By K. Muntasir. Andrew Jackson University. 2018.
In the absence of either complete clinical findings consistent with brain death buy zyban 150mg with visa, or confirmatory tests demonstrating brain death discount 150 mg zyban fast delivery, brain death cannot be diagnosed purchase zyban 150mg on-line. Brain death test Sufficient time period has been passed to exclude possibility of possible recovery of meaningful neurological function cheap zyban 150 mg with visa, several hours to days as per clinical factors. Ocular movement Absent oculocephalic reflex (doll’s eye ) Absent cold caloric responses (vestibulo-ocular reflex) Absent Facial sensory and motor response Absent Pharyngeal reflex and Tracheal reflex Absence of gag reflex. Observation period between two examination Depends on the age of the patient; 7 days to 2 month old minimum 48 hr interval. Communication with family and further decision making After the clinical criteria of brain death have been met, the physician should inform the next of kin, who can be approached about organ donation. Counseling The family should be counseled that the patient cannot recover Family should be counseled for organ donation If the patient cannot become an organ donor, withholding or withdrawing of life support may be discussed with the family. Referral Criteria If the patient is a potential organ donor, he should be transferred to a tertiary level centre that is certified by the competent authority and is capable of supporting the brain dead organ donor If in some cases further diagnostic studies are required to confirm brain death o Difficulty to determine coma. Supportive treatment should start early as soon as brain death has been recognized irrespective of the consent. Switch the focus of the management for elevated intracranial pressure and brain protection, to preservation of organ function and optimization of tissue oxygen delivery. Hemodynamic support Hypertension Hypertension and bradycardia preceding brain death characterize the Cushing’s response. Thyroid hormone replacement Thyroid hormone administration typically with T3 (triiodothyronine) which is the active form of thyroid hormone. Coagulopathy If clinically significant mucocutaneous bleeding, treatment with appropriate blood components is required. Absolute Contraindications to organ donation Malignancy (except primary brain tumors, low grade skin malignancies and carcinoma in situ of the cervix). Conclusion A severe shortage of organs the world over has led to increased pressure on the intensive care staff for early identification of the brain dead donor and optimum management of this condition. The diagnosis of brain death as per the Transplantation Human Organ Act 1994 is based on simple clinical bedside tests,no need of routine confirmatory test. This Act has made it possible in India to use this pool of patients for organ retrieval and transplantation. The process of organ donation and transplantation requires co-ordination between multidisciplinary teams operating almost simultaneously and sometimes in different locations like getting surgeons from different specialties together for both donor and recipient surgery. Further reading Evidence-based guideline update: Determining brain death in adults : Report of the Quality Standards Subcommittee of the American Academy of Neurology Eelco F. N Engl J Med 2008; 359:674-675 Transcranial Doppler Ultrasonography to confirm brain death: a meta-analysis Louisa M. Simini Intensive Care Med (1995) 21:657-662 Brain death: timing of apnea testing in primary brain stem lesion, G. In non-immunosuppressed patient two consecutive temperature (core) of more than 101° F warrants further investigation. New onset of fever below this range, in a hemodynamically stable patient requires a bedside assessment to look for a source of infection and non infectious fever and sending investigation appropriately. Genitourinary: Bacterial or fungal cystitis, Pyelonephritis, Perinephric abscess, Tubo-ovarian mass, Endometritis, Prostatitis vii. Cutaneous: Cellulitis, Suppurative wound infection, Necrotizing fasciitis, Bacterial myositis, Herpes zoster ix. Strict asepsis, hand hygiene measures & universal precautions can bring down the infection related fevers. Regular surveillance can help in identifying non-compliant staff, which can be appropriately counseled. Optimal Diagnostic Criteria, Investigations, treatment & referral criteria *Situation1: At secondary Hospital/ Non-Metro situations: Optimal standards of treatment in situations where technology & resources are limited. Symptoms and signs in the absence of fever, which mandate a comprehensive search for infection and aggressive, immediate empirical therapy: Unexplained hypotension, tachycardia, tachypnea, confusion, rigors, skin lesions, respiratory manifestations, oliguria, lactic acidosis, leukocytosis, leukopenia, immature neutrophils (i. A detailed medication history, line manipulation, blood transfusion, appearance of new rash, diarrhea, or any new procedure performed should be enquired b. Focused physical examination should be performed looking for any source of sepsis or non-infectious cause of fever.
The damaged cells release chemical mediators such as histamine from the mast cells buy 150 mg zyban mastercard, which dilate the near by blood vessels discount 150mg zyban. They get activated due to the tissue damage and this process leads to “walling off” the area and this helps to prevent spreading of the infectious material zyban 150 mg low price. It attaches to the target and releases a lethal burst of chemicals called as perforins that penetrate the cell wall buy discount zyban 150 mg on line. Interferon Interferons are proteins produced by body cells when they are invaded by viruses, is released into the bloodstream or intercellular fuid, in order to induce healthy cells to manufacture an enzyme that block viral replication. The complement system is the part of innate immune system plays an important defense against microorganisms, especially gram-negative bacteria. The complement system consists of a set of over twenty serum proteins which are getting activated as follows. The pathways include the classic pathway (C1qrs, C2, C4), the alternative pathway (C3, factor B, properdin) and these two pathways converge at the component C3. Generally, they take part in differentiating self and non self antigens and the presentation of processed foreign antigen to activate the T cells. It has the special ability to keep memory of frst time exposure of an antigen (primary immune response) and mounts better response when there is second time exposure of same antigen (secondary immune response). Natural (Due to natural entry of pathogen) Actively acquired Artificial (Due to artificially introduced antigen like immunization process) Natural (Baby receives the antibody synthesized by the Passively mother through mother’s milk acquired Artificial (Antibodies are introduced artificially) 150 10. Though the classifcation separates the cell mediated and humoral immunity with different cell types they do interact to bring an effective immune response. Specifc T-cells are stimulated to produce lymphokines that are responsible for the antigen-induced B-cells proliferation and differentiation. Through a process of clonal selection specifc B-cells are stimulated, the activated B-cell frst develops into a B-lymphoblast, becoming much larger and shedding all surface immunoglobulin. This terminal differentiation stage is responsible for production of primarily IgM antibody during the primary immune response. Upon subsequent encounter with antigen, these cells respond very quickly to produce large amounts of IgG, IgA or IgE antibody, generating the better secondary immune response. These stages are, of course, initiated upon encounter with antigen and activation by T-helper cell to secrete lymphokines. When high doses of antibody interact with the entire antigen’s epitopes thereby inhibits interactions with B-cell receptors. T cells are initially formed in the bone marrow and get its maturation and differentiation in the thymus gland. T cells are associated with certain types of allergic reactions called Delayed hypersensitivity and also in transplanted organ rejection. Suppressor (T ) cells appear S to regulate the immune response once the antibody formation reached the adequate levels. In addition, these proinfammatory cytokines activate the immune system, mobilizing neutrophils from bone marrow, causing dendritic cells to migrate to lymph nodes, and also initiating changes in adipocyte and muscle metabolism and also responsible for inducing fever. Antigens can be defned as a substance that can combine specifcally to the components of immune response such as lymphocytes and antibodies. An immunogen is any substance that has the ability to evoke B or T or both B and T mediated immune reactions. Whole antigen cannot combine with the antibody as antibodies are formed against specifc regions on the surface of an antigen called antigenic determinant or epitopes. Most antigens are proteins, nucleoproteins, lipoproteins, 153 glycoproteins, or large polysaccharides with a molecular weight greater than 10,000. However the low-molecular-weight substance that can combine with an antibody but cannot induce the formation of antibodies are called as haptens. However the following factors can also infuence it, 1) The antigenic response which is indicated by the quantum of antibody formed in response to antigenic stimulation varies depending on the dosage of antigen administered, route of administration and use of adjuvant etc. Because of this the virus which has the very low molecular weight proteins escapes the immune response. Recruit other cells and molecule to destroy the pathogen (effectors function or Biological activity) 154 Fig. When the same IgG molecule subjected to pepsin cleavage it resulted with a divalent antigen binding Fab part and fragments of Fc portion.
When collecting specimen wear gloves to protect self from contact with the specimen (body fluids in particular) 6 discount zyban 150 mg amex. Put the collected specimen into its container without contaminating outer parts of the container and its cover order zyban 150mg visa. All the specimens should be sent promptly to the laboratory order zyban 150mg fast delivery, so that the temperature and time changes do not alter the content buy 150 mg zyban visa. Collecting Stool Specimen Basic Nursing Art 72 Purpose • For laboratory diagnosis, such as microscopic examination, culture and sensitivity tests. Equipments required • Clean bedpan or commode • Wooden spatula or applicator • Specimen container • Tissue paper • Laboratory requests • Disposable glove, for patients confined in bed • Bed protecting materials • Screen • Hand washing sets Procedure i) For ambulatory patient Give adequate instruction to the patient to • Defecate in clean bedpan or commode (toilet) • Avoid contaminating the specimen by urine, menstrual period or used tissue papers, because these may affect the laboratory analysis. Obtain stool sample • Take the used bedpan to utility room/toilet container using spatula or applicator without contaminating the outside of the container. Clean voided urine specimen (Also called clean catch or midstream urine specimen) 2. Timed urine specimen • It is two types Short period → 1-2 hours Long period → 24 hours Purpose • For routine laboratory analysis • To cheek the presence of cells or microorganisms • For culture and sensitivity tests Equipments Required • Disposable gloves • Specimen container • Laboratory requisition form (Completely filled) • Water and soap or cotton balls and antiseptic solutions (swabs). Obtain urine specimen • Ask patient to void • Let the initial part of the voiding passed into the receptacle (bed pan or urinal) then pass the next part (the midstream) into the specimen container. Care of the specimen and the equipment • Handle and label the container correctly • Send the urine specimen to the laboratory immediately together with the completed laboratory requested forms • Empty the receptacles content properly • Give appropriate care for the used equipments 6. Collecting the urine • Usually it is begin in the morning • Before you begin the timing, the patient should void and do not use this urine (It is the urine that has been in the bladder some time) • Then all urine voided during the specified time (e. Collecting sputum specimen Sputum is the mucus secretion from the lungs, bronchi and trachea, but it is different prom saliva. If the patient fails to cough out, the nurse can obtain sputum specimen by aspirating pharyngeal secretion using suction. Patient preparation • Before collecting sputum specimen, teach pt about the difference between sputum and saliva, how to cough deeply to raise sputum. Obtain sputum specimen • Put on gloves, to avoid contact with sputum particularly it hemoptysis (blood in sputum) present. If contaminated clean (wash) with disinfectant • Cover the cape tightly on the container 3. Recomfort the patient • Give oral care following sputum collection (To remove any unpleasant taste) 4. Care of the specimen and the equipments used • Label the specimen container • Arrange or send the specimen promptly and immediately to laboratory. Document the amount, color, consistency of sputum, (thick, watery, tenacious) and presence of blood in the sputum. Collecting Blood Specimen The hospital laboratory technicians obtain most routine blood specimens. Venous blood is drown for most tests, but arterial blood is drawn for blood gas measurements. Patient preparation • Instruct the pt what to expect and for fasting (if required) • Position the pt comfortably 2. Select and prepare the vein sites to be punctured • Put on gloves • Select the vein to be punctured. Usually the large superficial veins used such as, brachial and median cubital veins. It must be tight enough to obstruct vein blood flow, but not to occlude arterial blood flow. Obtain specimen of the venous to blood Basic Nursing Art 81 • Adjust the syringe and needles • Puncture the vein sites • Release the tourniquet when you are sure in the vein • Withdraw the required amount of venous blood specimen • Withdraw the needle and hold the sites with dry cotton (to apply pressure) • Put the blood into the specimen container • Made sure not to contaminate outer part of the container and not to distract the blood cells while putting it into the container 4. Care of the specimen and the equipment • Label the container • Shake gently (if indicated to mix) • Send immediately to laboratory, accompanying the request • Give care of used equipments 6. Care of Patient with Fever This includes sponging of the skin with alcohol or cool water for reducing temperature Solution: Tepid (luck – warm) water Alcohol • Part of alcohol to 3 parts of Luke warm H2O remove patient’s gown • Take the patient temperature, sponge the body using the wash cloth alternately, sponge each part 2-3 min.
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