Nursing

Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life.

Nurses may be differentiated from other health care providers by their approach to patient care, training, and scope of practice. Nurses practice in a wide diversity of practice areas with a different scope of practice and level of prescriber authority in each. Many nurses provide care within the ordering scope of physicians, and this traditional role has come to shape the historic public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.

The American Nurses Association (ANA) states nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations

Homonymous hemianopsia : Online Medical Help

Homonymous hemianopsia

Hemianopsia or hemianopia is visual field loss on the left or right side of the vertical midline. It can affect one eye but usually affects both eyes. Homonymous hemianopsia, or homonymous hemianopia, is hemianopic visual field loss on the same side of both eyes. Hemianopias occur because the right half of the brain has visual pathways for the left hemifield of both eyes, and the left half of the brain has visual pathways for the right hemifield of both eyes. When one of these pathways is damaged, the corresponding visual field is lost.

INTUBATION And VENTILATION : Online Medical Help

INTUBATION  And VENTILATION

Preparation...

Intubation - Elective or Emergency

Elective: for patients undergoing GA

Emergency indications

Rapid Sequence Induction

The Essentials...

Monitoring - SPO2, BP, PR, ECG (Cardiac monitor)

Glove, Mask

Oxygen Source

Ambu-bag with mask/GA Machine/Endotracheal Tube/Laryngoscope/Different blade size (Mac 3-4 adult/Mac 2 for paediatrics). McCoy blade/Bougie if anticipated difficult airway/Glidescope

Drugs: Resuscitation, Opioid, Induction agent, Relaxants

make sure...

Oxygen source: wall, tank, GA Machine

Suction: Yaunker and suction tube, suction apparatus functioning

Airways: oropharyngeal airway or nasopharyngeal airway

Laryngoscope with functioning light bulb

Endotracheal tube of approriate sizes(7.5/8 for male, 7-7.5for female, 6.5-7 for gravid women/ Age/4 +4 for children with one size smaller and bigger as standby)

Lubricating jelly, Syringe 10-20mls

Good assistants

Tip and Tricks

Securing ETT

plaster - trouser like

string tie

Reason-risk of dislodgement

Male-20-23cm

Female-18-21cm

Paediatric-Age/2+12

Airway Physical Exam

Assessment of possibility of difficult airway;

Obesity

Short Neck

Large tongue

Loose teeth/Buck teeth

Poor mouth opening-<2FB

Limited neck movement

Beard

Receding chin/Small chin

The 4Ds of Difficult Intubation

Distortion: laryngeal oedema, blood, vomitus, tumour mass, abscess

Dysmobility of joints: TMJ, atlanto occipital, suspected cervical trauma on hard collar

Disproportion: thyromental distance <6cm, Mallampati scoring

Dentition: buck teeth

Mallampati Classes

Class 1: Faucillar pillars, soft palate, uvula

Class 2: Faucillar pillars, soft palate

Class 3: Soft palate

Class 4: Soft palate not seen

Positioning during intubation

Positioning...

Cricoid Pressure

How to perform intubation

Endotracheal Suctioning...

Importance

The proper method

Type of endotracheal suctioning - Open, Closed

Setting Ventilator... the basic

Contents

History

Basic Physiology

Pressure Control

Volume Control

Ventilators...

History...

“ … an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put; you will then blow into this, so that the lung may rise again … and the heart becomes strong…”

                                                 Andreas Vesalius (1555)

First description of positive pressure ventilation.

Took 400 years to apply on patient care.

Respiratory System...

a balloon connected to a tube

balloon = elastic element                  (lungs and chest wall)

tube = the resistive element (conducting airways)

Ventilation Simplified

Respiratory Pump = Mechanical Ventilator

Generate sufficient pressure to overcome both the resistance and compliance of the lung to allow gas exchange between the environment and the pulmonary capillary bed

Indications for Mechanical Ventilation

inadequate ventilation to maintain pH(raised CO2)

inadequate oxygenation

excessive breathing workload

congestive failure

circulatory shock

Goals of Mechanical Ventilation

Maintain appropriate levels of partial pressure of O2 and CO2 in arterial blood

Unload/reduce the workload of the ventilatory muscles

Protect the lung from overdistention and recruitment-derecruitment injury

Main Determinants

Mean Airway Pressure

refers to the mean pressure across the entire respiratory cycle, both inspiration and expiration

The most obvious method of increasing the pressure is to increase the tidal volume, this also will increase the PEAK and PLATEAU airway pressure. High risk of ventilator induced lung injury

Prolonging the Inspiratory Time increase the mean pressure

Inspiratory Time

Set as

% of respiratory cycle

I:E ratio

Expiratory time not set

remaining time after inspiration before next breathing

Increased inspiratory time

improved oxygenation

unnatural

increase risk of gas trapping

PEEP

-Increasing the FRC

-Re-inflating atelectatic lung areas and recruitment of collapsed alveoli

-Optimizing the V/Q ratio

-Reducing the right-left shunt

-Avoiding end expiratory alveolar collapse

Standard Parameter

Following settings are for all patients admitted into ICU for mechanical ventilation unless stated otherwise by doctor in charge of ICU

Mode: SIMV (Volume) or SIMV (Pressure 10-20)

Rate: 8-12 breaths/min

Tidal Volume(amount of air delivered for each breath: 6-10mls/kg

PBW Males= 50 + 2.3 [height (inches) - 60]

Females= 45.5 + 2.3 [height (inches) -60]

Start with fiO2 1.0 and titrate down with serial ABGs

Oxygen toxicity (eg. pulmonary fibrosis) does not usually occur if a FiO₂ of 1.0 is used for < 24 hours.

 The goal is to keep PaO₂ within 83-100 mmHg or SaO₂ within > 92% (try to avoid FiO₂ > 60%)

FiO₂ requirement can further be reduced by adding PEEP (positive end-expiratory pressure)

PEEP                                 :           5 - 20 cmH₂O.

 As a result, FiO2 can be kept at a minimum to avoid oxygen toxicity.

 In some situations higher levels of PEEP may be required but unless indicated levels of 5cmH2O is deem adequate.

FiO₂/PEEP Combination

Pressure Support

10cmH₂0

Helps decrease patient's work of breathing.

 A level of 10cmH₂O is deem necessary to overcome the ventilator circuit resistance (e.g. the demand valves that are triggered open with each breath, and the resistance of breathing through the small diameter of the endotracheal tube).

 Adequacy of pressure support (PS) can actually be gauge by increasing PS by 1 - 2 cmH₂O while assessing patient comfort and  RR < 30 or normal TV (500mL) is achieved.

Keep PS < 35 to avoid barotrauma and hemodynamic compromise secondary to a decrease in cardiac output.

Inspiratory:Expiratory

During spontaneous breathing, the normal I:E ratio is 1:2, indicating that for normal patients the exhalation time is about twice as long as inhalation time.

If exhalation time is too short “breath stacking” occurs resulting in an increase in end-expiratory pressure also called auto-PEEP.

Depending on the disease process, such as in ARDS, the I:E ratio can be changed to improve ventilation

Sensitivity - Trigger

When pressure triggering is used, a ventilator-delivered breath is initiated if the demand valve senses a negative airway pressure deflection (generated by the patient trying to initiate a breath) greater than the trigger sensitivity.

When flow-by triggering is used, a continuous flow of gas through the ventilator circuit is monitored. A ventilator-delivered breath is initiated when the return flow is less than the delivered flow, a consequence of the patient's effort to initiate a breath

Peak Flow Rate: 50 LPM, max flow delivered by ventilator during inspiration

Alarm Parameters: +/- 20% set parameters

Humidification: Activate

Ideal Breath Types of Mechanical Ventilation

synchronize with patient’s spontaneous breathing effort

maintain adequate & consistent VT & VE at low airway pressure

responds to rapid changes of pulmonary mechanics or patient’s demand

provide lowest possible work of breathing

Basic Classification:

Control:

Volume Controlled: Volume limited, volume targeted and pressure variable

Pressure Controlled: Pressure limited, pressure targeted and volume variable

Volume Control: Adv

Constant flow rate

Guaranteed tidal volume delivered

Variable peak pressure is dependent on the compliance of the lung

Less atelectasis

Precise control of PaCO2

Volume Control: Disadv

Pressure variable & difficult to control

Resultant high peak pressure: barotrauma, volutrauma, acute lung injury

Uneven distribution of ventilation

Increased muscle workload

Flow rate may not match demand

Pressure Control: Adv

Constant inspiratory pressure

Decelerating variable inspiratory flow rate-improved gas exchange

Improves gas distribution & reduce work of breathing

Better tolerance, less sedation needed

More homogenous ventilation

Reduction of peak pressure and risk of barotraumas

Pressure Control: Disadv

Variable tidal volume sec to changes in lung compliance & resistance-hypoventilation

Potentially excessive tidal volume as compliance improves

SIMV ( Synchronized Intermittent Mandatory Ventilation )

Mandatory breaths are delivered at set rate with VC or PC in synchrony with patient’s inspiratory effort

If no inspiratory effort detected, the ventilator delivers a mandatory breath at the scheduled time.

Between mandatory breath, patient is allowed to breath spontaneously.

Spontaneous breaths – pressure support

CPAP ( Continuous Positive Airway Pressure )

Spontaneous breathing mode: no mandatory breath delivered

Most commonly used mode to evaluate extubation readiness

Trouble Shooting

Patient

Machine

9 Spices for Super Health : Online Medical Help

There is no doubt that spices enhance the flavor and aroma of the food, but there are several that can also contribute to the overall health of our body. Some accelerate metabolism, others reduce cholesterol levels, and still others manage stress, as well as being powerful antioxidants with natural healing ability. Here then the seven major beneficial properties:


GINGER

If your muscles are sore after a hard workout at the gym, you may want to add a little ginger fresh or ground in food. A search of the University of Georgia has shown that daily consumption of ginger face decline of 25% muscle pain from exercise during the day. It is a spice -inflammatory that also helps against stomach ache and the common cold. Eating quotidiamente the ginger bread also soothes the pain caused by arthritis.

CINNAMON

This spice contains fiber, calcium, iron and manganese, reduces bad cholesterol and helps help maintain balance in the levels of sugar in the blood. It is said to work miracles for mood swings, reducing anxiety and stress . It also improves memory and attention.

TURMERIC

Used in Indian dishes, is known as detoxifying the liver and anti-inflammatory. It is a natural antibacterial agent, used to disinfect cuts and burns but it is also a powerful antioxidant and can slow the progression of Alzheimer's disease.

OREGANO

Dr. Bazilian considers oregano a mini salad because "one teaspoon has as much antioxidant power as three cups of chopped broccoli (but don't ditch the broccoli – have both!)." Oregano is among the highest in antioxidants of the dried herbs.

SAFFRON

Helps fight depression and is beneficial for the eyes . An Australian research has shown that saffron may help women with menstrual cramps.

CUMIN

A teaspoon of ground cumin provides a 4 milligrams of iron , contributing to the prevention of anemia. Cumin improves digestion and sleep and its antiseptic properties, in combination with vitamin C and iron, they help to strengthen the system immune . Rich in vitamin E, it tends to keep the skin healthy.

CAYENNE PEPPER 

Give energy and speeds up the metabolism, making a valuable contribution in weight loss. The cayenne pepper boosts the immune system and two teaspoons provide 47 percent of the daily value of vitamin A . So the next time you have a stuffy nose, we assume the cayenne pepper that will relieve nasal congestion .

CLOVE

For a long time the cloves are used to fight infections, colds and bacteria, as well as to relieve cough and help heal the toothache . This spice is also used to soothe sore throats and asthma but also helps prevent gas and bloating.

ROSEMARY

Rich source of antioxidants and anti-inflammatory compounds- these are thought to help boost the immune system and improve blood circulation. Laboratory studies have shown rosemary to be rich in antioxidants, which play an important role in neutralizing harmful particles called free radicals. Rosemary is a good source of iron, calcium, and vitamin B6. It is typically prepared as a dried whole herb or a dried powdered extract, while teas and liquid extracts are made from fresh or dried leaves.

What other spices that are good for health? let's share ...

Benefits of Roselle : Online Medical Help

The roselle (Hibiscus sabdariffa) is a species of Hibiscus native to the Old World tropics, used for the production of bast fibre and as an infusion. It is an annual or perennial herb or woody-based subshrub, growing to 2–2.5 m (7–8 ft) tall. The leaves are deeply three- to five-lobed, 8–15 cm (3–6 in) long, arranged alternately on the stems.

The flowers are 8–10 cm (3–4 in) in diameter, white to pale yellow with a dark red spot at the base of each petal, and have a stout fleshy calyx at the base, 1–2 cm (0.39–0.79 in) wide, enlarging to 3–3.5 cm (1.2–1.4 in), fleshy and bright red as the fruit matures. It takes about six months to mature. 

The scientists from University Kebangsaan Malaysia (UKM) found certain varieties of roselle to contain high levels of organic acid called hydroxycitric acid (HCA) which is currently used in some weight loss products and supplements. This finding has added further value to the fruit which is already known to be rich in both vitamin C and anthocyanins (potent antioxidants).

Although the potential of HCA as a weight lowering compound has been recognised since 1970s, few clinical studies have been conducted with this compound. These few studies resulted in both positive and negative results, the negative ones are most likely due to HCA being poorly available in the cytosol of a target cell. Better HCA compounds, such as potassium HCA, are being developed to address this, i.e. to further improve the bioavailablity and the efficacy of HCA.

In any case roselle is already known as a health drink due to its high contents of vitamin C and anthocyanins (antioxidants). Vitamin C and anthocyanins found in roselle juice or tea drink are good for our health and can increase the level of resistance of our body to diseases. In some countries roselle is becoming increasingly popular for health purposes, for example its leaves and fruits are claimed to be effective in controlling high blood pressure.

Roselle, or Rosella Fruit, or Binomially speaking Hibiscus Sabdariffa. This annual or perennial herb is one of the species of Hibiscus. The fruit of Roselle plant become mature in about six months and that is when it gets beautiful bright red color. While still immature, this plant can have whitish or yellowish colors with a dark reddish spot at the bottom of each petal. The stem of the Roselle plant is cultivated for the production of Bast Fiber or Skin Fiber which is then used to make burlap (Woven Fabric, Gunny Cloth, or Coarse Fabric).

Roselle plant has been and still is considered as an AntiHypertensives (used to treat hypertension or high blood pressure), Mild Laxative (used to induce bowel movements), and Diuretic (used to elevate the rate of urination to treat drug overdose or poisoning). The Red Calyces or Sepals of this plant are used by some countries for food colorings, for flowers, for syrups, for jams, or for many different kinds of drinks. And the green leaves of Roselle can be used for salads, for curry, for teas, for lotions, for wounds, and for sores.

So, the Nutrients in one cup (57 grams) of Raw Roselle Plant without any refuse are:

- Vitamin A
- Vitamin B2, Riboflavin
- Vitamin B3, Niacin
- Vitamin C
- Protein
- Calcium
- Iron
- Magnesium
- Phosphorus
- Potassium
- Sodium
- Natural Fats
- Carbohydrates
- Calories

According to these Nutrients we can come up with these Health Benefits of Roselle Plant:

Vitamin C:
- Improves wound healing
- Prevents cells from damages
- Improves gums health
- Improves teeth health
- Improves Immune System
- Protects from free radicals
- Reduces Aging
- Lowers Risks of some Cancers
- Improves Iron absorption
- Improves Lung health
- Prevents from frequent colds
- Protects from frequent infections

Calcium:
- Maintains healthy bones
- Improves nerve function
- Improves muscle function
- Supports Healthy blood clotting
- Reduces feet tingling
- Reduces hand tingling
- Lowers chance of retardation in children
- Reduces chance of bone deformities
- Reduces feet numbness
- Reduces hand numbness
- Improves teeth health 

Assessment Of Nervous Emergencies : Online Medical Help