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2nd Year FON - 125808
2nd Year FON - 125808
2nd Year FON - 125808
DEFIBRILLATION
Introduction
Defibrillation is a treatment for life-threatening cardiac dysrhythmias,
specifically ventricular fibrillation (VF) and non-perfusing ventricular
tachycardia (VT).
A defibrillator delivers a dose of electric current (often called a counter-
shock) to the heart. Although not fully understood, this
process depolarizes a large amount of the heart muscle, ending the
dysrhythmia. Subsequently, the body's natural pacemaker in
the sinoatrial node of the heart is able to re-establish normal sinus
rhythm.
A heart which is in asystole (flat line) cannot be restarted by a
defibrillator, but would be treated by cardiopulmonary
resuscitation (CPR).
In contrast to defibrillation, synchronized electrical cardioversion is an
electrical shock delivered in synchrony to the cardiac cycle. Although
the person may still be critically ill, cardioversion normally aims to end
poorly perfusing cardiac dysrhythmias, such as supraventricular
tachycardia.
Classifications of defibrillators
1. External
2. Internal (Trans venous) or implanted (implantable cardioverter-
defibrillator),
Indications
1. Cardiopulmonary resuscitation (CPR). This is an algorithm-based
intervention aimed to restore cardiac and pulmonary
function. Defibrillation is often an important step in CPR.
2. cardiac dysrhythmias, specifically ventricular fibrillation (VF)
3. pulseless ventricular tachycardia.
Contraindications
1. If the heart has completely stopped, as in asystole or pulseless
electrical activity (PEA), defibrillation is not indicated.
2. Defibrillation is also not indicated if the patient is conscious or has
a pulse.
N/B Improperly given electrical shocks can cause dangerous
dysrhythmias, such as ventricular fibrillation.
Prognosis
Survival rates for out-of-hospital cardiac arrests are poor, often less than
10%. Outcome for in-hospital cardiac arrests are higher at 20%. Within
the group of people presenting with cardiac arrest, the specific cardiac
rhythm can significantly impact survival rates. Compared to people
presenting with a non-shockable rhythm (such as asystole or PEA),
people with a shockable rhythm (such as VF or pulseless ventricular
tachycardia) have improved survival rates, ranging between 21-50%.
Types
1. Manual external defibrillator
Manual external defibrillators require the expertise of a healthcare
professional. They are used in conjunction with an electrocardiogram,
which can be separate or built-in. A healthcare provider first diagnoses
the cardiac rhythm and then manually determine the voltage and timing
for the electrical shock. These units are primarily found in hospitals and
on some ambulances.
2. Manual internal defibrillator
Manual internal defibrillators deliver the shock through paddles placed
directly on the heart. They are mostly used in the operating room and, in
rare circumstances, in the emergency room during an open heart
procedure.
3. Automated external defibrillator (AED)
Mechanism of action
A defibrillator delivers a dose of electric current (often called a counter-
shock) to the heart. Although not fully understood, this
process depolarizes a large amount of the heart muscle, ending the
dysrhythmia. Subsequently, the body's natural pacemaker in
the sinoatrial node of the heart is able to re-establish normal sinus
rhythm.
This shock attempts to stop the disorganized electrical activity and allow
the heart’s normal rhythm to resume. They are used to prevent or correct
an arrhythmia, a heartbeat that is uneven or that is too slow or too fast.
Defibrillators can also restore the heart’s beating if the heart suddenly
stops.
Cardiac Dysrhythmias
A. Normal sinus rhythm
B. Sinus bradycardia
a. Atrial and ventricular rhythms are regular.
b. Atrial and ventricular rates are less than 60 beats/minute.
c. PR interval and QRS width are within normal limits.
d. Treatment may be necessary if the client is symptomatic (signs of
decreased cardiac output).
e. Note that a low heart rate may be normal for some individuals, such as
in athletes.
Interventions
a. Attempt to determine the cause of sinus bradycardia; if a medication is
suspected of causing the bradycardia, withhold the medication and
notify the HCP.
b. Administer oxygen as prescribed for symptomatic client.
c. Administer atropine sulfate as prescribed to increase the heart rate to
60 beats/minute.
d. Be prepared to apply a noninvasive (transcutaneous) pacemaker
initially if the atropine sulfate does not increase the heart rate
sufficiently.
Avoid additional doses of atropine sulfate because this will induce
tachycardia.
f. Monitor for hypotension and administer fluids intravenously as
prescribed.
g. Depending on the cause of the bradycardia, the client may need a
permanent pacemaker.
C. Sinus tachycardia
a. Atrial and ventricular rates are 100 to 180
beats/minute.
b. Atrial and ventricular rhythms are regular.
c. PR interval and QRS width are within normal
limits.
2. Interventions
a. Identify the cause of the tachycardia.
b. Decrease the heart rate to normal by treating the underlying cause.
D. Atrial fibrillation
a. Multiple rapid impulses from many foci depolarize in the atria in a
totally disorganized manner at a rate of 350 to 600 times/minute.
b. The atria quiver, which can lead to the formation of thrombi.
c. Usually no definitive P wave can be observed, only fibrillating waves
before each QRS.
Interventions
a. Identify the cause and treat on the basis of the cause.
b. Evaluate oxygen saturation to assess for hypoxemia, which can cause
PVCs.
c. Evaluate electrolytes, particularly the potassium level, because
hypokalemia can cause PVCs.
d. Oxygen and medication may be prescribed in the case of acute
myocardial ischemia or MI.
Interventions
a. Initiate CPR until a defibrillator is available.
b. The client is defibrillated immediately with 120 to 200 joules
(biphasic defibrillator) or 360 joules (monophasic defibrillator); check
the entire length of the client 3 times to make sure no one is touching the
client or the bed; when clear, proceed with defibrillation.
c. CPR is continued for 2 minutes and the cardiac rhythm is reassessed
to determine need for further counter shock.
d. Administer oxygen as prescribed.
e. Administer anti dysrhythmic therapy as prescribed.
Management of Dysrhythmias
A. Vagal maneuvers
1. Vagal maneuvers induce vagal stimulation of the cardiac conduction
system
and are used to terminate supraventricular tachydysrhythmias.
3. Valsalva maneuver
a. The HCP instructs the client to bear down or induces a gag reflex in
the client to stimulate a vagal response.
b. Monitor the heart rate, rhythm, and BP.
c. Observe the cardiac monitor for a change in rhythm.
d. Record an electrocardiographic rhythm strip before, during, and after
the procedure.
e. Provide an emesis basin if the gag reflex is stimulated, and initiate
precautions to prevent aspiration.
f. Have a defibrillator and resuscitative equipment available.
B. Cardioversion
a. Cardioversion is synchronized counter shock to convert an
undesirable rhythm to a stable rhythm.
b. Cardioversion can be an elective procedure performed by the HCP for
stable tachy-dysrhythmias resistant to medical therapies or an emergent
procedure for hemodynamically unstable ventricular or supraventricular
tachy-dysrhythmias.
c. A lower amount of energy is used than with defibrillation.
d. The defibrillator is synchronized to the client’s R wave to avoid
discharging the
shock during the vulnerable period (T wave).
e. If the defibrillator is not synchronized, it could discharge on the T
wave and cause VF.
2. Pre-procedure interventions
a. If an elective procedure, ensure that informed consent is obtained.
b. Administer sedation as prescribed.
c. If an elective procedure, hold digoxin for 48 hours pre-procedure as
prescribed to prevent post-cardioversion ventricular irritability.
d. If an elective procedure for atrial fibrillation or atrial flutter, the client
should receive anticoagulant therapy for 4 to 6 weeks pre-procedure
and a trans-esophageal echocardiogram (TEE) should be performed to
rule out clots in the atria prior to the procedure.
4. Post-procedure interventions
a. Priority assessment includes ability of the client to maintain the
airway and breathing.
b. Resume oxygen administration as prescribed.
c. Assess vital signs.
d. Assess level of consciousness.
e. Monitor cardiac rhythm.
f. Monitor for indications of successful response, such as conversion to
sinus
rhythm, strong peripheral pulses, an adequate BP, and adequate urine
output.
g. Assess the skin on the chest for evidence of burns from the edges of
the pads.
C. Defibrillation
1. Defibrillation is an asynchronous counter shock used to terminate
pulseless VT or VF.
2. The defibrillator is charged to 120 to 200 joules (biphasic) or 360
joules (monophasic) for 1 counter shock from the defibrillator, and then
CPR is resumed immediately and continued for 5 cycles or about 2
minutes.
3. Reassess the rhythm after 2 minutes, and if VF or pulseless VT
continues, the defibrillator is charged to give a second shock at the same
energy level previously used.
4. Resume CPR after the shock, and continue with the life support
protocol.
Before defibrillating a client, be sure that the oxygen is shut off to avoid
the hazard of fire and be sure that no one is touching the bed or the
client.
CPR
Introduction
To provide CPR first make sure the scene is safe. Approach the victim
and assess their responsiveness by tapping them and asking them loudly,
“are you okay?” Yell for help. Use a cellphone to call 911 and send a
bystander to get an AED. Check the victim’s breathing and pulse. If they
are not responding, breathing, or only gasping, start CPR with
compressions. It is essential to minimize interruptions in chest
compressions to 10 seconds. Perform 30 chest compressions at a rate of
100-120 compressions per minute. Proper CPR can be tiring, so make
sure to ask to switch positions when exhausted if another rescuer is
available to help.
To deliver high-quality CPR,
1. Begin with high-quality chest compressions.
To begin, position the individual on their back on a firm, flat
surface.
Feel for the end of the breastbone (sternum).
Place the heel of one hand on the lower half of the breastbone.
Avoid pressing down on the very end of the breastbone as the
xiphoid process, may break off and cause damage.
Put the other hand on top of the first hand.
Press straight down. Let the chest rise completely between
compressions.
Your hands should remain in contact with the individual, without
bouncing or leaning on them.
2. Perform the head-tilt/chin-lift maneuver for breath.
Most masks have a pointed end, which should go over the
bridge of the nose.
First, place the mask over the victim’s mouth and nose then
open the airway by performing the head-tilt/chin-lift
maneuver.
Open the individual’s airway by first placing one hand on
their forehead.
Place your fingers on the bony part of their chin.
Gently tilt the head back while lifting the chin. If there is no
good seal between the mask and the individual’s face it will
be ineffective.
Give a breath for over one second and watch the chest rise.
Deliver the second breath.
If the chest doesn’t rise, reposition the airway. Let the head
go back to a normal position and then repeat the head-tilt-
chin/lift maneuver.
Then, give another breath and watch for the chest to rise.
If you suspect the victim has experienced head or neck
trauma, the jaw-thrust maneuver should be performed to
open the airway instead of the head-tilt-chin/lift maneuver.
To perform the jaw-thrust maneuver, place the index and
middle fingers on the lower jaw to physically push the lower
jaw upwards while the thumb is used to push down on the
chin to open the mouth.
When the AED arrives at the scene, turn the device on,
remove any clothing from the victim, and apply the AED
pads.
Place one below the right collarbone and the other to the side
of the left nipple below the armpit. Plugin the connector and
clear the victim while the AED analyzes the rhythm. If no
shock is advised, resume CPR, beginning with chest
compressions. If shock is advised, clear the victim again
before delivering a shock. Once the AED has charged, hit the
shock button.
After delivering the shock, resume CPR, beginning with 30
chest compressions. Open the airway and give two breaths.
Continue at this ratio of 30 compressions to 2 breaths until
the AED prompts you to stop or further help arrives.
3. Circulation
Once the rescue breaths have been given attention should be turned to
the circulation and rapid assessment to see if there is a pulse present. In
children the carotid, brachial or femoral artery can be palpated. If there
are no ‘signs of life’ then cardiac compressions should be the next step.
Stimulate– asking the child ‘are you ok, can you hear me?’ and gently
applying stimulation in the form of shaking an arm or gentle stimulation
by rubbing the chest.
Look: for any obvious obstruction- blood, vomit, trauma and look for
any signs of abdominal or chest wall movement
Once the airway has been opened normal breathing ensues the rescuer
then turns the child onto their side (into the recovery position) and
maintains their airway until further help arrives. If the airway opening
manoeuvres do not result in spontaneous breathing, then rescue
breaths must be given.
Breathing
5 x initial rescue breaths must be given
The airway must be kept open during the rescue breaths. If the rescuer
is out of hospital without any equipment, then mouth to mouth can be
used to give the breaths. In older children this requires the nose to be
pinched closed. In infants the rescuer should attempt to cover both the
nose and mouth with their mouth.
The breaths given should be able to make the child/ infants chest rise as
normal. Slow exhalation is required (around 1-1.5 seconds) – too
vigorous can cause the stomach to inflate and contents to be
regurgitated.
If this occurs in hospital a bag and mask device can be used to provide
the rescue breaths rather than a mouth.
Circulation
Once the rescue breaths have been given attention should be turned to
the circulation and rapid assessment to see if there is a pulse present. If
there are no ‘signs of life’ i.e. spontaneous breathing or movement after
the rescue breaths AND there is no central pulse present after 10 seconds
of palpation, or heart rate <60 then cardiac compressions should be the
next step.
For infants, the most effective position with two BLS providers present
is the hand encircling technique. The rescuers hands are placed around
the lower half of the infant’s sternum and compressions are carried out
with the thumbs. If only one provider two finger technique should be
used with the other hand stabilising the infants head.
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For children, the rescuer should use the heel of their hand over
the lower half of the sternum. The arm should remain straight and
chest should be compressed to 1/3 of the depth. For larger children or
small rescuers two hands can be used one on top of the other with
fingers interlocked to perform the compressions.
5. The routine use of cricoid pressure does not reduce the risk of
regurgitation during bag-mask ventilation and may impede
intubation success.
8. After discharge from the hospital, cardiac arrest survivors can have
physical, cognitive, and emotional challenges and may need
ongoing therapies and interventions.
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SECOND SEMESTER
Introduction
Summary
There are lots of risks posed to critically ill patients associated with
inadequate physical care and hygiene
Patients in critical care areas are often the most vulnerable of patients,
and as such, we have a duty of care to provide physical care and hygiene
in-line with what the individual requires.
AAAAAAAAAAAAAAAAAA
Introduction
The five stages of coping with dying (DABDA), were first described by
Elisabeth Kübler-Ross in her classic book, "On Death and Dying," in
1969. They describe the stages people go through when they learn that
they (or a loved one) are dying, beginning with the shock (or denial) of
the moment, and up to the point of acceptance.
The five stages of the Kübler-Ross stage model are the best-known
description of the emotional and psychological responses that many
people experience when faced with a life-threatening illness or life-
changing situation.
The stages do not only apply to death but any life-changing event for
which a loss is deeply felt, such as a divorce, the loss of a job, or the loss
of a home.
It's important to remember that some people will experience all of the
stages, some in order and some not, and other people may only
experience a few of the stages or even get stuck in one. These stages are
unique for each person facing illness, death, or loss, and most people do
not follow these in a linear pattern, they are helpful in describing some
of the emotions that accompany these life-changing events.
It's also interesting to note that the way a person has handled adversity in
the past will affect how a diagnosis of terminal illness is handled.
For example, a woman who always avoided adversity and used denial to
cope with tragedy in the past may find herself stuck in the denial stage
of coping for a long time. Similarly, a man who uses anger to deal with
difficult situations may find himself unable to move out of the anger
stage of coping.
Denial
Anger
Bargaining
Depression
Acceptance
Denial
They may demand a new set of tests, believing the results of the first
ones to be false. Some people may even isolate themselves from their
doctors and refuse to undergo any further medical treatment for a time.
Some people, however, will use denial as a coping mechanism long into
their illness and even to their death. Extended denial isn't always a bad
thing; it doesn't always bring increased distress.
Anger
Anger is the stage where the bottled-up feelings of the previous stages
are released in a huge outpouring of grief and directed at anyone who
happens to be in the way.
Doctors and nurses are yelled at in the hospital; family members are
greeted with little enthusiasm and often face random fits of rage. Even
strangers aren't immune to the actions anger may bring about.
In the book "On Death and Dying," Kübler-Ross astutely describes this
anger: "He will raise his voice, he will make demands, he will complain
and ask to be given attention, perhaps as the last loud cry, 'I am alive,
don't forget that. You can hear my voice. I am not dead yet!'"
For most people, this stage of coping is also short-lived. Again,
however, some people will continue in anger for much of the illness.
Some will even die angry.
Bargaining
When denial and anger don't have the intended outcome, in this case, a
mistaken diagnosis or miracle cure, many people will move on to
bargaining. Most of us have already tried bargaining at some point in our
lives.
Children learn from an early age that getting angry with Mom when she
says "no" doesn't work, but trying a different approach might. Just like
the child who has time to rethink his anger and begin the process of
bargaining with a parent, so do many people with a terminal illness.
Most people who enter the bargaining stage do so with their God. They
may agree to live a good life, help the needy, never lie again, or any
number of "good" things if their higher power will only cure them of
their illness.
Other people may bargain with doctors or with the illness itself. They
may try to negotiate more time saying things like, "If I can just live long
enough to see my daughter get married..." or "If only I could ride my
motorcycle one more time..."
Bargaining is the stage where one clings to an irrational hope even when
the facts say otherwise. It may be expressed overtly as panic or manifest
with an inner dialogue or prayer unseen by others.
The implied return favor is that they would not ask for anything more if
only their wish was granted. People who enter this stage quickly learn
that bargaining doesn't work and inevitably move on, usually to the
depression stage.
Depression
When it becomes clear that the terminal illness is here to stay, many
people experience depression. The increased burden of surgeries,
treatments, and physical symptoms of illness, for example, make it
difficult for some people to remain angry or to force a stoic smile.
Depression, in turn, may creep in.
Kübler-Ross explains that there are really two types of depression in this
stage. The first depression, which she called "reactive depression,"
occurs as a reaction to current and past losses.
For example, a woman who is diagnosed with cervical cancer may first
lose her uterus to surgery and her hair to chemotherapy. Her husband is
left without help to care for their three children, while she is ill and has
to send the children to a family member out of town.
Because of the high cost of cancer treatment, this woman and her spouse
can't afford their mortgage and need to sell their home. The woman feels
a deep sense of loss with each one of these events and slips into
depression.
Acceptance
They may have had time to make amends and say goodbye to loved
ones. The person has also had time to grieve the loss of so many
important people and things that mean so much to them.
Some people who are diagnosed late in their illness and don't have time
to work through these important stages may never experience true
acceptance. Others who can't move on from another stage—the man who
stays angry at the world until his death, for example—may also never
experience the peace of acceptance.
For the lucky person who does come to acceptance, the final stage
before death is often spent in quiet contemplation as they turn inward to
prepare for their final departure.
Recognizing Terminal Restlessness at the End of Life
However, in a hospital setting, where such a delay should not exist, the
distinction is less clear.
To confirm the death of a patient, you should observe the patient for a
minimum of 5 minutes. To ensure that you perform all necessary steps,
you can use a systematic A to E approach:
*In a patient who had been monitored, you may also notice continuous
asystole on the cardiac monitor. In a patient who has an arterial line
you can observe an absence of pulsatile flow.
Documentation
Nature of a certificate
A full explanation of the cause of death includes any other diseases and
disorders the person had at the time of death, even though they did not
directly cause the death.
The funeral home, cremation organization, or other person in charge of
the deceased person's remains will prepare and file the death certificate.
Preparing the certificate involves gathering personal information from
family members and obtaining the signature of a doctor, medical
examiner, or coroner. The process must be completed quickly -- within
three to ten days, depending on state law.
full name
address
birth date and birthplace
father's name and birthplace
mother's name and birthplace
complete or partial Social Security number
veteran's discharge or claim number
education
marital status and name of surviving spouse, if there was one
date, place, and time of death, and
the cause of death.
Certified copies bear an official stamp, and are necessary to carry out
many tasks after a death -- from obtaining a permit for burial or
cremation to transferring the deceased person's property to inheritors. In
an increasing number of states, certified copies are available only to
members of the deceased person's immediate family, the executor of the
estate, or someone who can prove that they have a direct financial
interest in the estate.
Last offices
Introduction
Aims
Water in a gallipot
Cotton wool in a gallipot
Bandage and scissors in a receiver
Gloves
Procedure:
Top shelf
cotton wool
sinus forceps/straight artery forceps in a receiver
scissors in a receiver
a pair of dressing forceps in a receiver
plaster & gauze bandage in a receiver
comb or brush in a receiver
bowel of water
soap in a dish
Wash cloths/flannels
Bottom shelf:
Mortuary sheet
Gloves, destructor bowl with lid
2 identification bands on which are written clearly the
patient’s full name, date & time of death, the ward & hospital
registration number.
Extra requirement:
Procedure
1. Prepare, set trolley & wheel to patient’s side
2. Give the patient a bed bath
3. Turn patient to the left lateral position & plug the anal canal with
cotton wool
4. Plug the other orifices with cotton wool but they should not be
noted externally.
5. Dress wound if any
6. Straighten the legs & tie the toes together with gauze bandage
using cotton wool to pad between the ankles.
7. Straighten the hands on the abdomen & tie the thumbs together
with gauze bandage using cotton wool to pad between the wrist.
8. Tie one identification band on the wrist.
9. Roll out the draw sheet, draw mackintosh & bottom sheet.
10. Roll in the mortuary sheet, make sure that the middle of the
mortuary sheet is central.
11. Remove the top sheet.
12. wrap the mortuary sheet round the body.
13. Attach the second identification band firmly on the sheet.
14. Screen the body until the porter arrives with the mortuary
trolley.
15. The nurse should accompany the porters & relatives to the
mortuary.
16. Dismantle trolley appropriately.
17. Sterilize articles that should be sterilized, dry others & keep
in the appropriate places.
Precautions
1. The effects of the patient are listed in duplicate & packed neatly no
matter how insignificant it may be & given to the nearest relative.
Valuables are separately wrapped & kept in a locked cupboard
until claimed. The relatives are to sign the list before claiming
items.
2. The nurse should follow the instructions of the family regarding
items to remain on the patient, e.g. rings, artificial dentures, rosary
beads, metals etc.
3. Two nurses should perform this procedure if possible.
4. It’s part of the reverence due to a person who has died to leave the
body for an hour before commencing last office. Part A of this
office is done to prevent deformity due to rigor mortis.
5. If the diseased suffered a contagious disease, the appropriate
precautions should be taken.
6. The body of the patient should be removed in a quiet & non
upsetting manner to avoid disturbing other patients.
7. The senior nurse on duty at the time of the death is responsible for
the patient’s belonging, hospital records, and the bill. The death
certificate is filled in duplicate copies, original is collected by
relative. Encourage them to register the death.
NB
CARBOLIZATION
To prevent cross-infection
To prevent odour
Keep the ward neat
Destroy micro-organisms
For the comfort of the next patient
Top shelf:
Bottom shelf:
Procedure:
To prevent cross-infection.
To keep the environment clean.
These are not in a sequential order but rather in order of how many
mourners slowly come to terms with loss.
Shock is often your very first response. When you go into shock, you
feel numb. This is your body’s way of protecting you.
The depth and length of this stage can vary. The biggest factors are the
degree of the relationship, cause of death, and whether it was a sudden
or unexpected death.
Everyone feels grief at some point, yet everyone feels grief differently.
This is important to keep in mind. Don’t let anyone tell you how you
“should” be feeling. This is a personal journey.
You must allow yourself the time to heal. It is a long journey and one
that can’t be rushed. Giving yourself the time you need to helps in the
recovery process.
You will experience bouts of depression and sadness during the grieving
process. This is normal.
Reach out to your support group. Often this is friends and family, but it
can even be a chat room of strangers. Talking about your grief will help
you work through the depression stage.
Grieving may cause you to neglect your own health. Watch out for this,
and do your best to avoid it.
Panic is another completely normal part of the grief process. Don’t let it
overtake your day to day routine.
Panic may include worrying over bills, your future, or facing the
unknown. Learning to accept help from others is a good way for you to
begin work on this stage.
You and your loved ones may have had unresolved issues, or perhaps
you blame yourself for the death. We all have regrets in life but
shouldn’t allow them to grow out of proportion.
Talking with someone can be a great way to ease your feelings of guilt.
Start by talking to friends and family, and if necessary see a professional
counselor. They are trained and ready to provide help for this exact
situation.
You want to blame someone for your loss. The questions of: “Why
him?” “Why me?” “How can this be happening?” may never be
answered.
Your emotions will be in turmoil after the death of a loved one. Feelings
can be overwhelming and will come in waves. You will suffer highs and
lows throughout this journey. You need to figure out constructive ways
to vent.
10. Grief causes a lack of direction and purpose.
Practice being grateful for your memories and understand that they are a
treasured and valued part of your story. At the same time, you will find
comfort in discovering a renewed purpose for your future.
It will take time and resolution, but eventually, you will see
improvement. Your life will take on new meaning. You will begin to
establish new relationships and treasure old relationships. Memories will
bring comfort and not sorrow.
For encouragement, remember examples from others grief and how they
survived.
12. Acceptance means that your loss has changed you, but you have not
been defeated by it.
As you learn to cope with the loss and come to terms with your grief,
you will discover new strengths within yourself. This experience has
changed you, and you’ve grown stronger through it.
Others who can't move on from another stage—the man who stays angry
at the world until his death, for example—may also never experience the
peace of acceptance.
You’ll still have a lot of questions. Here are some of the most common.
How does grief affect your body?
Your brain will go through changes during your grieving time. These
changes and disturbances are referred to as “grief brain.”
Panic attacks
Fatigue
Anxiety
Sleep disturbances, nightmares, and vivid dreams.
Memory loss
Disorientation
All of these feelings are normal. If you find yourself not being able to
work through it, seek professional guidance.
Talk to a hundred different people and you will get a hundred different
answers. Each person’s grief journey is individual.
The loss of control you may feel is extremely hard to deal with. The
memories will wash over you. Your brain can’t seem to shut down and
let you rest.
However, most people find these as the hardest two stages of grief:
Guilt: You may think there was some way you could have stopped
the death from occurring. Knowing that you could have done a
million and one things differently – but didn’t – you experience a
feeling of guilt. This feeling keeps you mired in that “stage” and
prevents you from pursuing further healing.
Acceptance: Many people expect the acceptance phase to be a
miraculous cure. The grief doesn’t end upon acceptance. You will
always have feelings of grief pop up. This is considered the final
step in the grieving cycle. Accepting your loss doesn’t mean you
feel good about your loved one dying. Rather, it means you come
to terms with the reality of your loss and learn to live your life in a
new way. This stage is more about accepting that you can’t change
what has happened. Acceptance is still hard.
One day you will notice that you don’t hurt as badly. Things tend to get
better little by little. Your pain will become manageable, and you will
feel more “happy” times than “sad” times.
Though you never forget the pain of losing your loved one, you have a
new reality of living. That reality will certainly include treasuring all the
memories you shared.
“Grief Without Denial.” by Constance Siegel
Take your time when grieving: There’s no way around it; grief
takes time.
Remember how they impacted your life: Focus on the positive.
Have a funeral that speaks to their personality: Celebrate your
loved one’s life in a special, unique way.
Continue their legacy: Carrying on in your loved one’s footsteps
is a great way to pay tribute to their life.
Continue to talk to them and about them: You can’t see your
loved one, but that doesn’t mean you need to stop talking to them.
Their life was real, and it mattered. Talk about that.
Know when to get help: It’s critical to give yourself time to
grieve. It is just as important to know when it’s time to get help. If
you need help, reach out to friends, family, or a professional.
Don’t avoid dealing with your grief. Working through grief is the
healthy way to start the process of recovery.
The grieving process refers to the way the death of a loved one affects
an individual over time, and also the steps that person takes as they learn
to cope with the loss.
1. Send something
Now if you get the sense that many people will send flowers, you may
want to think outside of the box. Some suggestions that people noted as
especially helpful include sending/dropping off:
People often need practical support after the death of a loved one for two
reasons:
(1) because their deceased loved one used to handle certain things and
fill certain roles
(2) because grief makes it hard to care about the minute day-to-day life.
Ask yourself, what might my loved one need help with and what unique
skills do I have to offer? If you find that you aren’t the best person to
help fill a potential need, you might also consider purchasing a gift
certificate so your loved one can hire someone at their own convenience
(i.e. a cleaning service or a landscaper).
A few examples of helpful practical support that were shared include…
3. Be there
Examples of how to “be there” in a real way vary, but include some of
the following: When a supportive friend or family member…
One of the grief theories, the Dual Process Model, says that a
griever will oscillate between confronting their loss and avoiding the
loss. Under this model, seeking respite from grief is a healthy part of
coping. Sometimes a person needs a little time to feel normal or to
engage in activities that give them a boost of positive emotion. This
being the case, it may be helpful to offer or encourage distraction; with
the caveat that you should never push a person to minimize, move on, or
forget their loss and with the understanding that their grief could
overcome them at any moment (especially in the early days).
Laughter
Sharing positive memories of their loved one
Taking them out for a meal
Taking them to the movies or on other recreational outings
Accompanying them to parties or other social gatherings
Something people often express their appreciation for having friends and
family who are willing to be present for the sad and uncomfortable
moments without trying to fix them and without showing fear,
discomfort, or judgment. Being willing to “go there” with a bereaved
individual can mean many things such as…
6. Don’t forget
You can show your ongoing support for a grieving loved one by …
FEVER
In health, body temperature is regulated around a set
point of 37 ± 1°C, and a circadian temperature rhythm
exists in which the highest temperature of each day
occurs around 6 P.M. The variance between the
highest and lowest core temperature in a given day is
usually no more than 1° to 1.5°C. This circadian
rhythm may differ among individuals but should be
consistent in each person. Relative to the core (blood)
temperature, oral temperature tends to be about 0.4°C
lower and axillary temperature up to 1°C lower, than
rectal temperature, probably because of fecal bacterial
metabolism, averages about 0.5°C higher.
Fever is a physiologic disorder in which the temperature
is elevated above one's normal temperature. An elevated
body temperature may accompany any condition in which
exogenous or endogenous heat gain exceeds mechanisms
of heat dissipation such as occurs with vigorous exercise,
exposure to a warm ambient temperature, or the use of
drugs that cause excess heat production or limit heat
dissipation. In these situations, the hypothalamic
"thermostat" remains "set" in the normal range. In true
fever, mechanisms to regulate the body temperature above
the normal set point are actively operating.
In most patients with fever lasting 1 to 2 weeks, the
etiology will be found or the fever will disappear.
Occasionally, despite the history, physical examination,
laboratory and radiologic procedures, fever (temperature
above 38.3°C) will continue beyond 2 to 3 weeks without
diagnosis.
5 Nursing Care Plans for Fever -Hyperthermia
Fever, also known as hyperthermia or pyrexia, is a
medical condition when there is an uncontrolled rise in
the body temperature, measured as above 37.5 degrees
Celsius.
It results from the failure of the body’s thermoregulatory
center, the hypothalamus to control the body temperature
between the normal range of 36 to 37.5 degrees Celsius.
There are several possible etiologies or causes of
hyperthermia, and the most common ones include an
ongoing infection, trauma, exposure to hot environment,
and increased metabolic rate due to extreme activity.
A fever can also be triggered by intake of some
medications, either as an adverse side effect (e.g.
antibiotics, sulfa drugs, and chemotherapy agents), or as
withdrawal symptom (e.g. fentanyl or heroin withdrawal).
Fever can be assessed by taking temperature from
different routes, including tympanic, axillary, oral, and
rectal.
Below are 5 nursing care plans that a nurse can consider
in the care of a patient who has hyperthermia.
Nursing Care Plan 1
Nursing Diagnosis: Hyperthermia related to upper
respiratory tract infection (URTI) as evidenced by
temperature of 38.5 degrees Celsius, rapid and shallow
breathing, flushed skin, profuse sweating, and weak pulse.
Interventions Rationales
Remove excessive
To regulate the temperature of the
clothing, blankets and
environment and make it more comfortable
linens. Adjust the room
for the patient.
temperature.
Interventions Rationales
0
Regular catheter care is required to ensure
that there is no recurrence of infection. This
involves proper documentation to show that
++6Perform regular it is done frequently.
catheter care properly.
Definition of pain
1. The International Association for the Study of Pain
(IASP) defined pain as “an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage, or described in terms of such
damage.”
2. Another great definition of pain is from Margo
McCaffery, a nurse expert on pain, who defined it as
“pain is whatever the person says it is and exists
whenever the person says it does.” What your patient
says about the pain he is experiencing is the best
indicator of that pain. We can’t prove or disprove
what the patient is feeling. We also can’t assume.
Classification of Pain
Pain can be classified into two types. You can distinguish
one from the other according to the cause, onset, and
duration.
Types of pain
There are 2 main types of pain:
Acute pain – a normal response to an injury or
problems)
surgery.
Acute pain
Acute pain provides a protective purpose to make the
patient informed and knowledgeable about the presence
of an injury or illness. The unexpected onset of acute pain
reminds the patient to seek support, assistance, and relief.
The physiological signs that occur with acute pain emerge
from the body’s response to pain as a stressor. Acute pain
can have a sudden or slow onset with an intensity ranging
from mild to severe. It can happen after a medical
procedure, surgery, trauma or acute illness. It has a
duration of less than 6 months.
worse?”
Quality (characteristic): “Tell me what it’s exactly
Chronic pain
For pain to be classified as chronic, the patient needs to be
experiencing it for more than 6 months. Its intensity can
range from mild to extremely incapacitating. In some
cases, chronic pain can restrict a patient’s ability to
perform his Activities of Daily Living and this usually
ends up with feelings of despair.
Chronic pain has two subcategories: malignant and non-
malignant.
1. Malignant refers to pain associated with cancer
2. and other progressive diseases. Non-malignant chronic
pain, on the other hand, refers to pain that persists beyond
the expected time of healing.
Chronic pain may be related to
-Chronic physical and psychological disability
-Injuring agents (biological, chemical, physical,
psychological)
Possibly evidenced by
-Patient’s report of pain
-Changes in sleep pattern
-Changes in appetite
-Irritability, restlessness, depression
-Weight changes
-Atrophy of involved muscles
-Less interaction with people
-Sympathetic mediated responses
-Facial mask
-Guarding behavior
Desired outcome
-Verbalizes or demonstrates relief or control of pain
-Demonstrates use of both non-pharmacological and
pharmacological pain relief strategies
-Shows the ability to engage in activities
-Shows use of appropriate therapeutic interventions
Nursing Interventions Rationale
Perform a comprehensive
assessment. Assess
location, characteristics, Assessment is the first step in
onset, duration, frequency, managing pain. It helps ensure that
quality and severity of the patient receives effective pain
pain. relief.
Overview
A barium enema is an X-ray exam that can detect
changes or abnormalities in the large intestine (colon).
The procedure is also called a colon X-ray.
An enema is the injection of a liquid into your rectum
through a small tube. In this case, the liquid contains a
metallic substance (barium) that coats the lining of the
colon. Normally, an X-ray produces a poor image of soft
tissues, but the barium coating results in a relatively clear
silhouette of the colon.
Why it's done
In the past, doctors used barium enema to investigate the
cause of abdominal symptoms. But this test has mostly
been replaced by newer imaging tests that are more
accurate, such as CT scans.
In the past, your doctor may have recommended a barium
enema to determine the cause of signs and symptoms,
such as the following:
Abdominal pain
Rectal bleeding
Changes in bowel habits
Unexplained weight loss
Chronic diarrhea
Persistent constipation
Similarly, a barium enema X-ray previously may have
been ordered by your doctor to detect such conditions as:
Abnormal growths (polyps) as part of colorectal
cancer screening
Inflammatory bowel disease
Risks
A barium enema exam poses few risks. Rarely,
complications of a barium enema exam may include:
Inflammation in tissues surrounding the colon
Obstruction in the gastrointestinal tract
Tear in the colon wall
Allergic reaction to barium
Barium enema exams generally aren't done during
pregnancy because X-rays present a risk to the developing
fetus.
How you prepare
Before a barium enema exam, you'll be instructed to
empty your colon. Any residue in your colon may obscure
the X-ray images or be mistaken for an abnormality.
To empty your colon, you may be asked to:
Follow a special diet the day before the exam. You
may be asked not to eat and to drink only clear
liquids — such as water, tea or coffee without milk or
cream, broth, and clear carbonated beverages.
Fast after midnight. Usually, you'll be asked not to
drink or eat anything after midnight before the exam.
Take a laxative the night before the exam. A
laxative, in a pill or liquid form, will help empty your
colon.
Use an enema kit. In some cases, you may need to
use an over-the-counter enema kit — either the night
before the exam or a few hours before the exam —
that provides a cleansing solution to remove any
residue in your colon.
Ask your doctor about your medications. At least a
week before your exam, talk with your doctor about
the medications you normally take. He or she may
ask you to stop taking them days or hours before the
exam.
What you can expect
During the exam
During your barium enema, you'll wear a gown and be
asked to remove eyewear, jewelry or removable dental
devices. The exam will be performed by a radiology
technician and a physician who specializes in diagnostic
imaging (radiologist).
You'll begin the exam lying on your side on a specially
designed table. An X-ray will be taken to make sure your
colon is clean. Then a lubricated enema tube will be
inserted into your rectum. A barium bag will be connected
to the tube to deliver the barium solution into your colon.
If you're having an air-contrast (double-contrast) barium
enema, air will flow through the same tube and into your
rectum.
The tube that's used to deliver the barium has a small
balloon near its tip. When positioned at the entrance of
your rectum, the balloon helps keep the barium inside
your body. As your colon fills with barium, you may feel
the urge to have a bowel movement. Abdominal cramping
may occur.
Do your best to hold the enema tube in place. To relax,
take long, deep breaths.
You may be asked to turn and hold various positions on
the exam table. This helps ensure that your entire colon is
coated with barium and enables the radiologist to view the
colon from various angles. You also may be asked to hold
your breath at times.
The radiologist may press firmly on your abdomen and
pelvis, manipulating your colon for better viewing on a
monitor attached to the X-ray machine. A number of X-
rays will likely be taken of your colon from various
angles.
A barium enema exam typically takes about 30 to 60
minutes.
After the exam
After the exam, most of the barium will be removed from
your colon through the enema tube. When the tube is
removed, you'll be able to use the toilet to expel
additional barium and air. Any abdominal cramping
usually ends quickly, and you should be able to return to
your usual diet and activities right away.
You may have white stools for a few days as your body
naturally removes any remaining barium from your colon.
Barium may cause constipation, so you may find you can
reduce your risk of constipation by drinking extra fluids
in the days following your exam. Your doctor may
recommend a laxative, if needed.
Check with your doctor if you're unable to have a bowel
movement or pass gas more than two days after the exam
or if your stool doesn't return to its normal color within a
few days.
Results
The radiologist prepares a report based on the results of
the examination and sends it to your doctor. Your doctor
will discuss the results with you, as well as subsequent
tests or treatments that may be required:
Negative result. A barium enema exam is considered
negative if the radiologist detects no abnormalities in
the colon.
Positive result. A barium enema exam is considered
positive if the radiologist detects abnormalities in the
colon. Depending on the findings, you may need
additional testing — such as a colonoscopy — so that
any abnormalities can be examined more thoroughly,
biopsied or removed.
If your doctor is concerned about the quality of your X-
ray images, he or she may recommend a repeat barium
enema or another type of diagnostic test.
4.5.1 Radiographs
The use of radiographs for dental
applications is covered by the Ionising
Radiation Regulations 1999 and the
Ionising Radiation (Medical Exposure)
Regulations 2000 (IRMER).16,17 Although
there is no requirement for the explicit
recording of the justification it is
recommended that this should be done
unless the justification is obvious from the
records. There is however a regulatory
requirement for reporting of the
radiograph. A quality assurance
programme should be established to
optimise the quality of radiographs
produced. Full details are provided in the
Department of Health’s Guidance Notes
for Dental Practitioners on the Safe Use of
X-ray Equipment.18
Justification: No person shall carry out a
medical exposure unless it has been
justified by the practitioner as showing
sufficient net benefit. When referring a
patient, the referrer must supply details of
the patient’s radiographic history to the
receiving practitioner.
Study models
Vitality tests