By R. Hamil. Sacred Heart University.

As coagulopathy progresses 400mg albenza, patients bleed from multiple sites cheap 400 mg albenza with visa, clotting at bleeding sites taking progressively longer buy generic albenza 400mg on line. Skin symptoms are easily visible; subdermal haemorrhages cause purpura generic albenza 400 mg online, the skin may appear cyanotic quality 400mg albenza, mottled or cool, and in latter stages gangrene may develop. Bleeding may occur from traumatic endotracheal suction, further complicating respiratory function. The gastrointestinal tract is especially susceptible to haemorrhage, and so gastric drainage/aspirate and stools should be assessed for blood (including occult and melaena). Intensive care nursing 308 If patients are not being fed enterally, stomach decompression (free nasogastric drainage) reduces stomach stretch and acid accumulation, thus helping to prevent haemorrhage. Early beliefs that heparin would release clotting factors from microthrombi for normal homeostasis proved unfounded. Since hypovolaemia is a common complication, fluid replacement with whole blood and plasma substitutes is likely (see Chapter 33). Symptoms typically include purpura, neurological deficits, multifocal neuropsychiatrie disturbances and renal failure. Heparin stimulates heparin-dependent anti-platelet antibodies, causing intravascular platelet aggregation, thrombocytopenia and arterial and venous stenosis (Cavanagh & Colvin 1997). Many nursing interventions may provoke haemorrhage: ■ endotracheal suction ■ turning ■ cuff blood pressure measurement ■ rectal temperature ■ enemas ■ rectal/vaginal examinations ■ plasters and tape ■ shaving ■ mouthcare Some interventions may be necessary, although alternative approaches should be considered. For example, wet shaves are likely to cause bleeding; electric shavers may be safely used (staff may need to ask families to bring electric razors in, as electric shavers are usually unavailable in hospitals for infection control reasons). Invasive cannulae and procedures should be minimised to reduce risks of haemorrhage. The sight of blood can cause many people great distress, often out of all proportion to the amount of volume lost. The loss of 5 ml of blood is physiologically unimportant, but Intensive care nursing 310 can cause a large enough stain on bedding to create distress, and possible fainting. Visitors should be warned about the possible sight of blood, escorted to the bedside, and observed until staff are satisfied about their safety. Relatives experiencing stress may transmit their fears to patients; apart from humanitarian reasons for reducing stress, it may increases fibrinolytic activity (Thelan et al. Early treatments with anticoagulants have been largely superseded by more conservative (temporary) approaches of replacing clotting factors and treating symptoms to buy time while the underlying pathology is treated. Nursing care should focus on avoiding complications of trauma, while minimising anxiety to both patients and relatives. Of journal articles, Kesteven & Saunders (1993) and Rutherford (1996) give useful overviews. Kelly’s haematological investigations included: Kelly’s results Normal Prothrombin time 22 sec 1–15 sec Partial thromboplastin time 60secs 39–48 sec Thrombin time 15 sec 10–13 sec Fibrinogen levels 0. With reference to physiology, explain why Kelly developed coagulation disorder from hyperthermia and hypermetabolic state. Outline the rationale for this treatment and the nursing approaches which can maximise their therapeutic benefits (e. Reflect on how such a discussion should be managed, appraise the feasibility of organ donation (e. When patients with pre-existing chronic renal failure are admitted, renal management usually continues previous care (e. Distinctions between acute and chronic renal failure are arbitrary (often 100 days), but imply differences between potentially recoverable and incurable conditions. Acute renal failure is therefore potentially reversible; treatment aims to replace renal function while optimising recovery of renal tissue. Acute renal failure can be classified as: ■ prerenal ■ intrarenal (intrinsic) ■ postrenal In this chapter, some treatments for renal failure are discussed, while haemofiltration is covered in Chapter 35. This chapter also describes some renal hormones (renin, atrial natriuretic factor and insulin-like growth factor) and rhabdomylolysis. Renal failure is failure of the kidneys to perform normal metabolic functions (see Table 32.

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The most convenient route of drug administration is usually by mouth cheap 400mg albenza with amex, and absorption processes in the gastro-intestinal tract are among the best understood buy cheap albenza 400 mg. Unless administered intravenously trusted 400mg albenza, most drugs are in gut wall absorbed incompletely (Figure 4 cheap 400 mg albenza. However cheap 400 mg albenza with visa, differences in bioavailability did account for an epi- Bioavailability of a drug formulation can be measured experi- demic of phenytoin intoxication in Australia in 1968–69. Restoring the original manufactur- ing conditions restored potency but led to some confusion, with Many factors in the manufacture of the drug formulation influ- both toxicity and underdosing. Pharmaceutical factors are therefore important should be by generic name or by proprietary (brand) name. This is determined by the lipid solubility of Time→ the drug and the area of membrane available for Figure 4. Sometimes polar drugs can be absorbed via specific transport processes (carriers). It is usually available only from the company liver, which can extract drug from the portal blood that introduced it until the patent expires. After this, other com- before it reaches the systemic circulation via the hepatic vein. This is called presystemic (or ‘first-pass’) panies can manufacture and market the product, sometimes metabolism. At this time, pharmacists usually shop • ‘Bioavailability’ describes the completeness of around for the best buy. If a hospital doctor prescribes by propri- absorption into the systemic circulation. The amount of etary name, the same drug produced by another company may drug absorbed is determined by measuring the plasma be substituted. The for- bioavailability implies that no drug enters the systemic mulation of a drug (i. This is a particular concern with slow-release or drugs and different pharmaceutical formulations of the sustained-release preparations, or preparations to be adminis- same drug, but also from one individual to another, tered by different routes. Drug regulatory bodies have strict cri- depending on factors such as dose, whether the dose teria to assess whether such products can be licensed without is taken on an empty stomach, and the presence of gastro-intestinal disease, or other drugs. The rate at which a drug enters the body determines for another may give rise to clinical problems unless the the onset of its pharmacological action, and also influences the preparations are ‘bioequivalent’. Regulatory authorities intensity and sometimes the duration of its action, and is therefore require evidence of bioequivalence before important in addition to the completeness of absorption. They provide an approach to improving (brand named or generic) are sufficiently similar for their sub- absorption and distribution. If evidence is presented that a new One approach to improving absorption or distribution to a rel- generic product can be treated as therapeutically equivalent to atively inaccessible tissue (e. This does not imply that all possible pharmacokinetic absorbed and from which active drug is liberated after absorp- parameters are identical between the two products, but that tion. There are two main mechanisms of Oral drug administration may be used to produce local effects drug absorption by the gut (Figure 4. Non-polar lipid-soluble dependent acrylic coat that degrades at alkaline pH as in the agents are well absorbed from the gut, mainly from the small intestine, because of the enormous absorptive surface area provided by villi and microvilli. Naturally occurring polar substances, including sugars, amino acids and vitamins, are Relatively well- Relatively poorly absorbed and/or absorbed and/or absorbed by active or facilitated transport mechanisms. Drugs good tissue poor tissue that are analogues of such molecules compete with them for penetration penetration transport via the carrier. The following advantages have been claimed for the rec- tal route of administration of systemically active drugs: Prolonged action and sustained-release preparations 1. Exposure to the acidity of the gastric juice and to digestive Some drugs with short elimination half-lives need to be adminis- enzymes is avoided. The portal circulation is partly bypassed, reducing ence to the prescribed regimen difficult for the patient. The aim of such Rectal diazepam is useful for controlling status epilepticus in sustained-release preparations is to release a steady ‘infusion’ of children.

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Pain • Morphine is effective in the relief of acute left ventricular relief by acupuncture may also be mediated by encephalin failure order albenza 400 mg with mastercard, via dilatation of the pulmonary vasculature and release buy albenza 400 mg online, because it is antagonized by naloxone purchase albenza 400 mg on-line. Narcotic analgesics exert their effects by binding to opioid • Morphine inhibits cough albenza 400mg, but codeine is preferred for this receptors buy 400mg albenza mastercard. In addition to their involvement in brain function, the opioid Mechanism of action peptides play a neuroendocrine role. Administration in humans Morphine relieves both the perception of pain and the emo- suppresses the pituitary–gonadal and pituitary–adrenal axis tional response to it. High concentrations of Adverse effects opioid peptides are also present in sympathetic ganglia and Certain patients are particularly sensitive to the pharmacolog- the adrenal medulla. These include the very young, the elucidated, but they may play an inhibitory role in the sympa- elderly and those with chronic lung disease, untreated thetic system. Morphine depresses the sensitivity the sensitivity of the receptors decreases, necessitating an of the respiratory centre to carbon dioxide, thus causing a pro- increased dose to produce the same effect (‘tolerance’). Patients with decreased withdrawal of the drug, endogenous opioids are not sufficient respiratory reserve due to asthma, bronchitis, emphysema or to stimulate the insensitive receptors, resulting in a withdrawal hypoxaemia of any cause are more sensitive to the respiratory state characterized by autonomic disturbances, e. Bronchoconstriction occurs via sweating and piloerection (‘cold turkey’) and abdominal pain. Morphine causes vomiting in 20–30% of patients by stimulation of the chemoreceptor trig- Use ger zone. Dopamine receptors are important and opioid- • The most important use of morphine is for pain relief. The induced emesis is responsive to dopamine-receptor antagonists effective dose is highly variable. Morphine increases smooth muscle requirements (if known) should be taken into account tone throughout the gastro-intestinal tract, which is combined when selecting a dose. The result is constipation with hard • Morphine may be given as an intravenous bolus if rapid dry stool. In • Morphine is effective orally, although larger doses are common with most other opioids it causes pupillary constric- needed due to presystemic metabolism. This provides a useful diagnostic sign in narcotic over- given by mouth initially every four hours, giving dosage or chronic abuse. Patients with prostatic hypertrophy additional doses as needed between the regular doses as a may suffer acute retention of urine, as morphine increases the ‘top-up’, the daily dose being reviewed and titrated. Morphine is metabolized by • Spinal (epidural or intrathecal) administration of combination with glucuronic acid and also by N-dealkylation morphine is effective at much lower doses than when and oxidation, about 10% being excreted in the urine as mor- given by other routes and causes fewer systemic side phine and 60–70% as a mixture of glucuronides. It is useful in those few patients with opioid- occurs in the liver and gut wall, with extensive presystemic responsive pain who experience intolerable side effects metabolism. The dose–plasma concentration relationships for when morphine is administered by other routes. There is an advantage in using properties and contributes substantially to the analgesic diamorphine rather than morphine for this purpose, since action of morphine. Only low concentrations of this active its greater solubility permits smaller volumes of more metabolite appear in the blood after a single oral dose. Morphine-6-glucuronide is eliminated in the respiratory depression of the neonate. This is exacerbated by urine, so patients with renal impairment may experience severe the prolonged elimination t1/2 in neonates of about 22 hours. The birth of opiate- dependent babies born to addicted mothers demonstrates the Drug interactions ability of morphine and its glucuronide to cross the placenta. They are more potent but shorter-acting and are used to treat severe pain or as an Use adjunct to anaesthesia. They can be given those of morphine, although it is more potent as an analgesic intrathecally and via patient-controlled devices. The more rapid central effect of intravenous Use diamorphine than of morphine (the faster ‘buzz’), due to rapid Tramadol is widely used for moderate to severe pain, includ- penetration of the blood–brain barrier, makes this plausible (see ing post-operative pain. Diamorphine is used for the same purposes as mor- by intramuscular or intravenous injection phine. It is more soluble than morphine, and this may be rele- vant to limit injection volume (e. Pharmacokinetics Adverse effects Diamorphine is hydrolysed (deacetylated) rapidly to form 6-acetylmorphine and morphine, and if given by mouth owes These differ from pure opioid agonists, including less respira- its effect entirely to morphine. This abdominal pain, hypotension, psychiatric reactions, as well as accounts for its rapid effect when administered intravenously seizures and withdrawal syndromes have been reported.

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