Insert the needle at the L3-4 or L4-5 intervertebral space advancing until there is a decrease in resistance or the feeling of a pop as the dura is penetrated 8 buy cheap ramipril 10mg on line hypertension goals. Collect about 1cc per tube and send tubes for 1) culture and gram stain 2) glucose and protein 3) cell count and differential 4) hold buy 10mg ramipril with visa arrhythmia icd 9 codes. Locate the 3 to 5 intercostals space in the mid to anterior axillary line avoiding breast tissue 4 buy generic ramipril 5 mg pulse pressure significance. Anesthetize skin, subcutaneous tissue, periosteum of rib, chest-wall muscles and pleura with 1% lidocaine 6. Make sterile incision one intercostal space below target and bluntly dissect with hemostat until superior portion of rib is reached (Remember nerve-artery-vein run along the inferior side of the rib! Push hemostat over tope of rib, through pleura and into pleural space—don’t go deeper than 1 cm into pleural space 8. Spread open hemostat and place chest tube in clamp, then guide to desired distance 9. Placement: pneumothorax—insert tube anteriorly toward apex, pleural effusion— insert tube inferiorly and posteriorly 10. Secure tube with purse-string sutures: suture first tied to skin, then wrapped around tube once and tied at the tube 11. Locate the 3 to 5 intercostals space in the mid to anterior axillary line avoiding breast tissue 4. Anesthetize skin, subcutaneous tissue, periosteum of rib, chest-wall muscles and pleura with 1% lidocaine 6. Secure tube: suture first tied to skin, then wrapped around tube once and tied at the tube 14. Indications: Need for minute to minute blood pressure monitoring, need for arterial blood gas monitoring, need for frequent labs in the absence of a functioning central venous line. Test with Allen test first: clench hand while simultaneously compressing ulnar and radial arteries, watch for hand to blanch, then release ulnar artery and entire hand flush. Infiltrate area of maximal impulse with 1% lidocaine—aspirate first to ensure that you’re not in the artery 6. Use a needle to make a small skin puncture over point of maximal impulse and discard needle 7. Angio Head/Body: Ordering guidelines: always give an indication Specific considerations—you will need to speak with the radiologist to determine the best study and any special considerations. If the patient breathes over the set rate, he or she will receive a fully supported breath, regardless of how much effort is generated. No patient Set breath delivered within an interval based on the interaction, pressure or volume modes. Ventilator waits for a spontaneous breath by the patient as a trigger to Uses: Commonly for neonates. If this is not sensed it Contraindications: uncomfortable automatically gives a breath at the end of the Advantages: Regular breaths guaranteed. Any other breaths during the cycle Disadvantages: Patient is not allowed to breathe are not supplemented with the ventilator, i. Disadvantages: Can be uncomfortable for small Ventilators: All but the Sechrist patients, need to have appropriate sensing. Breath is controlled by the either on the patient’s initiative or at the set interval Pmax, not the set tidal volume. Allows synchrony with the Contraindications: Not a friendly mode in the patient with maximal support. Especially in patients with high Contraindications: Any patient w/o spontaneous airway pressures. Advantages: Delivers a guaranteed tidal volume Disadvantages: Provides no supportive ventilation. Where to Start: Initial Ventilator Settings Obviously, the individual patient and clinical setting will determine the mechanical ventilation needs, but the following is a good place to start, realizing that the settings will most likely require adjusting to achieve the desired effect. Preemie Infant/Toddler Child Adolescent/Ad ult Rate 40 30 20 12 - 48 - Inspiration 0. Obtain first gas 15-20 minutes after initially starting ventilation or after major changes. The trend is more important than any specific blood gas, oxygen saturation, or chest film. Surgical patients are excellent examples of organisms under stress, and a great deal of acute physiology can be learned by caring for them--airway and pulmonary issues, fluid/electrolyte issues, neuroendocrine response to stress, pain and sedation, etc. In general, pediatricians know about infants and children, and “medical” issues, and surgical attendings/residents know about “surgical/technical” issues. If a collaborative relationship is formed, the patients will receive the best of both sets of knowledge. Finally, because of the potential for miscommunication to lead to mis-understandings and problems with care, these patients present excellent opportunities to practice the art of communication and finesse. Post-operative care must be approached in an organized, timely manner, with attention to the acute nature of the patient’s changing physiology. Before the patient arrives, you should familiarize yourself with the patient’s past medical/surgical history and the planned surgical procedure. Only when you know what they planned to do, and what they did it on, will you be prepared to evaluate your patient when he/she arrives, and anticipate potential problems that you must watch for. When the patient arrives--the initial evaluation The patient has just undergone general anesthesia, been intubated +/- extubated, and had some fairly invasive procedure performed. The anesthetic record can be viewed as the “history of present illness” for the surgical patients--it contains information related to maintaining physiologic stability during the course of the operation. Each hospital’s record is somewhat different, but all will contain the following information: 1. Maintenance of anesthesia--potent inhalational agents (halothane/isoflurane/sevoflurane), nitrous oxide, narcotics, propofol. Lines and tubes Fluids in the Operative and Post-operative patient Pediatrician: “Why do they always get so much fluid? Major abdominal procedures can lead to losses of 15 cc/kg/hr in “third space” losses which must be replaced. Effect of Anesthesia on Fluid Balance: General anesthesia produces vasodilatation and some degree of myocardial contractility (usually overcome by sympathetic drive induced by the surgical stimulus), and thus a volume bolus may be needed. There is much discussion about which is better, what the cost/benefit ratio is, etc. You should at least be aware of which is which, and of the implications of choosing one over the other. Water flows along its concentration gradient, hence, water will leave the vascular space with the sodium, and less so with albumin.
The stimulus is engorgement of pulmonary capillaries with blood and increase in interstitial fluid volume cheap ramipril 10 mg amex arrhythmia when sleeping. The response is increase in breathing rate For example buy ramipril 10mg mastercard heart attack high 3000 miles from the south, in left heart failure blood “backs up” in pulmonary circulation ramipril 5 mg online prehypertension hypertension, and J receptors mediate change in breathing pattern including rapid shallow breathing and dyspnea (difficulty in breathing) General and Cellular nonrespiratory lung function Filtration: filter out small blood clots (small pulmonary emboli) Immunologic: bronchial secretion contains Immuno globulin ( IgA ) Alveolar macrophages are phagocytic and remove bacteria and small particles inhaled by lungs. Macrophages also function in attraction of polymorpho nuclear leukocytes, release Vasoactive and chemo tactic substances. In less severe degree it results: (1) Depressed mental activity, sometimes culminating in coma. As a result, or O2 is extracted from the blood to support the oxidative metabolism of the tissues. Examples - Respiratory depression due to drug overdose (barbiturate poisoning) - Severe weakness of the muscles that support respiration e. It is caused by a decrease in the amount of hemoglobin available for binding of O2 so that the O2 content of the arterial blood is abnormally low. The major reasons of anemic hypoxia are: - Reduced erythropoiesis - Blood loss - Synthesis of abnormal hemoglobin - Carbon monoxide poisoning (3) Stagnant hypoxia If the blood flow through a tissue is sluggish, blood would stay in the capillaries for a longer time than the normal. Therefore, the blood will have to meet the oxygen requirements of the tissue for a longer time. The stay of blood in the capillaries may be so long that even after extracting a very large fraction of O2 carried by the blood, all the requirements of the tissue cannot be met. Examples: - Reduced cardiac output: cardiac failure, hemorrhage, circulatory shock - Local vasoconstriction: exposure of the extremities to the cold (4) Histotoxic hypoxia If the tissues are unable to use oxygen brought to them by blood, even that results in hypoxia. In this situation thesupply of O2 to the tissues is normal but they are unable to make full use of it. Examples: - Cyanide poisoning - Beriberi Oxygen therapy Oxygen therapy may be required for respiratory failure due to lung disease or poisoning. Methods of oxygen administration Oxygen may be administered in many ways: (1) Cannula (intranasal tube) The simplest way is to connect a cannula to an oxygen cylinder and insert it into one or both nostrils. This raises the concentration of oxygen in the inspired air but generally not to 100%, which may be a boon if the hypoxic drive is important to maintain the ventilation of the patient. Patients who remain unconscious for fairly long periods of long time are given an endotracheal or tracheostomy tube, which are connected to a ventilator. Effectiveness of hypoxia in different types of hypoxia Oxygen therapy is very useful in some types of hypoxia, may have some value in some types, whereas, in some cases it is not useful at all. This raises the oxygen pressure gradient for diffusion between the alveoli and the blood from the normal value of 60mmHg to as high as 560mmHg, an increase more than 800%. Eve so, a little amount of extra oxygen, between 7 and 30%, can be transported in the dissolve state in the blood when alveolar oxygen is increased to maximum even though the amount transported by the hemoglobin is hardly altered. Cyanosis The term cyanosis means blueness of the skin, and its cause is excessive amounts of deoxygenated hemoglobin in the skin blood vessels, especially in the capillaries. This deoxygenated hemoglobin has an intense dark blue-purple color that is transmitted through the skin. In general, definite cyanosis appears whenever the arterial blood contains more than 5g deoxygenated hemoglobin in each 100ml of blood. The common sites where cyanosis is observed are lips, nailbeds, ear lobes, cheeks, and mucous membranes of the oral cavity. A person with anemia almost never becomes cyanotic because there is not enough hemoglobin for 5g to be deoxygenated in 100ml of arterial blood. Conversely, in a person with excess red blood cells, as occurs in polycythemia vera, the great excess of available hemoglobin that can become deoxygenated leads frequently to cyanosis, even under otherwise normal conditions. Disorders of the respiratory system Pulmonary edema Pulmonary edema refers to the condition in which fluid accumulates in the interstitial spaces and alveoli of the lungs. Emphysema Emphysema is characterized by a loss of lung elasticity and abnormal dilation of the air spaces distal to the terminal bronchioles with destruction of the alveolar walls and capillary beds. Chronic bronchitis In chronic bronchitis airway obstruction is caused by inflammation of both major and small airways. It is more common in men than in women, but changing smoking habits may soon change this disproportion. Asthma Asthma is characterized by spastic contraction of the bronchiolar smooth muscles, which causes extremely difficult breathing. It is a disease characterized by intermittent attacks of dyspnea and wheezing caused by paroxysmal narrowing of the bronchial airways. Alterations in breathing patterns Dyspnea Dyspnea is a subjective sensation of difficulty in breathing. The terms dyspnea, breathlessness, and shortness of breath are often used interchangeably. It is often associated with respiratory diseases, but it can occur in healthy individuals also. Dyspnea in disease Dyspnea is observed in at least three different cardiopulmonary disease states: (a) Primary lung diseases: such as pneumonia, asthma, and emphysema (b) Heart disease: Pulmonary edema (c) Neuromuscular disorders: myasthenia gravis and muscular dystrophy of the respiratory muscles. Dyspnea in healthy individuals (a) Exercise: In healthy individuals dyspnea occurs during exercise, particularly in untrained individuals. This feeling is greatly enhanced in people who have a psychologicalfear of not being able to receive a sufficient quantity of air, such as in entirely small or crowded rooms. Periodic breathing An abnormality of breathing called periodic breathing occurs in a number of disease conditions. The person breathes deeply for a short interval of time and then breathes slightly or not all for an additional interval. Cheyne -Stokes breathing The most common type of periodic breathing is Cheyne-Stokes breathing, is characterized by slowly waxing and waning respiration, occurring over and over again every 45 seconds to 3 minutes. Occurrence in disease: (a) Congestive heart failure and uremia: Cheyne-Stokes breathing is commonly found in congestive heart failure and uremia. Occurrence in healthy individuals: (a) Sleep (b) High altitude (c) Infancy 271 Causes Cheyne-Stokes breathing is due to sluggishness of chemical regulation of respiration. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. The clinical nursing skills for the nurses are of paramount important not only to provide comprehensive care but also enhance clinical competence. The purpose of preparing this lecture note is to equip nurses with basic clinical nursing skills, which will enable them to dispatch their responsibility as well as to develop uniformity among Ethiopian Professional Nurse Training Higher Institutions. The lecture note series is designed to have two parts: part-I is composed of most basic clinical skills, where as part two will be covering most advances clinical skills as well as fundamental concepts related to the skills.
An interesting anatomical fact is that almost all mammals have seven cervical vertebrae buy ramipril 5 mg amex heart attack 90 percent blockage, regardless of body size buy discount ramipril 2.5 mg pulse pressure product. This means that there are large variations in the size of cervical vertebrae 10mg ramipril amex blood pressure chart high diastolic, ranging from the very small cervical vertebrae of a shrew to the greatly elongated vertebrae in the neck of a giraffe. Curvatures of the Vertebral Column The adult vertebral column does not form a straight line, but instead has four curvatures along its length (see Figure 7. When the load on the spine is increased, by carrying a heavy backpack for example, the curvatures increase in depth (become more curved) to accommodate the extra weight. Primary curves are retained from the original fetal curvature, while secondary curvatures develop after birth. In the adult, this fetal curvature is retained in two regions of the vertebral column as the thoracic curve, which involves the thoracic vertebrae, and the sacrococcygeal curve, formed by the sacrum and coccyx. Each of these is thus called a primary curve because they are retained from the original fetal curvature of the vertebral column. The cervical curve of the neck region develops as the infant begins to hold their head upright when sitting. Disorders associated with the curvature of the spine include kyphosis (an excessive posterior curvature of the thoracic region), lordosis (an excessive anterior curvature of the lumbar region), and scoliosis (an abnormal, lateral curvature, accompanied by twisting of the vertebral column). Kyphosis, also referred to as humpback or hunchback, is an excessive posterior curvature of the thoracic region. This can develop when osteoporosis causes weakening and erosion of the anterior portions of the upper thoracic vertebrae, resulting in their gradual collapse (Figure 7. Lordosis, or swayback, is an excessive anterior curvature of the lumbar region and is most commonly associated with obesity or late pregnancy. The accumulation of body weight in the abdominal region results an anterior shift in the line of gravity that carries the weight of the body. Compensatory curves may also develop in other areas of the vertebral column to help maintain the head positioned over the feet. The cause is usually unknown, but it may result from weakness of the back muscles, defects such as differential growth rates in the right and left sides of the vertebral column, or differences in the length of the lower limbs. Although most individuals do not require treatment, a back brace may be recommended for growing children. If scoliosis is present, an individual will have difficulty in bending directly forward, and the right and left sides of the back will not be level with each other in the bent position. General Structure of a Vertebra Within the different regions of the vertebral column, vertebrae vary in size and shape, but they all follow a similar structural pattern. Because of this, the vertebral bodies progressively increase in size and thickness going down the vertebral column. The large opening between the vertebral arch and body is the vertebral foramen, which contains the spinal cord. In the intact vertebral column, the vertebral foramina of all of the vertebrae align to form the vertebral (spinal) canal, which serves as the bony protection and passageway for the spinal cord down the back. When the vertebrae are aligned together in the vertebral column, notches in the margins of the pedicles of adjacent vertebrae together form an intervertebral foramen, the opening through which a spinal nerve exits from the vertebral column (Figure 7. Each paired transverse process projects laterally and arises from the junction point between the pedicle and lamina. The vertebral spines can easily be felt as a series of bumps just under the skin down the middle of the back. A superior articular process extends or faces upward, and an inferior articular process faces or projects downward on each side of a vertebrae. The paired superior articular processes of one vertebra join with the corresponding paired inferior articular processes from the next higher vertebra. The shape and orientation of the articular processes vary in different regions of the vertebral column and play a major role in determining the type and range of motion available in each region. Arising from the vertebral arch are the transverse, spinous, superior articular, and inferior articular processes. The disc consists of a fibrous outer layer called the anulus fibrosus and a gel-like center called the nucleus pulposus. The intervertebral foramen is the opening formed between adjacent vertebrae for the exit of a spinal nerve. Regional Modifications of Vertebrae In addition to the general characteristics of a typical vertebra described above, vertebrae also display characteristic size and structural features that vary between the different vertebral column regions. Thus, cervical vertebrae are smaller than 282 Chapter 7 | Axial Skeleton lumbar vertebrae due to differences in the proportion of body weight that each supports. Thoracic vertebrae have sites for rib attachment, and the vertebrae that give rise to the sacrum and coccyx have fused together into single bones. Cervical Vertebrae Typical cervical vertebrae, such as C4 or C5, have several characteristic features that differentiate them from thoracic or lumbar vertebrae (Figure 7. Cervical vertebrae have a small body, reflecting the fact that they carry the least amount of body weight. You can find these vertebrae by running your finger down the midline of the posterior neck until you encounter the prominent C7 spine located at the base of the neck. The transverse processes of the cervical vertebrae are sharply curved (U-shaped) to allow for passage of the cervical spinal nerves. The superior and inferior articular processes of the cervical vertebrae are flattened and largely face upward or downward, respectively. The first cervical (C1) vertebra is also called the atlas, because this is the vertebra that supports the skull on top of the vertebral column (in Greek mythology, Atlas was the god who supported the heavens on his shoulders). The transverse processes of the atlas are longer and extend more laterally than do the transverse processes of any other cervical vertebrae. The superior articular processes face upward and are deeply curved for articulation with the occipital condyles on the base of the skull. The inferior articular processes are flat and face downward to join with the superior articular processes of the C2 vertebra. The second cervical (C2) vertebra is called the axis, because it serves as the axis for rotation when turning the head toward the right or left. The axis resembles typical cervical vertebrae in most respects, but is easily distinguished by the dens (odontoid process), a bony projection that extends upward from the vertebral body. The dens joins with the inner aspect of the anterior arch of the atlas, where it is held in place by transverse ligament. The axis (C2 vertebra) has the upward projecting dens, which articulates with the anterior arch of the atlas. Thoracic Vertebrae The bodies of the thoracic vertebrae are larger than those of cervical vertebrae (Figure 7. The characteristic feature for a typical midthoracic vertebra is the spinous process, which is long and has a pronounced downward angle that causes it to overlap the next inferior vertebra. The superior articular processes of thoracic vertebrae face anteriorly and the inferior processes face posteriorly. These orientations are important determinants for the type and range of movements available to the thoracic region of the vertebral column. Thoracic vertebrae have several additional articulation sites, each of which is called a facet, where a rib is attached.
Continuous conduction is slow because there are always voltage-gated Na channels opening 2.5 mg ramipril with amex arteria bologna, + and more and more Na is rushing into the cell buy ramipril 5 mg low price arrhythmia vs heart attack. Saltatory conduction is faster because the action potential basically jumps + from one node to the next (saltare = “to leap”) order ramipril on line blood pressure medication regimen, and the new influx of Na renews the depolarized membrane. Along with the myelination of the axon, the diameter of the axon can influence the speed of conduction. Much as water runs faster in a + wide river than in a narrow creek, Na -based depolarization spreads faster down a wide axon than down a narrow one. This concept is known as resistance and is generally true for electrical wires or plumbing, just as it is true for axons, although the specific conditions are different at the scales of electrons or ions versus water in a river. The concentrations of ions in the extracellular fluid are the basis for how the membrane potential is established and changes in electrochemical signaling. After the repolarizing phase of the action + + + potential, K leakage channels and the Na /K pump ensure that the ions return to their original locations. Astrocytes can become reactive in cases such as these, which impairs their ability to maintain the local chemical + environment. This sodium/potassium imbalance negatively affects the internal chemistry of cells, preventing them from functioning normally. Often, the action potentials occur so rapidly that watching a screen to see them occur is not helpful. A speaker is powered by the signals recorded from a neuron and it “pops” each time the neuron fires an action potential. A stimulus starts the depolarization, but the action potential runs on its own once a threshold has been reached. These special types of potentials influence a neuron and determine whether an action potential will occur or not. The amount of change in the membrane potential is determined by the size of the stimulus that causes it. In the example of testing the temperature of the shower, slightly warm water would only initiate a small change in a thermoreceptor, whereas hot water would cause a large amount of change in the membrane potential. For a membrane at the resting potential, a graded potential represents a change in that voltage either above -70 mV or below -70 mV. Both of these ions have higher concentrations outside the cell than inside; because they have a positive charge, they will move into the cell causing it to become less negative + - relative to the outside. If a positive charge moves out of a cell, the cell becomes more negative; if a negative charge enters the cell, the same thing happens. Types of Graded Potentials For the unipolar cells of sensory neurons—both those with free nerve endings and those within encapsulations—graded potentials develop in the dendrites that influence the generation of an action potential in the axon of the same cell. For other sensory receptor cells, such as taste cells or photoreceptors of the retina, graded potentials in their membranes result in the release of neurotransmitters at synapses with sensory neurons. Summation All types of graded potentials will result in small changes of either depolarization or hyperpolarization in the voltage of a membrane. If the total change in voltage in the membrane is a positive 15 mV, meaning that the membrane depolarizes from -70 mV to -55 mV, then the graded potentials This OpenStax book is available for free at http://cnx. For receptor potentials, threshold is not a factor because the change in membrane potential for receptor cells directly causes neurotransmitter release. However, generator potentials can initiate action potentials in the sensory neuron axon, and postsynaptic potentials can initiate an action potential in the axon of other neurons. Graded potentials summate at a specific location at the beginning of the axon to initiate the action potential, namely the initial segment. For sensory neurons, which do not have a cell body between the dendrites and the axon, the initial segment is directly adjacent to the dendritic endings. For all other neurons, the axon hillock is essentially the initial segment of the axon, and it is where summation takes place. Summation can be spatial or temporal, meaning it can be the result of multiple graded potentials at different locations on the neuron, or all at the same place but separated in time. Spatial summation is related to associating the activity of multiple inputs to a neuron with each other. Temporal summation is the relationship of multiple action potentials from a single cell resulting in a significant change in the membrane potential. At point B, a mix of excitatory and inhibitory postsynaptic potentials result in a different end result for the membrane potential. The process of converting electrical signals to chemical signals and back requires subtle changes that can result in transient increases or decreases in membrane voltage. To cause a lasting change in the target cell, multiple signals are usually added together, or summated. Does spatial summation have to happen all at once, or can the separate signals arrive on the postsynaptic neuron at slightly different times? Synapses There are two types of connections between electrically active cells, chemical synapses and electrical synapses. In a 534 Chapter 12 | The Nervous System and Nervous Tissue chemical synapse, a chemical signal—namely, a neurotransmitter—is released from one cell and it affects the other cell. In an electrical synapse, there is a direct connection between the two cells so that ions can pass directly from one cell to the next. If one cell is depolarized in an electrical synapse, the joined cell also depolarizes because the ions pass between the cells. Other synapses are similar to this, and the specifics are different, but they all contain the same characteristics. Neurotransmitter Release 2+ When an action potential reaches the axon terminals, voltage-gated Ca channels in the membrane of the synaptic end 2+ 2+ bulb open. The concentration of Ca increases inside the end bulb, and the Ca ion associates with proteins in the outer 2+ surface of neurotransmitter vesicles. The Ca facilitates the merging of the vesicle with the presynaptic membrane so that the neurotransmitter is released through exocytosis into the small gap between the cells, known as the synaptic cleft. Once in the synaptic cleft, the neurotransmitter diffuses the short distance to the postsynaptic membrane and can interact with neurotransmitter receptors. One neurotransmitter binds to its receptor and will not bind to receptors for other neurotransmitters, making the binding a specific chemical event (Figure 12. The presynaptic element is the synaptic end bulb of the axon where Ca enters the bulb to cause vesicle fusion and neurotransmitter release. The neurotransmitter is cleared from the synapse either by enzymatic degradation, neuronal reuptake, or glial reuptake. Neurotransmitter Systems There are several systems of neurotransmitters that are found at various synapses in the nervous system. These groups refer to the chemicals that are the neurotransmitters, and within the groups are specific systems. Both of these receptors are named for drugs that interact with the receptor in addition to acetylcholine.