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Don’t give potassium if the patient suffers from renal insufficiency order super viagra 160 mg on-line erectile dysfunction drugs compared, renal failure discount 160 mg super viagra with mastercard erectile dysfunction drugs for diabetes, or Addison’s disease best super viagra 160 mg what std causes erectile dysfunction. Do not give potassium if the patient has hyper- kalemia order discount super viagra on-line erectile dysfunction treatment natural remedies, severe dehydration, acidosis, or takes potassium-sparing diuretics. Sodium Sodium is the major cation in extracellular fluid found in tissue spaces and ves- sels. Sodium plays an important role in the regeneration and transmission of nerve impulses and affects water distribution inside and outside cells. When it shifts into the cell, depolarization (contraction) occurs; when it shifts out of the cell, potas- sium goes back into the cell and repolarization (relaxation) occurs. The kidneys regulate the sodium balance by retaining urine when the sodium concentration is low and excreting urine when the sodium concentration is high. Most excess sodium is excreted in urine although sodium also leaves the patient as perspira- tion and in feces. The serum sodium level, which is the ratio of sodium to water, is the indicator of the sodium level in a patient’s body. A patient’s serum sodium level moves out of the normal range when the patient is retaining too much or too little water, has a high or low concentrations of sodium, or a combination of both. A patient is hypernatremic when there is a high concen- tration of sodium and hyponatremic when there is a low concentration of sodium. Hypernatremia Hypernatremia occurs when the patient’s serum sodium is greater than 145 mEq/L. This happens for one of two reasons: The patient’s sodium concentration has increased while the volume of water remains unchanged or the patient’s water volume has decreased while the sodium concentration remains unchanged. Regardless of what happened, the patient experiences hyperosmolality, which is a higher-than-normal concentration of sodium. This causes water to shift out of cells and into extracellular space resulting in cellular dehydration. However, a patient whose consciousness is impaired or who cannot swallow, such as a frail elderly patient, is at risk for hypernatremia. These are: • Agitation • Restlessness • Weakness • Seizures • Twitching • Coma • Intense thirst • Dry swollen tongue • Edematous (swollen) extremities The nurse should educate the patient to: • Avoid foods rich in sodium such as canned foods, lunch meats, ham, pork, pickles, potato chips, and pretzels. Hyponatremia Hyponatremia occurs when the patient’s serum sodium is less than 135 mEq/L. There are two reasons why this happens: the patient has increased the volume of water while the sodium concentration remains normal or the patient losses sodium while the water volume remains normal. The nurse must recognize the following symptoms of hyponatremia: • Fatigue, • Headache, • Muscle cramps, • Nausea, • Seizures, • Coma. The nurse should educate the patient to: • Not drink excessive amounts of pure water on a hot day or after extreme exercise. Fluid replacement should be an electrolyte solution such as Gatorade or other commercial preparations that include sodium. Calcium Calcium is found in equal proportion in intracellular fluid and extracellular fluid. Calcium plays a critical role in transmission of nerve impulses, blood clotting, muscle contraction, and the formation of teeth and bone. There are three forms of calcium in serum that can fluctuate among forms depending on changes to the serum pH and/or serum protein (albumin) levels. Complex form, which is where calcium is combined with phosphate, cit- rate, or carbonate. However, ionized cal- cium (iC) levels are sometimes reported separately (4–5 mg/dL). Eggs, green leafy vegetables, broccoli, legumes, nuts, and whole grains provide smaller amounts. Absorption is influenced by the amount of vitamin D available and the levels of calcium already present in the body. Hypercalcemia Hypercalcemia is a condition when the serum calcium level is higher than 10. The calcium level may need to be lowered quickly because severe hypercalcemia can be life threatening. Administer furosemide (Lasix) or ethcrynic acid (Edecrin) loop diuret- ° ics after adequate fluid intake is established. Hemodialysis is the most effective method to lower calcium levels in severe cases when kidney function is not normal. Too little calcium intake causes cal- cium to leave the bone to maintain a normal calcium level. Fractures (broken bones) may occur if a calcium deficit persists because of calcium loss from the bones (demineralization). Patients who experience hypocalcemia may have the following symptoms: • Depression. Patient education should include information about dietary sources of cal- cium, the need to maintain physical activity to avoid bone loss, avoid overuse of antacids, and chronic use of laxatives. Patients should be taught to use fruits and fiber for improving bowel elimination. Mag- nesium is the coenzyme that metabolizes carbohydrates and proteins and is involved in metabolizing nucleic acids within the cell. Hypermagnesemia Hypermagnesemia is a condition experienced by a patient whose serum magne- sium level is greater than 2. The major cause of hypermagnesia is an excessive intake of magnesium salts in laxatives such as magnesium sulfate, milk of magnesia, and magnesium citrate. Patients who take lithium (anti- psychotic medication) are also at risk for hypermagnesemia. Hypomagnesemia Hypomagnesemia happens when the serum magnesium level is less than 1. This can be caused by long-term administration of saline infusions which can result in the loss of magnesium and calcium. Diuretics, certain antibiotics, laxatives, and steroids are drug groups that promote magnesium loss. Hypomagnesemia also enhances the action of digitalis and can cause dig- italis toxicity. Patients who have hypomagnesemia may exhibit no signs and symptoms until the serum level approaches 1. Signs of severe hypomagnesemia include tetany-like symptoms caused by hyperexcitability (tremors, twitching of the face), ventricular tachycardia that leads to ventricular fibrillation, and hypertension. Treatment for hypomagnesemia includes: • Administering intravenous magnesium sulfate in solution slowly. Use an infusion pump to prevent rapid infusion that might result in cardiac arrest.
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However order super viagra with american express erectile dysfunction ultrasound, when new structural groups are incorporated into the structure of a drug the activity of the drug could be changed generic 160 mg super viagra fast delivery impotence and diabetes 2. Consequently 160 mg super viagra with mastercard psychological erectile dysfunction drugs, it will be necessary to carry out a full trial programme on the new analogue buy super viagra 160 mg without a prescription impotence marijuana facts. Both these modifications can be costly pro- cesses if they have to be carried out at a late stage in drug development. The use of specialized dosage forms does not usually need extensive additions to the trials programme but these formulation methods are only suitable for use with some drugs. The structural factors controlling a compound’s lipid solubility are the opposite of those responsible for a compound’s water solubility. Consequently, lipid solubility may be improved by replacing polar groups by nonpolar struc- tures or groups that are significantly less polar in nature. Conse- quently, the pH of the biological fluid may affect the solubility of a drug and, as a result, its activity. In general, increasing the hydrophilic nature of the salt should increase its water solubility. However, there are numerous exceptions to this generalization, and each salt should be treated on its merits. Acidic drugs are usually converted to their metallic or amino salts, whilst the salts of organic acids are normally used for basic drugs (Table 3. The degree of water solubility of a salt will depends on the structure of the acid or base (see section 3. For example, acids and bases whose structures contain water solubilizing groups will form salts with a higher water solubility than compounds that do not contain these groups (Figure 3. However, if a drug is too water soluble, it will not dissolve in lipids and so will not usually be readily transported through lipid membranes (Appendix 5). This normally results in either its activity being reduced, or the time for its onset of action being increased. The possible positions of hydrogen bonds are shown by the dashed lines------; lone pairs areomitted forclarity. Note: hydrogen bonds are not shown for the acidic protons of the acids as these protons are donated to the base on salt formation. Similarly, no hydrogen bonds are shown for the lone pairs of the amino groups, because these lone pairs accept a proton in salt formation presence of a high concentration of chloride ions in the stomach will reduce the solubility of sparingly soluble chloride salts because of the common ion effect. Acidic and basic groups are particularly useful, since these groups can be used to form salts (see section 3. However, the formation of zwitter- ions by the introduction of either an acid group into a structure containing a base or a base group into a structure containing an acid group can reduce water solubility. Introduction of weakly polar groups, such as carboxylic acid esters, aryl halides and alkyl halides, will not significantly improve water solubility and can result in enhanced lipid solubility. In all cases, the degree of solubility obtained by the incorporation cannot be accurately predicted since it also depends on other factors. Consequently, the type of group introduced is gener- ally selected on the basis of previous experience. The incorporation of acidic residues into a lead structure is less likely to change the type of activity, but it can result in the analogue exhibiting haemo- lytic properties. Furthermore, the introduction of an aromatic acid group usually results in anti-inflammatory activity, whilst carboxylic acids with an alpha functional group may act as chelating agents. Basic water solubilizing groups have a tendency to change the mode of action, since bases often interfere with neurotransmitters and biological processes involving amines. However, their incorporation does mean that the analogue can be formulated as a wide variety of acid salts. Groups that are linked to the lead by ester, amide, phosphate, sulphate and glycosidic links are more likely to be metabol- ized from the resulting analogue to reform the parent lead compound as the analogue is transferred from its point of administration to its site of action. Compounds with this type of solubilizing group are acting as prodrugs (see section 9. However, the rate of loss of the solubilizing group will depend on the nature of the transfer route, and this could affect the activity of the drug. Consequently, the route used to introduce a new water solubilizing group and its position in the lead structure will depend on the relative reactivities of the pharmacophore and the rest of the molecule. The reagents used to introduce the new water solubilizing group should be chosen on the basis that they do not react with, or in close proximity to, the pharmacophore. This will reduce the possibility of the new group affecting the relevant drug–receptor interactions. Introduction at the begining avoids the problem of a later introduction changing the type and/or nature of the drug–receptor interaction. A wide variety of routes may be used to introduce a water solubilizing group; the one selected will depend on the type of group being introduced and the chemical nature of the target structure (Figures 3. Many of these routes require the use of protecting agents to prevent unwanted reactions of either the water solubilizing group or the lead structure. O-alkylation, N-alkylation, O-acylation and N-acylation reactions are used to introduce both acidic and basic groups. Phosphate acid halides have been used to introduce phosphate groups into lead structures. The hydroxy groups of the acid halide must normally be protected by a suitable protecting group. These protecting groups are removed in the final stage of the synthesis to reveal the water solubilizing phosphate ester. Structures containing hydroxy groups have been intro- duced by reaction of the corresponding monochlorinated hydrin and the use of suitable epoxides amongst other methods. This activity may be either similar to that of the original compound but different in potency and unwanted side effects or com- pletely different to that exhibited by the original compound. A study of the structure–activity relationships of a lead compound and its analogues may be used to determine the parts of the structure of the lead compound that are responsible for both its beneficial biological activity, that is, its pharmacophore, and also its unwanted side effects. This information may be used to develop a new drug that has increased activity, a different activity from an existing drug and fewer unwanted side effects. Structure–activity relationships are usually determined by making minor changes to the structure of a lead to produce analogues (see section 2. The investigation of numerous lead compounds and their analogues has made it possible to make some broad generalizations about the biological effects of specific types of structural change. It is believed that structural changes that result in analogues with increased lipid character may exhibit either increased activity because of better membrane penetration (Figure 4. However, whatever the change, its effect on water solubility, transport through membranes, receptor binding, and metabolism and other pharmacokinetic properties of the analogue should be considered as far as is possible before embarking on what could be an expensive synthesis. Furthermore, changing the structure of the lead com- pound could result in an analogue that is too big to fit its intended target site. Computer assisted molecular modelling (see Chapter 5) can alleviate this problem, provided that the structure of the target is known or can be simulated with some degree of accuracy. However, it is emphasized that although it is possible to predict the effect of structural changes there will be numerous exceptions to the predictions, and so all analogues must be synthesized and tested. These types of structural change usually result in analogues that exhibit either a different potency or a different type of activity to the lead.
Extending practice should be part of each nurse’s professional development super viagra 160mg lowest price back pain causes erectile dysfunction, and so relevant material discount super viagra 160 mg otc impotence clinics, with written reflections on the process purchase super viagra overnight delivery erectile dysfunction over the counter, can provide valuable additions to professional profiles purchase super viagra on line amex erectile dysfunction drug mechanism. Implications for practice ■ change will occur, and the rate of change will increase ■ nurses can either proactively manage change or reactively be managed by others Intensive care nursing 454 ■ any change forced on people against their will is usually overturned at the earliest opportunity ■ change management should therefore seek to alter values ■ bottom-up approaches are more likely to succeed, as they adopt the norms of majorities ■ change is stressful for all concerned, and so should be carefully planned ■ detailed planning, with specific target dates and achievable goals, helps to prevent procrastination ■ change agents should facilitate informed decision making ■ change agents should acknowledge their own and others’ limitations ■ all staff are likely to need support through the stressful time of change ■ opposition to change can provide a forum for constructive debate ■ change agents should pre-plan how and when their initiative will be evaluated, and be prepared to modify plans where necessary Summary The pace of change is accelerating; nurses and nursing can choose between managing change or being managed by others. Other chapters in this book may have triggered ideas that readers wish to translate into practice. Changes are more likely to succeed if carefully planned, and so this chapter has described models and strategies to help them succeed in introducing change. Further reading Wright (1998) provides a practical description of change management; action research (Webb 1989) offers a way to develop change through practice. Toffler (1970) remains challenging, developing wider perspectives (although providing little immediate help for nurses wishing to make changes). The problems of ritualised nursing are illustrated by Walsh and Ford (1989) and Ford and Walsh (1994). Journals specialising in nursing management frequently include articles on change management (e. How are nurses or other members of healthcare teams (doctors, pharmacists, cleaners, porters) affected by these changes? Using your own example: (a) Identify the style and approaches used (top-down, bottom-up, etc. This chapter provides a trouble-shooting introduction for staff not normally in charge of their units (hence the direct address to readers). The terms manager and management in this chapter normally refer to the nurse-in-charge of the shift, rather than to more senior management; where appropriate, senior management is specifically identified. Some information may be factual, but much of it will be a matter of sharing experience and ideas in order to help others make clinical decisions. Hence, for the most part, options, rather than answers, are provided, and the issues will serve their purpose if they help readers to clarify their own values. Starting to manage Much has been written about management, mostly from industrial perspectives, although there is a growing body of literature on health service management. Vaughan and Pilmoor (1989) suggest that management is getting the work done through people. The nurse-in-charge should establish constructive working conditions at the start of the shift, enabling the development of the individual strengths and skills of staff, while recognising individual needs and limitations. Managers should individually assess and proactively plan and respond to needs for each shift, rather than seeking to impose their own agendas on staff. You may remember most patients from your previous shift; if not, briefly assess patients before taking handover. You may need to walk through your unit to take handover, but if not a brief look at the unit can suggest both the number and dependency of patients (high-dependency patients usually have more equipment and people at a bedspace). Since managers rely on their staff to achieve the work, staff are the manager’s most important resource. Staff numbers are important—are there enough staff for patients already on the unit and the expected/potential admissions? Some staff need more support than others; each has different experience, knowledge and skills to draw on. Most staff will probably be known to you and so scanning the off-duty roster helps your planning; with new or unfamiliar (e. Allocation of staff may be guided by managerial structures such as named and team nursing; specific allocation should consider: ■ the need to maintain patient safety ■ the optimisation of patient treatment ■ the development and support of staff. The most experienced member of staff may be able to give the best care to the sickest patient, but without gaining experience of nursing very sick patients, junior staff will be denied opportunities to develop their skills. If they are continually denied developmental experience, they may become demotivated and leave, or be unable to care safely for the sicker patients when more experienced staff are not available. Safety during break cover should also be considered: two junior nurses may safely manage adjacent patients when both are present, but become unsafe if caring for two patients when covering each other’s breaks. The Health and Safety at Work Act (1974) places specific requirements on managers (and employees) to ensure workplaces are safe; the nurse-in-charge also has wider moral responsibilities for the health and safety of their staff and patients. Fire exits should remain clear and accessible at all times, and safety and emergency equipment should be Intensive care nursing 458 complete and in working order. Emergency equipment varies between units, but may include the resuscitation trolley, emergency intubation trolley and, on cardiothoracic units, thoracotomy pack. The nurse-in-charge is responsible for all patients on their unit, even if some responsibilities are devolved to team/area sub-managers. Following handover, the nurse- in-charge should visit each patient to make their own assessment, identify the needs of each bedside nurse, and pass on any relevant additional information/expectations. Sufficient time should be allowed for bedside nurses to take individual handovers, complete their own safety checks and make their own patient assessment; seeking information before bedside nurses can fully assimilate it can create stress for the nurse without providing the manager with full information. Looking through each patient’s notes gives bedside nurses time to complete their initial assessment and checks, while giving managers information that may have been missed in handover (relevant points should then be passed on to the bedside nurse). The nurse-in-charge should ensure that imminent shifts are adequately covered by checking staff numbers and initiating the booking of any additional staff required. Many agencies provide their main service during office hours, and so planning should include all shifts until the agency’s next ‘working’ period; on-call services may be able to provide emergency cover, but they often have few remaining staff to allocate. However, this can cause a conflict of roles between their responsibility to the unit as a whole (as manager) and individual responsibility to their patient; it also limits their availability to other members of staff. Instead, it may be reasonable to allocate two patients to one member of staff; the appropriateness or otherwise of assuming direct patient care necessarily remains an individual decision, based on resources available and remembering that the nurse-in- charge remains accountable for whatever decision is made. Managers need to maintain clinical skills and credibility; with career progression and increasing management duties, staff may need to identify shifts when they assume direct patient care without unit management responsibilities. Staff morale Managers are responsible for enabling others to achieve their work goals, and so need to motivate and communicate (Drucker 1974). Nursing demands a high level of cognitive, affective and psychomotor skills, and the ability of staff to realise their potential is affected by their morale. Maintaining staff and unit morale is therefore an important management skill; loyal staff are more likely to support managers during crises. It follows that managers need good interpersonal skills and respect for, as well as of, their staff. If aware of unsatisfactory practices, they should approach staff constructively, identifying why staff are acting that way (rationale, knowledge base), treating the incident as a developmental learning opportunity rather than a belittling and humiliating experience for the junior nurse (or possibly the manager); if patient safety is compromised, managers may need to act before any discussion. Delayed, compromised or missed breaks often cause dissatisfaction, so that ensuring the smooth (and safe) organisation of breaks for staff is an important duty of managers. Organising break relief varies between units and shifts; where units have a system that works and is familiar to staff, this should be followed. Managers may need to assume some direct patient responsibilities to cover breaks; this can also provide them with valuable opportunities to assess patients and the nurse’s skills and needs. However, possible conflicts with managerial duties (see above) should be considered, especially if providing relief in inaccessible areas (e.