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We have become dependent on myriad diagnostic studies that cheap 500mg meldonium otc treatment for bronchitis, while at times helpful buy meldonium 250 mg fast delivery treatment questionnaire, are sometimes unnecessary cheap 500mg meldonium mastercard medicine 7253 pill, expensive generic 250 mg meldonium with mastercard medicine 3 times a day, overutilized, time-consuming, and, occasionally, dangerous. Perioperative Care of the Surgery Patient 5 History and Physical Exam Nonsurgical Problem Surgical Problem Needs hospital admit Does not need hospital admit Appropriate medical referral Needs emergent Needs nonemergent Outpatient— surgery surgery referred to surgeon for workup Minimal diagnostic Tests and workup O. While specifics of the history and physical exam differ depending on the specific complaint of the patient and are discussed in greater detail in the ensuing chapters, there are a few constants to keep in mind. As simple and as seemingly easy as this is to do, it is something that all physi- cians, on occasion, fail to do. It can be time-consuming, since patients do not always clearly and concisely articulate their problem. Based on the chief complaint or complaints, the physician then can ask more directed questions to illuminate the problem further. Very often, the physician needs to act like a good newspaper reporter, concisely obtaining the What, Where, When, and How of a problem: What is the problem? Another critically important component of the patients’ history includes a listing of their past medical history, usually starting with whether or not they have ever experienced earlier episodes of their current problem. If they have, then a description of the type and success of the therapy may be helpful. One should inquire, in a systematic manner, about any history of major medical illnesses. The patient’s past medical history in the case presented at the beginning of this chapter is critically important. This certainly will give the examiner a clearer understanding of what the patient does and what sort of familial or social support the patient may have. Always inquire, in as nonjudgmental manner as pos- sible, about social habits such as smoking, alcohol intake, illegal drug 6 R. As delicate and uncomfortable as these ques- tions may be to both the patient and examiner, the answers are clini- cally and at times critically important. A thorough listing, including dosages, of medications is necessary and frequently provides insight into the patient’s underlying medical conditions. Inclusion of any adverse reactions or allergies to medications is of obvious import. This so-called “eyeball” test, while difficult to scientifically validate, can be helpful, particularly when the patient’s presenting problem requires urgent or emergent surgical intervention. This makes intuitive sense, and, if one performs the examination in the same order each time, the likelihood of missing an important physical finding decreases. Avoid the tendency to examine first, and sometimes only, the body area for which the patient has a complaint. The specifics of the physical exam will be dealt with more thoroughly in later chapters. Risk Assessment Cardiac It is estimated that more than 3 million patients with coronary artery disease undergo surgery every year in the United States. The challenge is proper assessment of an individual for coronary artery disease and whether preoperative intervention actu- ally improves the patient’s final outcome or merely shifts morbidity and mortality to another procedure or healthcare professional. This is one area where evidence-based medicine has made an attempt to provide healthcare professionals/surgeons with guidelines (Tables 1. One cannot emphasize enough the need to optimize the patient’s underlying cardiac conditions prior to surgery. Congestive heart failure should be controlled, blood pressure optimized, cardiac rhythm stabilized, and medications fine-tuned. Frequently, the surgeon must handle these issues, but a cardiologist or primary care physician can be extremely helpful in achieving these goals. The amount of testing that goes on in the name of cardiac risk assess- ment is staggering. The American College of Cardiology/American Heart Association Guideline Algorithm for Perioperative Cardiovas- cular Evaluation of Noncardiac Surgery provides useful and reason- able recommendations, which, if followed, may avoid unnecessary and expensive studies. Pulmonary In patients with a history of pulmonary disease or for those who will require lung resection surgery, preoperative assessment of pul- monary function is of value. Postoperative respiratory complications are leading causes of postoperative morbidity and mortality, ranking second only to cardiac complications as immediate causes of death. History and physical exam can be helpful in assessing a patient’s risk of pulmonary problems, and, frequently, these are all that are necessary. Perioperative Care of the Surgery Patient 9 normal physical exam and at low risk based on history. Preoperative laboratory testing is generally not predictive of peri- operative pulmonary problems. Studies often confirm what a careful physician already has deciphered from a history and physical exam. If emergent, detailed risk assessment must be deferred to the postoperative period. If so, further testing is generally unnecessary if the patient is stable/asymptomatic. If so, further testing is generally unnecessary if the patient is stable/asymptomatic. Unstable chest pain, decompensated congestive heart failure, symptomatic arrhythmias, and severe valvular heart disease require evaluation and treatment before elective surgery. Does the patient have intermediate clinical predictors of risk, such as prior myocardial infarction, angina pectoris, prior or compensated heart failure, or diabetes? Consideration of the patient’s capacity to function and the level of risk inherent in the proposed surgery can help identify patients who will benefit most from perioperative noninvasive testing. Patients with intermediate risk and good-to-excellent functional capacity can undergo intermediate-risk surgery with very little risk. Consider additional testing for patients with multiple predictors about to undergo higher-risk surgery. Further testing can be performed on patients with poor functional capacity in the absence of clinical predictors of risk, especially if vascular surgery is being planned. For high-risk patients about to go to high-risk surgery, coronary angiography or even cardiac surgery may be less than the noncardiac operation. Clinical, surgery-specific, and functional parameters are taken into account to make the decision. Indications for coronary revascularization are identical whether or not considered in preparation for noncardiac surgery. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Copyright 1996 The American College of Cardiology Foundation and American Heart Association Inc. Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Copyright 1996 The American College of Cardiology Foundation and American Heart Association Inc. Summary of evidence-based recommendations for supplemental evaluation of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Committee on Perioperative Cardiovascular Evaluation for Noncardiac Surgery, 1996.
Other significant and ongoing assessments focus on pain and psychosocial responses cheap 250mg meldonium mastercard treatment e coli, daily body weights order meldonium 500mg with mastercard treatment 0f gout, caloric intake buy generic meldonium 500 mg on line symptoms 8 weeks, general hydration best 500 mg meldonium medicine uses, and serum electrolyte, hemoglobin, and hematocrit levels. Assessment for excessive bleeding from blood vessels adjacent to areas of surgical exploration and débridement is necessary as well. Gerontologic Considerations In elderly patients, a careful history of preburn medications and preexisting illnesses is essential. Nursing assessment of the elderly patient with burns should include particular attention to pulmonary function, response to fluid resuscitation, and signs of mental confusion or disorientation. Because of lowered resistance, burn wound sepsis and lethal systemic septicemia are more likely in elderly patients. Nursing care of the elderly patient with burn injuries promotes early mobilization, aggressive pulmonary care, and attention to preventing complications. Diagnosis Nursing Diagnoses Based on the assessment data, priority nursing diagnoses in the acute phase of burn care may include the following: Excessive fluid volume related to resumption of capillary integrity and fluid shift from the interstitial to the intravascular compartment Risk for infection related to loss of skin barrier and impaired immune response Imbalanced nutrition, less than body requirements, related to hypermetabolism and wound healing needs Impaired skin integrity related to open burn wounds Acute pain related to exposed nerves, wound healing, and treatments Impaired physical mobility related to burn wound edema, pain, and joint 317 contractures Ineffective coping related to fear and anxiety, grieving, and forced dependence on health care providers Interrupted family processes related to burn injury Deficient knowledge about the course of burn treatment Collaborative Problems/Potential Complications Based on the assessment data, potential complications that may develop in the acute phase of burn care may include: Heart failure and pulmonary edema Sepsis Acute respiratory failure Acute respiratory distress syndrome Visceral damage (electrical burns) Planning and Goals The major goals for the patient may include restoration of normal fluid balance, absence of infection, attainment of anabolic state and normal weight, improved skin integrity, reduction of pain and discomfort, optimal physical mobility, adequate patient and family coping, adequate patient and family knowledge of burn treatment, and absence of complications. Achieving these goals requires a collaborative, interdisciplinary approach to patient management. To monitor changes in fluid status, careful intake and output and daily weights are obtained. Changes, including those of blood pressure and pulse rate, are reported to the physician (invasive hemodynamic monitoring is avoided because of the high risk of infection). Low-dose dopamine to increase renal perfusion and diuretics may be prescribed to promote increased urine output. The nurse is responsible for providing a clean and safe environment and for closely scrutinizing the burn wound to detect early signs of infection. Meticulous hand hygiene before and after each patient contact is also an essential component of preventing infection, even though gloves are worn to provide care. The nurse protects the patient from sources of contamination, including other patients, staff members, visitors, and equipment. Tube feeding reservoirs, ventilator circuits, and drainage containers are replaced regularly. Visitors are screened to avoid exposure of the immunocompromised patient to pathogens. Patients can inadvertently promote migration of microorganisms from one burned area to another by touching their wounds or dressings. Bed linens also can spread infection through either colonization with wound microorganisms or fecal contamination. Regular bathing of unburned areas and changing of linens can help prevent infection. Maintaining Adequate Nutrition Oral fluids should be initiated slowly after bowel sounds resume. If vomiting and distention do not occur, fluids may be increased gradually and the patient may be advanced to a normal diet or to tube feedings. The nurse collaborates with the dietitian or nutrition support team to plan a protein- and calorie-rich diet that is acceptable to the patient. Family members may be encouraged to bring nutritious and favorite foods to the hospital. Milkshakes and sandwiches made with meat, peanut butter, and cheese may be offered as snacks between meals and late in the evening. If caloric goals cannot be met by oral feeding, a feeding tube is inserted and used for continuous or bolus feedings of specific formulas. Parenteral nutrition may also be required but should be used only if gastrointestinal function is compromised (see Chapter 36). The patient can use this information to set goals for nutritional intake and to monitor weight loss and gain. Ideally, the patient will lose no more than 5% of preburn weight if aggressive nutritional management is implemented. The patient with anorexia requires encouragement and support from the nurse to increase food intake. Catering to food preferences and offering high-protein, high-vitamin snacks are ways of encouraging the patient to increase intake. Promoting Skin Integrity Wound care is usually the single most time-consuming element of burn care after the emergent phase. The physician prescribes the desired topical antibacterial agents and specific biologic, biosynthetic, or synthetic wound coverings and plans for surgical excision and grafting. The nurse needs to make astute assessments of wound status, use creative approaches to wound dressing, and support the patient during the emotionally distressing and very painful experience of wound care. The nurse serves as the coordinator of the complex aspects of wound care and dressing changes for the patient. The nurse must be aware of the rationale and nursing implications for the various wound management approaches. Nursing functions include assessing and recording any changes or progress in wound healing and keeping all members of the health care team informed of changes in the wound or in treatment. The nurse also assists the patient and family by providing instruction, support, and encouragement to take an active part in dressing changes and wound care when appropriate. To increase its effectiveness, analgesic medication is provided before the pain becomes severe. Nursing interventions such as teaching the patient relaxation techniques, giving the patient some control over wound care and analgesia, and providing frequent reassurance are helpful. Other pain-relieving approaches include distraction through video programs or video games, hypnosis, biofeedback, and behavioral modification. Lack of sleep and rest interferes with healing, comfort, and restoration of energy. If necessary, sedatives are prescribed on a regular basis in addition to analgesics and anxiolytics. The nurse works quickly to complete treatments and dressing changes to reduce pain and discomfort. The patient is encouraged to take analgesic medications before painful procedures. Oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silica-based lotion, exercise and splinting to prevent skin contracture, and diversional activities all help promote comfort in this phase. Promoting Physical Mobility An early priority is to prevent complications of immobility. Deep breathing, turning, and proper positioning are essential nursing practices that prevent atelectasis and pneumonia, control edema, and prevent pressure ulcers and contractures. Low-air-loss and rotation beds may be useful, and early sitting and ambulation are encouraged. If the lower extremities are burned, elastic pressure bandages should be applied before the patient is placed in an upright position.
Nonetheless generic 250mg meldonium with mastercard medicine 2355, it is acknowledged that the researcher enters into the process with their own discount meldonium 250 mg fast delivery treatment 3 cm ovarian cyst, personal preconceptions and inevitably influences the data obtained through the data gathering process (i generic meldonium 250mg with mastercard symptoms vomiting diarrhea. Grounded theory draws attention to the perspectives of research participants order meldonium 250mg visa medicine 101, including their subjective accounts of social and psychological events and of associated phenomenal and social worlds (Maxwell, 2005; Pidgeon, 1996; Rubin & Rubin, 1995). The ultimate purpose of grounded theory is to develop a theory that remains close to, and illuminates, the phenomenon under investigation by studying the experience from the standpoint of those who live it (Jones, Torres & Arminio, 2006). Grounded theory was deemed a suitable approach for the current study due to its commitment to communicating the participant perspective. I believe that the consumer perspective on medication adherence provides a valuable contribution to knowledge in the area, particularly because of the complexity of medication adherence and the failure of health services to address medication adherence effectively amongst people with schizophrenia on a large scale despite the extensive research in the area. With its openness to generating theory which has not necessarily been pre-established in research, I perceived a grounded theory approach to the topic of medication adherence as potentially groundbreaking as well as valuable both in academic and practical terms, with potential clinical implications (Rubin & Rubin, 69 1995). Although the research presented was influenced by a grounded theory approach, however, the analysis did not ultimately involve theory generation as this was beyond the scope of the thesis. Grounded theory methods have become a topic of debate from both proponents and opponents of the approach. Post-modernists and post- structuralists dispute the positivistic premises assumed by grounded theory’s major supporters and within the logic of the method itself (Charmaz, 2003). The positivistic assumptions of grounded theory stem from the reliance on a realist ontology, which posits that there is a “real”, objective reality that researchers are able to directly and, therefore, objectively and accurately capture and represent (Willig, 2001). There has also been divergence in the grounded theory methodology between Glaser and Strauss (in collaboration with his more recent co-author, Juliet Corbin), who have developed the grounded theory method into conflicting directions, leading to a split between Glaserian and Straussian grounded theory. Glaser’s position is close to traditional positivism, as it assumes an objective, external reality. Furthermore, the researcher is positioned as a neutral observer who discovers data, reduces inquiry to a set of manageable research questions and objectively renders data (Charmaz, 2003). Strauss and Corbin’s position assumes an objective external reality, aims toward unbiased data collection, proposes a set of technical procedures and supports verification (Charmaz, 2003). Strauss and Corbin’s stance is aligned more with post-positivism, however, as it additionally advocates giving voice to participants, representing them as accurately as possible, discovering and acknowledging how participants’ views of reality may conflict with researchers’ and recognizing creativity as well as science in the analytic product and process (Charmaz, 2003). As the primary researcher, I aimed to be reflexive throughout the conduction of the research presented. As acknowledged earlier, whilst the research presented was influenced by a grounded theory approach, a process model of medication adherence as part of the analysis was not produced as this was beyond the scope of the thesis. Participation was completely voluntary and participants were free to withdraw from the study at any time prior to the completion of interviews. As the primary investigator, I distributed information sheets to potential participants for their perusal. Potential participants were encouraged to discuss the study and share all documents with other members of the public, such as family members, peers, case managers or health workers prior to deciding whether to participate or not. Upon agreeing to participate, prospective interviewees were given a consent form to sign and were then screened to ensure they met the requirements for the study. Transcriptions were transferred into a study database to allow the results of this study to be 71 analysed and reported. Respondents were assured that their identities (and the identities of other people discussed in interviews) would remain confidential as no identifying information would be included in the write-up. Pseudonyms were created for participants (and other people discussed, such as prescribers) to help to preserve their anonymity and other identifying information was changed or excluded from transcriptions. Information provided by participants in interviews was only used for the purpose of the study. The initial recruitment strategy involved distributing flyers to various outpatient services, which was ineffective in attracting participants (see Appendix A for example flyer). Approaching potential participants was much more effective in the early stages of recruitment, with the assistance of a research nurse. Presenting my research to outpatient groups and asking for expressions of interest in participating also proved an effective means of recruitment. The research nurse was of great assistance as she had contact details of several consumers who were willing to participate in research as they had done so in the past. The research nurse facilitated this process significantly, through identifying relevant contacts or by recognizing potential candidates in settings (such as the medication clinic) where I was unable to. Snowball sampling then occurred naturally as many interviewees stated that they enjoyed interviews and, thus, agreed to distribute information sheets to peers who met the study requirements. As my details were listed on the information sheet (see Appendix C), I was then contacted by consumers and interviews were arranged. Recruitment ceased following theoretical saturation, when I noticed consistent repetition of codes and no new conceptual insights were generated (Bloor & Wood, 2006). I decided that I had reached theoretical saturation in consultation with my supervisors. Two more interviews were conducted after this to ensure that saturation had been achieved. Of note, the grounded theory principle of theoretical sampling was not adhered to. Theoretical sampling refers to the purposive selection of research participants to compare with prior cases in order to gain a deeper understanding of analysed cases (Glaser & Strauss, 1967). Sampling is, thus, based on emerging codes and categories until a full and varied category is developed and tested against incoming cases. All participants in the research presented were outpatients with schizophrenia and exclusion criteria were minimal. As interviewees’ experiences were so varied and they were asked to reflect on their experiences at different stages of their illnesses, theoretical sampling was deemed unnecessary. Although it could be argued that 73 inclusion of service providers views, for example, may have broadened the theory, this would have been inconsistent with the focus of this research; the consumer perspective. Of note, it was found during screening for entry into the study, that some people who had been given formal diagnoses of schizoaffective disorder also matched the criteria for schizophrenia and were, therefore, included in the study. Participants were also required to sign a consent form prior to taking part (see Appendix D). The exclusion criteria for this study were intellectual disability and severe co-morbid conditions (such as drug dependence which could hinder capacity to interview). Furthermore, the original exclusion criterion of people being prescribed typical antipsychotic medication was also removed as it was decided that this could potentially render irrelevant interesting discussions about past experiences with medications amongst interviewees who were previously prescribed typical antipsychotic medications. Furthermore, the 74 views of consumers who continue to be prescribed typical medications are considered just as important as those who are prescribed atypical medications, particularly considering that there are adherence difficulties associated with both types of medication. The screening process was tested on two pilot interviewees and on some peers who did not have a previous diagnosis of schizophrenia and it proved effective. The same approach had previously also been used effectively by a fellow student examining cognition amongst people with schizophrenia.
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