanced rheumatic valvular heart disease (4). Their benefit has been extrapo- lated from trials in adults with congestive heart failure due to multiple etiologies (10). Management of chorea Chorea has traditionally been considered to be a self-limiting benign disease, requiring no therapy. However, there are recent reports that a protracted course can lead to disability and/or social isolation (11). The signs and symptoms of chorea generally do not respond well to anti-inflammatory agents. Neuroleptics, benzodiazepines and anti- epileptics are indicated, in combination with supportive measures such as rest in a quiet room. Haloperidol, diazepam, carbamazepine have all been reported to be effective in the treatment of chorea (12– 14). There is no convincing evidence in the literature that steroids are beneficial for the therapy of the chorea associated with rheumatic fever. Pulse therapy (high dose of venous methylprednisolone) in children with rheumatic carditis. Surgery for rheumatic heart disease Surgery is usually performed for chronic rheumatic valve disease. In general terms, the necessity for surgical treatment is determined by the severity of the patient’s symptoms and/or evidence that cardiac function is sig- nificantly impaired.

The fever may subside suddenly (decline by crisis or gradually (decline by lysis) Crisis: Crisis is sudden return to normal temperature from a very high temperature within a few hours of days True crisis: The temperature falls suddenly within few hours and touches normal cheap sevelamer 400mg visa, accompanied by a marked improvement in the patents condition Subnormal temperature: When the body temperature falls below normal it is called subnormal temperature buy sevelamer us. It may be danger signal and not a sign of improvement Lysis: The temperature falls in a zig­zag manner for two of three days of a week before reaching normal during which time purchase sevelamer without prescription, the other symptoms also gradually disappear Constant fever or Continuous fever; Constant fever or Continuous fever is one in which the temperature varies not more then two degrees between morning and evening and it does nor reach normal for a period of days of weeks Remittent fever: Remittent fever is a fever characterized by variations of more than two degrees between morning and evening but does not reach normal level Intermittent or quotidian fever: The temperature is raises from normal or subnormal to high fever and back at regular intervals. Usually the temperature is higher in the evening than the morning Inverse fever: In this type the highest range of temperature is recorded in the morning hours and the lowest in the evening which is contrary to that found in the normal course of fever Hectic fever: When the difference between the high and low point is very great, the fever is called hectic or swinging fever. Relapsing fever: Relapsing fever is one in which there are brief febrile period followed by one or more days of normal temperature Irregular fever: When the fever is entirely irregular in its course, it cannot be classified under any one of the fevers described above and it is called irregular fever Rigor: Rigor is sudden severe attack of shivering in which the body temperature rises rapidly to a stage of hyperpyrexia as seen in malaria Low pyrexia: In low pyrexia the fever does not rise above 99 to 100°F or 37. The temperature is to be checked every 4 hours of even more frequently for those who are actually ill, who are having high fever, and post operative patients. It may vary with the nature of the diseases Respiratory system: Shallow and rapid breathing Circulatory system; Increased pulse rate and palpitation Alimentary system: Dry mouth, coated tongue, loss of appetite, nausea, vomiting, constipation, or diarrhea Urinary system: Diminished urinary output, burning micturition, high colored urine Nervous system: Headache, reslessness, irritability, insomnia, convulsions, delirium Musculo­skeletal system: Heavy sweating, hot flushes, goose flush, shivering or rigors. Integumentry system: Heavy sweating, hot flushes, goose flush, shivering or rigors Fever is not a disease but it is a sign. Fever if not too high hastens the destruction of bacteria by increasing phagocytes, and by producing immune bodies. A temperature of 104 to 105°F for several hours will destroy the organisms of syphilis and gonorrhoea. The range in the body temperature within which the cells can function efficiently is between 34 to 41°C (94 to 106°F). Irreversible changes may occur in the nervous system if the body temperature goes above 41°C or below 34°C Care in Fevers 1) Regulation of the body temperature : Care of the patients in fevers focuses on reducing the elevated body temperature. When the patients temperature is moderately elevated, various methods of reducing the temperature be started. Administration of cool drinks 2) Application of cold compress and ice bags 3) Cold sponging and cold packs 4) Cold bath 5) Ice cold lavages and enemas 6) Use of hypothermic blankets of mattresses When surface cooling is used treatment is directed at not only cooling the body but also prevent­ ing shivering. Shivering must be prevented because it increases metabolic activity, produces heat, in­ creases the oxygen usage markedly, increases circulation, may cause hyperventilation and respiratory alkalosis. It takes longer time to reduce body temperature in a shivering patient 2) Meeting the nutritional need: The cellular metabolism is greatly increased during fever. The oxygen consumption in the body tissues approximately 13 percent for each centigrade degree of rise in 114 temperature of 7 percent for each Fahrenheit degree, Therefore a high caloric diet is indicated in fevers. Unless it is contraindicated, the fluid intake is increased to 3000ml in 24 hours to prevent dehy­ dration and to eliminate the waste products Care in rigor: Rigor is characterized by three stages: 1) The first stage or cold stages: the patient shivers uncontrollably. The temperature may continue to rise During the second stage, remove all the blankets and hot appliances. Pulse is rhythmic fluctuation of fluid pressure against the arterial wall created by the pumping action of the heart muscle by placing fingers over an artery particularly at the location where it cross the bond Sites for checking pulse: 1) Temporal artery 2) Carotid artery 3) Brachial artery 4) Radial artery 5) Femoral artery 6) Popliteal artery 7) Dorsalis pedis 8) Posterior tibial artery Apical pulse Auscultated in adult Apical pulse is palpated to count pulse rate in infants Characteristics of pulse 1) Rate: It is number of pulse beats in a minute. Normal rate in adult is 80 to 100 per minute 2) Rhythm: It refers to regularity of the beats, beats are spaced at regular intervals they are said to be regular. Interval varies between the beats it is called irregular 115 3) Strength: The strength/ amplitude of a pulse reflects the volume of blood ejected against the arterial wall 4) Volume: It refers to the fullness of the artery it is the force of the blood felt at each beat 5) Tension: It is the degree of compressibility 6) Equality: It refers to assess both radial pulses and compare the characteristics of both 7) Principles: Exercise, emotion and anxiety will cause increased pulse rate, finger tips sensitive to touch will fell the pulsation. Moderate pressure allow one to feel superficial radical artery characteristics of the pulse vary with individuals Factors involved in pulse 1) Age: The heart rhythm in infants and children often varies markedly with respiration 2) Autonomic nervous system: Stimulation of the pare sympathetic nervous system results in decreas­ ing in the pulse rate. If more than this quantity of air passes out in and out of the lungs the respiration is said to be deep Rhythm: In normal respiration rhythm is normal Various sites of respiration 1) Chest 2) Abdomen Factors involved in respiration: 1) Age: Normal growth from infancy to adulthood results in a larger lung capacity as lung capacity increases the respiratory rate decreases. Medications narcotic decreases respiratory rate and depth 2) Stress: Stress increases the rate and depth of respiration 3) Exercise: It increases rate and depth of the air decreases to meet the body’s need for additional oxygen 4) Altitude: The oxygen content of the air decreases as the altitude increases 5) Gender: Men normally have larger lung capacity than woman 6) Body position;A straight erect position promotes full chest expansion. When the ventricles are contraction the pressure is at its highest this is known as the ‘Systolic Pressure’ ‘Diastolic Pressure’ is when the ventricles are relaxing and the blood pressure is at its lowest Hypertension: when the systolic pressure is above the normal level Hypotension: when the systolic pressure is below the normal range Purposes: (1) To acquire a base line. Characteristics of pain : 1) Severity :Ranges from no pain to excruciating pain 2) Timing :duration and onset of pain 3) Location: body area involved. Factors increasing and decreasing pain: age, gender, activity, rest, sleep, diet, culture, home rem­ edies, drugs, alcohol, diversional activities like listening to music, watching T. Pain Assessment: Pain intensity scale 117 Simple Descriptive Pain Intensity Scale No pain Mild pain Moderate Severe Very Worst pain pain Severe pain 0­10 Numeric Pain Intensity Scale 0 1 2 3 4 5 6 7 8 9 10 Visual Analog Scale No pain pain as bad as it could be possible or unbarrable pain Faces Pain Scale­ Revised: This instrument has 6 faces depicting expressions that range from con­ tented to obvious distress. The patient is asked to point to the face that most closely resembles the intensity of his or her pain. Bleeding from the kidneys or ureters causes urine to become dark red, bleeding from the bladder or urethra causes bright red urine. Urine that stands several, minutes in a container becomes cloudy renal disease many appear cloudy or foamy because of high protein concen­ trations. The stronger the odour 118 Characteristics of Normal Urine: 1) Volume: One to two litres in 24 hours but varies 2) Color: Yellow or amber but varies. The type of test deter­ mines the method of collection Specimen collection: The nurse collects random. Urinalysis: The laboratory performs a urinalysis on a specimen obtained by any of the previously described methods. Specific gravity: The specific gravity is the weight or degree of concentration of a substance com­ pared with an equal volume of water Urine culture: A urine culture requires a sterile or clean voided sample of urine. Urine test Purposes of Sugar test: Testing the urine for the persons and the amount of sugar provides the doctors with information about the amount of insulin needed by the patient. Purpose of Acetone test: Acetone is an abnormal finding that indicates that the body has begun to break down stored fats to use for energy, since it is not able to use the sugar. Purpose of Albumin test: High albumin excretion is a prognostic of renal failure and complications such as myocardial infarction. Albuminuria is presently the most reliable early indicator of adverse renal and cardiovascular events in diabetic patients. The most accurate method is to obtain a double voided urine specimen in which the first voided is set aside and the patient is asked to void a short time later. This second voiding consists of the most recently produced urine from the kidney and is the best indicator of the amount of sugar being excreted at that moment not of urine that may have been in the bladder for hours. If the patient has a Foley’s catheter the urine specimen should be taken from the tubing, which contains the latest formed urine not from the drainage bag. Preparation of articles Correct collection and preparation of urinary specimens for diagnostic testing contributes to ac­ curate test results. Bedside tests for urine glucose and acetone must be done precisely according to the direction to obtain accurate results. Timing of the reading is crucial and the result may be incorrect if the reading is taken too early or too late. Patient family teaching : 1) Encourage reporting for routine urinalysis and follow up examination 2) Advice avoidance of any medicine unless specifically prescribed 3) Teach the patient and family the importance of fluid intake 4) Teach the patient and family how to perform the test Patient condition: Presence of sugar in the urine about 140 ­ 180 mgm/ 100 ml of blood is glycosuria Presence of ketone in the urine is ketonuria. 0 For example, the stool will be almost black if the person eats red meat & dark green vegetables, such as spinach. The absence of bile may cause the stool to appear whiter or clay­coloured Certain drugs influence the colour of the stool.

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