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Generalized Anxiety Disorder This disorder is characterized by chronic buy geriforte pills in toronto gayatri herbals, unrealistic cheap 100 mg geriforte with mastercard rumi herbals chennai, and exces- sive anxiety and worry cheap 100 mg geriforte amex herbs chips. Symptoms include restlessness, feeling “on edge,” becoming easily fatigued, difficulty concentrating, and irritability. Anxiety Disorder Due to a General Medical Condition The symptoms of this disorder are judged to be the direct physi- ological consequence of a general medical condition. Medical conditions that have been known to cause anxiety disorders include endocrine, cardiovascular, respiratory, metabolic, and neurological disorders. The symptoms may occur during substance intoxication or withdrawal and may involve intense anxiety, panic attacks, phobias, or obsessions or compulsions. Biochemical: Increased levels of norepinephrine have been noted in panic and generalized anxiety disorders. Abnormal elevations of blood lactate have also been noted in clients with panic disorder. Decreased levels of serotonin have been implicated in the etiology of obsessive-compulsive disorder. Genetic: Studies suggest that anxiety disorders are preva- lent within the general population. Medical or Substance-Induced: Anxiety disorders may be caused by a variety of medical conditions or the ingestion of various substances. Psychodynamic Theory: The psychodynamic view focuses on the inability of the ego to intervene when conflict occurs between the id and the superego, producing anxiety. When developmental defects in ego func- tions compromise the capacity to modulate anxiety, the individual resorts to unconscious mechanisms to resolve the conflict. Overuse or ineffective use of ego defense mechanisms results in maladaptive responses to anxiety. Cognitive Theory: The main thesis of the cognitive view is that faulty, distorted, or counterproductive thinking patterns accompany or precede maladaptive behaviors and emotional disorders (Sadock & Sadock, 2007). When there is a disturbance in this central mechanism of cognition, there is a consequent disturbance in feeling and behavior. Because of distorted thinking, anxiety is maintained by erroneous or dysfunctional appraisal of a situation. There is a loss of ability to reason regarding the problem, wheth- er it is physical or interpersonal. The individual feels vulnerable in a given situation, and the distorted think- ing results in an irrational appraisal, fostering a negative outcome. Restlessness, feeling “on edge,” excessive worry, being easily fatigued, difficulty concentrating, irritability, and sleep dis- turbances (generalized anxiety disorder). Repetitive, obsessive thoughts, common ones being related to violence, contamination, and doubt; repetitive, compul- sive performance of purposeless activity, such as handwash- ing, counting, checking, and touching (obsessive-compulsive disorder). Marked and persistent fears of specific objects or situations (specific phobia), social or performance situations (social phobia), or being in a situation from which one has difficulty escaping (agoraphobia). Common Nursing Diagnoses and Interventions (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. It is an alerting signal that warns of impend- ing danger and enables the individual to take measures to deal with threat. Long-term Goal Client will be able to recognize symptoms of onset of anxiety and intervene before reaching panic stage by time of discharge from treatment. Presence of a trusted individual provides client with feeling of security and assurance of personal safety. Use simple words and brief messages, spoken calmly and clearly, to explain hospital experiences to client. In an intense- ly anxious situation, client is unable to comprehend anything but the most elementary communication. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor). When level of anxiety has been reduced, explore with client possible reasons for occurrence. Recognition of precipitating factor(s) is the first step in teaching client to interrupt escalation of the anxiety. Encourage client to talk about traumatic experience un- der nonthreatening conditions. Help client understand that this was an event to which most people Anxiety Disorders ● 167 would have responded in like manner. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues. Teach signs and symptoms of escalating anxiety, and ways to interrupt its progression (e. Client is able to maintain anxiety at level in which problem solving can be accomplished. Client is able to demonstrate techniques for interrupting the progression of anxiety to the panic level. Possible Etiologies (“related to”) Phobic stimulus [Being in place or situation from which escape might be difficult] [Causing embarrassment to self in front of others] Defining Characteristics (“evidenced by”) [Refuses to leave own home alone] [Refuses to eat in public] [Refuses to speak or perform in public] [Refuses to expose self to (specify phobic object or situation)] Identifies object of fear [Symptoms of apprehension or sympathetic stimulation in presence of phobic object or situation] Goals/Objectives Short-term Goal Client will discuss phobic object or situation with nurse or therapist within 5 days. Long-term Goal Client will be able to function in presence of phobic object or situation without experiencing panic anxiety by time of dis- charge from treatment. Explore client’s perception of threat to physical integrity or threat to self-concept. It is important to understand the client’s perception of the phobic object or situation in order to assist with the desensitization process. Discuss reality of the situation with client in order to rec- ognize aspects that can be changed and those that cannot. Client must accept the reality of the situation (aspects that cannot change) before the work of reducing the fear can progress. Include client in making decisions related to selection of alternative coping strategies. If the client elects to work on elimination of the fear, tech- niques of desensitization may be employed. This is a sys- tematic plan of behavior modification, designed to expose the individual gradually to the situation or object (either in reality or through fantasizing) until the fear is no longer experienced. This is also sometimes accomplished through implosion therapy, in which the individual is “flooded” with stimuli related to the phobic situation or object (rather than in gradual steps) until anxiety is no longer experienced in relation to the object or situation. Fear is decreased as the physical and psychological sensations diminish in response to repeated exposure to the phobic stimulus under non- threatening conditions. Encourage client to explore underlying feelings that may be contributing to irrational fears. Help client to understand how facing these feelings, rather than suppressing them, can result in more adaptive coping abilities. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues. Client does not experience disabling fear when exposed to phobic object or situation, or 2.

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Some deficiencies are caused by changes in the body that affect absorption of vitamins cheap 100mg geriforte mastercard herbals on demand. After administering prescribed vitamin therapy cheap geriforte vedantika herbals, the patient should be educated about the importance of eating well-balanced meals and taking vitamin supplements if necessary geriforte 100mg without a prescription krishna herbals. Minerals are inorganic substances that the body uses for blood cells, tissues, and to stimulate enzymes to cause a catabolic reaction in the body. In the next chapter, we’ll examine the balancing act of fluids and electrolytes and how they maintain equilibrium. We’ll also see how to use fluid and elec- trolyte therapies to restore the equilibrium if they become imbalanced. What vitamin protects the heart and arteries and cellular components from being oxidized? Fat-soluble vitamins are immediately excreted in urine shortly after they are absorbed. What vitamin is given to help alleviate symptoms of neuritis caused by isoniazid therapy for tuberculosis? You would be unable to move, talk, and eventually your brain would be unable to function. In order for muscles to contract, your body needs the proper balance between fluids and electrolytes inside and outside of cells. Electrolytes are salts whose positive and negative charges generate the electrical impulse to contract muscles in your body. Diseases and treatment of disease can cause fluids and electrolytes to become imbalanced and require the patient to receive medication to restore the balance. In this chapter, you’ll learn how to recognize the signs and symptoms of fluid and electrolyte imbalance and learn about therapeutic treatment that brings them back into balance. However, water is 45% to 55% of an older adult’s body weight and as much as 70% to 80% of an infant’s weight is water. Lean adults have more water than heavy adults because adipose cells (cells containing fat) contain less water than other cells. Water is the solvent that contain salts, nutri- ents, and wastes that are solutes dissolved in the water and transported by the water throughout the body. The space is occupied by plasma and lymph, transcellular fluid, and fluid in the bone and connective tis- sues. About a third is plasma and two thirds of extracellular fluid is in the space between the cells. Although fluid in the transcellular space is a small volume when compared with intracellular and extracellular compartments, the increase or decrease in volumes in transcellular spaces can have a dramatic effect on the fluid-electrolyte balance. Electrolytes An electrolyte is a substance that splits into ions when placed into water. An ion is an electrically charged particle that is either positively or negatively charged. A pos- itively charged ion is called a cation and a negatively charged ion is called an anion. Sodium (Na+), potassium (K+), calcium (Ca2+) , and Magnesium (Mg++) are • electrolytes that are cations. An electrolyte is stored either intracellularly (inside the cell) or extracellu- larly (outside the cell). Fluid Concentration Electrolytes move between compartments based on the concentration of elec- trolytes, the gradients of the concentration, and the electrical charge. For exam- ple, there is a higher concentration of sodium outside the cell than inside the cell. The heart pumps the blood, pres- sure is exerted on the vessels from outside the body, and muscles relax and con- tract to help the heart move the fluid through the vascular system. Fluid moves into and out of the cells and the extracellular spaces by osmotic pressure. This is the pressure exerted by the flow of water through a semipermeable membrane separating two solutions with different concentrations of solute. Osmotic pres- sure is determined by the concentration of the electrolytes and other solutes in water and is expressed as osmolarity or osmolality. Serum osmolality is a better indicator of the concentration of solutes in body fluids than tonicity; tonicity is primarily used as a measure- ment of the concentration of intravenous solutions. This is a fluid that has a higher concentration of particles of solute than water. The concentration of solutes is important when determining the proper replacement fluid for a patient whose fluids and electrolytes are imbalanced. Dextran 40 tends to interfere with platelet func- tion resulting in prolonged bleeding times. It is helpful for patients who are old and malnourished and for those with hypopro- teinemia resulting from other causes. Plasmanate is non-antigenic and must not be given to patients who have anemia, increased blood volume, or congestive heart failure. Blood and Blood Products Blood and blood products consist of whole blood, packed red blood cells, plasma, and albumin. Whole blood should be used to treat severe cases of anemia—not mild cases of anemia—because one unit of whole blood elevates hemoglobin by 0. Fluid Replacement The amount of water a patient requires each day depends on the patient’s age and the nature of the patient’s medical condition. Each day the patient losses: • 400 mL to 500 mL of water through evaporation from the skin. This means that each day the patient must take in between 1900 mL and 2400 mL of fluid in order to maintain fluid-electrolyte balance. However, dis- ease and the treatment of disease can increase the patient’s output of water requiring that the patient increase the intake of water. For example, a patient who has a fever loses as much as 15% more water than the normal daily water loss. That is, the patient loses between 2185 mL and 2760 mL of water each day when he or she has a fever. Potential nursing diagnoses for a patient that is receiving fluid volume replacement therapy are: • Risk for fluid volume excess. This can occur when the patient is given too much replacement fluid, fluid is infused too rapidly, or the volume is too much for the patient’s physical size or condition. The patient should be taught: • To recognize signs and symptoms of fluid volume excess and fluid volume deficit. Potassium Potassium is an electrolyte cation that is more prevalent inside cells than it is in extracellular fluid. It is used to transmit and conduct neurological impulses and to maintain cardiac rhythms. In order for a muscle to contract, the concentration of potassium inside the cell moves out and is replaced by sodium, which is the prevalent electrolyte out- side the cell (see Sodium). The concentration of potassium and sodium is maintained by the sodium-potassium pump found in cell membranes.

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Morphine can be used with children; by the age of six purchase 100mg geriforte amex jeevan herbals review, clearance and half-life have reached adult levels (Knight 1997) buy 100 mg geriforte mastercard herbs not to mix. It has few cardiovascular effects order generic geriforte herbs like viagra, but analgesia remains unpredictable (Viney 1996). Its high lipid solubility makes it useful for epidural infusions (McCaffery & Beebe 1994). Transcutaneous patches are also available, but impaired peripheral perfusion may limit absorption in the critically ill. The metabolite nor-pethidine is a highly toxic central nervous system stimulant, causing twitches, tremors, muscle jerks and fits (McCaffery & Beebe 1994). The half-life of nor- pethidine exceeds fifteen hours (McCaffery &: Beebe 1994); the antagonist for pethidine is naloxone hydrochloride. However, although naloxone eliminates pethidine, it does not eliminate nor-pethidine (McCaffery & Beebe 1994). Success is difficult to predict (Seymour 1995a), and excessive electrical stimulation may cause pain. Placebos As pain perception is influenced by psychology, chemically inactive substances may relieve pain if patients believe they will work. However, if caregivers appear sceptical, patients will probably lose trust in a placebo’s effectiveness, and because the drug is a placebo, this necessitates lying to patients (directly or by implication), which is ethically questionable. Consequentialists might justify such lies by the benefits obtained from pain Intensive care nursing 70 relief, but deontologists are less likely to consider any lie acceptable. Nurses have various roles in pain management, ranging from provision of simple comforts to administering and observing controlled drugs. In all aspects of care, holistic and humanistic approaches can reduce patient suffering. Further reading Classic books on pain management include Melzack and Wall (1988) or McCaffery and Beebe (1994); Hayward’s (1975) classic study on postoperative pain remains valuable. Although Melzack’s own work on the gate control theory is authoritative, Davis (1993) gives a clear summary. In addition to acute postoperative pain, Mr Hunt is known to suffer with chronic back pain from kyphotic scoliosis in his thoracic vertebrae. These should include patient-controlled infusions, epidural and interpleural techniques. Using the literature, your own, colleagues’ and patients’ experiences debate the most effective approach to manage Mr Hunt’s pain. Chapter 8 Pyrexia and temperature control Fundamental knowledge Sweat production and function Introduction Howie (1989) suggests that nurses treat pyrexia immediately, regardless of causes or severity. Pyrexia (fever) is a homeostatic elevation of body temperature which may be problematic. This chapter describes benefits and problems, together with ways to monitor and treat pyrexia. The thermoregulatory centre (anterior hypothalamus) responds to central and peripheral thermoreceptors to conserve heat (vasoconstriction) and increase heat production (shivering) when cold and heat loss when hot (sweating, vasodilation). The thermoregulatory setpoint varies between individuals, but in health maintains body temperature, usually at 36–37°C). Heat damages living tissue; as most bacteria and viruses are more susceptible to heat than human cells, pyrexia can be a defence mechanism so that temperatures up to 40°C may be best untreated. The management of pyrexia should be guided by individual assessment rather than rigid protocols. Hyperpyrexia (heatstroke; above 40°C) damages human cells and so should be treated before reaching the limits of life (at about 43– 44°C). Infants are especially prone to rapid pyrexial fluctuations due to hypothalamic immaturity, higher metabolic rates and more brown fat (insulation). Since thermoregulatory impairment may cause febrile convulsions, pyrexial children should be monitored frequently. Older people may have impaired thermoregulation due to reduced metabolism; thus when feeling cold, they may appreciate additional bedding. Pyrexia and temperature control 73 Pyrexia Body temperature fluctuates during each day (circadian rhythm) and in different parts of the body so that monitoring temperature trends is more important than absolute figures; the sites chosen affect measurement (e. Analysing blood gases by different body temperatures will give different results, even though the only change may be the removal of a pulmonary artery catheter. Holtzclaw (1992) describes three stages to the febrile response: ■ chill phase: discrepancy between existing body temperature and the new hypothalamic set point; the person feels cold, shivering to increase hypermetabolism ■ plateau: temperature overshoots the new set point, triggering heat loss mechanisms; endogenous pyrogen levels also start to fall ■ diaphoresis and flushing: heat loss through evaporation, with massive reduction in endogenous pyrogen levels, which causes uneven resolution of pyrexia Fever is a symptom, not a disease; attempts to cool patients, whether by reducing bedding or through active interventions such as tepid sponging, may stimulate further hypothalamus-mediated heat production (Bartlett 1996) and so become self-defeating. Shivering increases metabolism three- to fivefold, consuming oxygen and nutrients needed for tissue repair, while increasing carbon dioxide production. Fever can be protective as it: ■ inhibits bacterial and viral growth by restricting supply of iron and zinc (needed for cell growth) (Ganong 1995); most micro-organisms cannot replicate in temperatures above 37°C (Murray et al. Mild to moderate fevers are therefore beneficial and should remain untreated (Rowsey 1997b). However, fever and hypermetabolism create physiological stress because: ■ each 1°C increases oxygen consumption by 13 per cent (Nowak & Handford 1994); more carbon dioxide is also produced; ■ increased intracranial pressure from hypermetabolism (Morgan 1990) may compound problems for patients with neurological pathologies and head injuries; ■ permanent brain damage may be caused by protein denaturation (the mechanism inhibiting bacterial growth) (Gloss 1992), although there is no evidence of neural damage from brief pyrexias of up to 42°C (Styrt & Sugarman 1990). Intensive care nursing 74 Hyperpyrexia Hyperpyrexia (also called ‘heatstroke’ and ‘severe hyperthermia’) is a temperature of 40. Incidence of hyperpyrexia is increasing, largely due to use of the recreational ‘ecstasy’ (see Chapter 41). At 42°C autoregulation fails, enzymes become dysfunctional and membrane permeability increases (causing electrolyte imbalance and further cell dysfunction—see Chapter 23). Measurement Hypothalamic temperature (site of the thermoregulatory centre) is the ideal core measurement. Pulmonary artery temperature, the closest measurable site to hypothalamic temperature (Bartlett 1996), remains the ‘gold standard’ (Fulbrook 1993), although catheter calibration is rarely checked on insertion, and impractical afterwards. Since pulmonary artery catheters are highly invasive, temperature measurement alone does not justify their use. Studies assessing accuracy of other sites frequently identify drifts of about 1°C from the pulmonary artery temperature, leaving the choice largely to personal preference. Smith’s (1998) paediatric study found significant differences between mercury-in-glass and electronic/tympanic thermometers, but since neither were compared with pulmonary artery temperature, Smith’s conclusions about the unsuitability of electronic thermometry are unfounded. Erickson and Kirklin (1993) found good correlation between tympanic and pulmonary artery measurement. Some anecdotal reports suggest inaccuracies, although Board’s (1995) small study found them to be accurate; Erickson et al. Like mercury-in-glass thermometers, chemical thermometers rely on visual interpretation and so can be subjective. Rectal temperature measurement causes emotional trauma for children (Rogers 1992) and should therefore be avoided, while with adults it is undignified and so should only be used if benefits can be justified. The proximity of the axillary artery to the skin surface should make axillary temperature similar to central temperature provided the thermometer tips maintain skin contact (hollow axillary pockets, more frequent in older people, make contact difficult). Fulbrook (1993) found axillary measurement compared favourably with pulmonary artery temperature provided thermometers were left in place for 12 minutes (Rogers (1992) cites only 5 minutes), but Fulbrook subsequently (1997) identified discrepancies of between 1. Since the tympanic membrane shares carotid artery blood supply with the hypothalamus (Klein et al.

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