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Some clinical and basic research demonstrated that Ourengedokuto also improves decreased cerebral blood flow purchase elavil 50mg,29 ischaemia-induced neuronal death30 and damaged cognitive function order 50mg elavil with visa. Chotosan (Diao-Teng-San) Chotosan comprises ten components generic elavil 50 mg amex, of which nine are herbs: Pinelliae tuber, Poria, Ginseng radix, Zingiberis rhizoma, Uncariae ramulus et uncus, Ophiopogonis tuber, Aurantii nobilis pericarpium, Chrysanthem flos, Saphoshnikoviae divaricata and the mineral gypsum fibrosum (considered to be a herb in kampo medicine). Chotosan is administered to older patients with physical weakness and such subjective symptoms as headache, heavy feeling of the head, vertigo, hot flush, tinnitus, insomnia and painful tension of the shoulder. Terasawa and co-workers demonstrated a double-blind, Japanese kampo medicine | 251 placebo-controlled clinical study of Chotosan in the treatment of vascular dementia. The change in the revised version of Hasegawa’s dementia scale from the start point in the Chotosan group tended to be higher than that in the placebo group with no statistical significance. Kampo formulae for renal diseases Saireito (Chai-Ling-Tang) Saireito consists of 12 component herbs: Bupleuri radix, Pinelliae tuber, Alismatis rhizoma, Scutellariae radix, Zizyphi fructus, Ginseng radix, Poly- porus, Poria, Atractylodis rhizoma, Cinnamomi cortex, Glycyrrhizae radix and Zingiberis rhizoma. Saireito is a combined formulation of Shosaikoto and Goreisan that has been reported to be useful in improving nephritic syndrome. Saireito has also been used for the treatments of hydrodipsia (water thirst) and oliguria, renal diseases such as glomerular nephritis and nephrosis, hepatitis and oedema. Kampo formulae for gynaecological disease Tokishakuyakusan (Dang-Gui-Shao-Yao-San) Tokishakuyakusan consists of six component herbs: Angelicae radix, Paeo- niae radix, Cnidii rhizoma, Atractylodis lanceae rhizoma, Alismatis rhizoma and Poria. Tokishakuyakusan has been used traditionally for gynaecological diseases such as ovarian dysfunction, endometriosis and menopausal syndrome in women. Tokishakuyakusan applies for the treatment of menoxenia, menstrual colic, sterility, abortion, vertigo, headache, oedema, anaemia, vasomotor imbalance, coldness of limbs and chilblains of the feet, nephritis and hypotonia. The symptoms are an impairment of intelligence and performance, 252 | Traditional medicine impairment of memory and language disintegration. It was suggested that steroidal sex hormones seem to be one of the essential substances for main- tenance of the limbic system and forebrain functions, which regulate memory, emotion, orientation of time and space, motivation and cognitive functions in menopausal women. Therefore Tokishakuyakusan may have therapeutic efficacy for the treatment of age-related deterioration and diseases such as dementia of Alzheimer’s type. Keishibukuryogan (Gui-Zhi-Fu-Ling-Wang) Keishibukuryogan consists of five component herbs: Cinnamomi cortex, Poria, Moutan cortex, Persicae semen and Paeoniae radix. Keishibukuryogan has been used for the treatment of coldness, hot flush, headache, stiff shoulder, vertigo, congestion in the small veins, telangiec- tasia, rough skin, discoloration of the tongue and gums, oppressive pain, resistance and fullness of the lower abdomen. Shimotsuto (Si-Wu-Tang) Shimotsuto is an extract of four component herbs: Angelicae radix, Cnidii rhizoma, Paeonide radix and Rehmannia radix. Shimotsuto has been used traditionally for the treatments of fatigue after childbirth or abortion, abnormality of menstruation, climacteric disorder, coldness, chilblains and anaemia. Kampo formulae for respiratory diseases Bakumondoto (Mai-Men-Dong-Tang) Bakumondoto consists of six component herbs: Ophiopogonis tuber, Pinel- liae tuber, Zizphi fructus, Glycyrrhizae radix, Ginseng radix and Oryzae fructus. Bakumondoto has been used for the treatment of bronchitis and pharyngitis accompanying severe dry cough. Kakkonto (Ge-Gen Tang) Kakkonto consists of seven component herbs: Radix puerariae, Zizyphi fructus, Glycyrrhizae radix, Zingiberis rhizoma, Ephedra herba, Paeoniae radix and Cinnamomi cortex. From ancient times Kakkonto has been applied for the improvement of symptoms in the acute phase of viral infection, such as common cold, influenza and varicella-zoster. Kakkonto is used in Japan to alleviate fever, headache, sore throat, chills and polyarthralgia in the acute phase of influenza, and shoulder pain. Japanese kampo medicine | 253 Shoseiryuto (Xiao-Qing-Long-Tang) Shoseiryuto consists of eight component herbs: Pinelliae tuber, Glycyrrhizae radix, Ephedra herba, Paeoniae radix, Cinnamomi cortex, Schisandrae fructus, Asiasari radix and Zingiberis processum rhizoma. Shoseiryuto has been used clinically for the treatment of certain ‘cold’ syndromes: bronchitis, bronchial asthma, allergic rhinitis and rhinitis accompanying oedema, paroxysmal sneezing and watery nasal secretion relating to abnormal water balance. There is evidence from a double-blind clinical study that Shoseiryuto is effective in the treatment of allergic rhinitis Saibokuto (Chai-Pu-Tang) Saibokuto consists of 10 component herbs: Bupleuri radix, Pinelliae tuber, Poria, Scutellariae radix, Ginseng radix, Zizyphi fructus, Magnoliae cortex, Perillae herba, Glycyrrhizae radix and Zingiberis rhizoma. Saibokuto has been used for the treatments of respiratory diseases such as paediatric asthma, bronchial asthma, bronchitis, cough, weakness of the constitution and anxiety neurosis accompanying unusual feelings in the throat and oesophagus, and depressed feeling, and occasionally palpitation, vertigo and nausea. Kampo formulae for digestive disorders Shosaikoto (Xiao-Chai-Hu-Tang) Shosaikoto consists of seven component herbs: Pinelliae tuber, Zyzyphi fructus, Glycyrrhizae radix, Ginseng radix, Bupeuri radix, Zingiberis rhizoma and Scutellariae radix. Shosaikoto is specifically used for treatments of patients with tenderness on pressure of the right subcostal region, and has been applied for cure and improvement of chronic dysfunction of the digestive system, dysfunction of liver diseases such as chronic hepatitis, infectious diseases with fever, common cold in a late stage and weak constitution of children, etc. Rikkunshito (Liu-Jun-Zi-Tang) Rikkunshito consists of eight component herbs: Ginseng radix, Atractylodis rhizoma, Poria, Pinelliae tuber, Aurantii nobilis pericarpium, Zizyphi fructus, Glycyrrhizae radix and Zingiberis rhizoma. Rikkunshito has been used for the treatment of several complaints accom- panied by digestive disorders such as gastric ulcer and chronic gastritis, and several digestive disorders after gastrectomy. Hachimijiougan has been used in older and elderly patients who exhibit weakness, cold and numbness in the lumbar region and lower extremities, together with nocturia. Hachimijiougan also has been used for the treatment of nephritis, diabetes, impotence, sciatica, lumbago, beri-beri, bleary eye, itch, oedema, bladder catarrh, prostatomegaly and hypertension. Kampo formulae for pain Shakuyakukanzoto (Shao-Yao-Gan-Cao-Tang) Shakuyakukanzoto consists of Paeoniae radix and Glycyrrhizae radix (Figure 8. Shakuyakukanzoto has been shown to ameliorate cramp associ- ated with cirrhosis in a double-blind clinical study. It has also been used for the treatment of sciatica, acute lumbago, gastrospasm, celiagra caused by gallstones or urinary calculus, myalgia, arthralgia and menstrual colic. A Japanese herbal medicine (Kami-Untan-to) in the treatment of Alzheimer’s diseases: A pilot study. Choto-san in the treatment of vascular dementia: a double-blind, Placebo controlled study. In: Yamada H, Saiki I (eds), Juzen- taiho-to (Shi-Quan-Da-Bu-Tang) – Scientific evaluation and clinical application. Effect of shosaikoto, a Japanese and Chinese traditional herbal mixture, on the mitogenic activity of lipopolysaccharide: a new pharmacological testing method. Effect of Kampo-hozai (traditional medicine) on immune responses, in vitro studies of Sho-saiko-to and Dai-saiko-to on antibody responses to sheep red blood cells and lipopolysaccharide. In: Hosoya E, Yamamura Y (eds), Recent Advances of Kampo (Japanese Herbal) Medicines. In: Yamada H, Saiki I (eds), Juzen-taiho-to (Shi-Quan-Da-Bu-Tang) – Scientific evaluation and clinical application. In: Yamada H, Saiki I (eds), Juzen-taiho-to (Shi-Quan-Da-Bu-Tang) – Scientific evaluation and clinical application. Lignin-carbohydrate complexes: Intestinal immune system modulating ingredients in Kampo (Japanese herbal) medicine, Juzen- taiho-to. Intestinal immune system modulating poly- saccharides in a Japanese herbal (Kampo) medicine, Juzen-taiho-to. Combination effects of herbs in a multi-herbal formula: expression of Juzen-taiho-to’s immuno-modulatory activity on the intestinal immune system. In: Yamada H, 256 | Traditional medicine Saiki I (eds), Juzen-taiho-to (Shi-Quan-Da-Bu-Tang) – Scientific evaluation and clinical application. Stimulating effect of Japanese herbal (Kampo) medicine, Hochuekkito on upper respiratory mucosal immune system. Hochuekkito, a Kampo (traditional Japanese herbal) medicine, enhances mucosal IgA antibody response in mice immunized with antigen-entrapped biodegradable microparticles. Anti-dementia action of Kampo (Japanese herbal) medicines effects of Kampo medicines on central nervous system. Choto-san in the treatment of vascular dementia: a double-blind, Placebo controlled study. The effects of Kampo medicine ‘Oren- gedoku-to’ on clinical manifestations and cerebral blood flow in chronic stage of cerebro- vascular diseases. Effect of Orengedokuto and Chotosan on disruption of spatial cognition (in Japanese). However, most Korean people are of Mongolian trait and are different ethnologically from the genuine Chinese race. In addition, the Korean language is Altaic and entirely different from the Chinese language. History Historical records show that there has long been interaction between Korea and China from ancient times: cultural exchanges, trade, immigration of peoples and even many wars. Confucianism, Buddhism, Taoism and much classical literaturewrittenintheChinesealphabetwereintroducedandwidelyaccepted duringthethree-kingdomperiodinKorea. Duringthistimeperiod,itwasmost likely that the traditional Chinese medicine and its medical classics such as the Huang Ti Nei Ching (the Yellow Emperor’s Classic of Internal Medicine), Shang Han Lun, and Shen Nung Pen Chao Ching were introduced and widely practised along with acupuncture and herbal therapies. Due to its geographical location and developed maritime capabilities with a naval force during the three-kingdom period, Korea played the role of the cross-road culture between China and Japan. The English pronunciation of Korea was actually derived initially from the Kokuryo kingdom, and then the Koryo dynasty.

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In addition elavil 25mg on line, the individual must be able to place his or her body so that his or her body weight can be used to apply pressure to the neck via the noose discount elavil 10 mg on-line. The materials and objects that can be made into a noose are many and vary from the obvious (ties generic elavil 50 mg on line, belts, shoelaces, etc) to the unusual (underwear, shirts, etc). To attempt to reduce the possibility of hanging suicides many police station cells have been redesigned and attachment points for the noose (pipes, bars, etc) have been removed or covered. However, the lack of these obvious points did not deter some individuals who placed the bed on end and used the upper end as the fixing point. Installation of fixed beds or benching should preclude the use of that method in future. It must be remembered that hanging can still be achieved, although is clearly more difficult, from a low suspension point, and any protrusion from a wall or fitment in a cell can potentially be used as the upper attachment for the noose. In addition to removing the fixing points, attempts have been made to remove the items that have been used as nooses in the past and belts, shoelaces, etc. Paper clothing has been used, although this has not been entirely successful because it entails removing all of the individual’s clothing, which is clearly impractical in many cases and may raise problems with human rights. If made strong enough to withstand any degree of wear, the paper clothing would also be strong enough to act as a noose. Given the speed with which hanging can be effected, it is most unlikely that anything other than a permanent watch over the suicidal detainee would provide a foolproof method to prevent hanging in a cell. A cycle of 15-min- utes checks will allow more than ample time for an individual to hang himself or herself and cannot be considered to be adequate protection against this type of suicide. Ligature Strangulation Because the possibility of suspension is reduced by the changes in the design of the cells, the possibility of other forms of self-asphyxiation are likely to increase. Self-strangulation by ligature is considered to be possible but dif- ficult (14); because the pressure has to be applied to the neck in these cases by the conscious muscular effort of the hands and arms, it follows that when consciousness is lost and the muscular tone lessens, the pressure on the liga- ture will decrease, the airway obstruction and/or the vascular occlusion will cease, and death will generally be averted. However, if the ligature is knotted or if the material is “non-slip” and looped around itself, then it is possible for the individual to apply the pressure to the neck and for that pressure to be maintained even after consciousness is lost and, as a result, death may follow. As with hanging, the key to preventing these deaths lies in careful evalu- ation and, if necessary, the removal of clothing and observation. Incised Injuries All prisoners should be carefully searched before incarceration, and any sharp objects or objects that could be sharpened must be removed. The extent of the search will probably depend on the mental state of the individual, and the possibility of an intimate search to exclude weapons concealed in the vagina or rectum should be considered in those individuals who are considered most at risk. Even if the individual is found before death has occurred, the effects of pro- found blood loss may make death inevitable, despite resuscitation attempts. Drugs When considering the possibility of suicide using drugs while in police custody, the two key factors are, once again, evaluation and searching. Care- ful searching (possibly including intimate searches in some cases) will pre- vent the ingestion of drugs by an individual after he or she has been placed in Deaths in Custody 343 the cell. The forensic physician must always be aware of the possibility that excessive quantities of a drug or drugs were taken before arrest and detention and may exert their effect when the individual is in the cell. Definition The exact definition of this syndrome remains elusive, despite many publications apparently describing similar events (19,20). Indeed, the many different names given to these apparently similar conditions (Bell’s mania, agitated delirium, excited delirium, and acute exhaustive mania) throughout the years indicate that it is a syndrome that may have many different facets, not all of which may be present in any single case. However, all of these descriptions do comment on the high potential for sudden collapse and death while the individual is in the highly excited states that they all describe. It is now accepted that such syndromes do exist, and although it is now com- monly associated with use and abuse of cocaine (21), it is important to note that it was described in 1849 well before cocaine use and abuse became com- mon (19). Features The clinical features of excited delirium are generally accepted to be the following: • A state of high mental and physiological arousal. In addition to these clinical observable features, there will certainly also be significant physiological and biochemical sequelae, including dehydration, lactic acidosis, and increased catecholamine levels (22). These biochemical and physiological features may be such that they will render the individual at considerable risk from sudden cardiac arrest, and the descriptions of cases of individuals suffering from excited delirium (23) indicates that the sudden death is not uncommon. Shulack (23) also records that: “the end may come so sud- denly that the attending psychiatrist is left with a chagrined surprise,” and continues: “the puzzlement is intensified after the autopsy generally fails to disclose any findings which could explain the death. In the context of restraint associated with death in cases of excited delirium, the presence of injuries to the neck may lead to the conclusion that death resulted from asphyxia, but this interpretation needs careful evaluation. What is perhaps of greater importance is that in all of the cases described in the clinical literature (19,20,23–25), there has been a prolonged period of increasingly bizarre and aggressive behavior, often lasting days or weeks before admission to hospital and subsequent death. The clinical evidence avail- able for the deaths associated with police restraint indicates that although there may have been a period of disturbed behavior before restraint and death, the duration of the period will have been measured in hours and not days. This change in time scale may result from the different etiology of the cases of excited delirium now seen, and it is possible that the “natural” and the “cocaine-induced” types of excited delirium will have different time spans but a common final pathway. The conclusion that can be reached concerning individuals displaying the symptoms of excited delirium is that they clearly constitute a medical emergency. The police need to be aware of the symptoms of excited delirium and to understand that attempts at restraint are potentially dangerous and that forceful restraint should only be undertaken in circumstances where the indi- vidual is a serious risk to himself or herself or to other members of the public. Ideally, a person displaying these symptoms should be contained and a forensic physician should be called to examine him or her and to offer advice to the police at the scene. The possibility that the individual should be treated in situ by an emergency psychiatric team with resuscitation equipment and staff available needs to be discussed with the police, and, if such an emer- gency psychiatric team exists, this is probably the best and safest option. If such a team does not exist, then the individual will need to be restrained with as much care as possible and taken to the hospital emergency room for a full medical and psychiatric evaluation. These individuals should not be taken directly to a psychiatric unit where resuscitation skills and equipment may not be adequate. From consideration of the medical aspects of these deaths recorded in their report, it would appear that six of the deaths resulted from natural disease and four were related to drug use or abuse. Of the remaining six cases, one was associated with a baton blow to the head, two to asphyxiation resulting from pressure to the neck, two to “restraint asphyxia,” and one to a head injury. Therefore, in the deaths during the 7 years that this group considered, a total of four deaths (<1. However, the close association of these deaths with the actions of the police in restraining the individual raises questions about the pathologists’ con- clusions and their acceptance by the courts. It is common for several pathologi- cal opinions to be obtained in these cases; in a review of 12 in-custody deaths, an average of three opinions had been obtained (range 1–7) (27). Indeed, in one of the cases cited as being associated with police actions, seven pathological opinions were sought, yet only one opinion is quoted. This points to the consid- erable difficulty in determining the relative significance of several different and, at times, conflicting areas of medical evidence that are commonly present in these cases. The area of restraint that causes the most concern relates to asphyxiation during restraint. It has been known in forensic circles for many years that indi- viduals may asphyxiate if their ability to breathe is reduced by the position in which they are placed or into which they fall (Subheading 7. This type of asphyxiation is commonly associated with alcohol or drug intoxication or, rarely, with neurological diseases that prevent the individual from extract- ing themselves from a position that either partially or completely occludes their mouth and nose or limits the freedom of movement of the chest wall. Death resulting from these events has been described as postural asphyxia to indicate that it was the posture of the individual that resulted in the airway obstruction rather than the action of a third party. Reay concluded that positional restraint (hog-tieing) had “measurable physiological effects. This article raised 346 Shepherd the possibility that asphyxiation was occurring to individuals when they could not move themselves to safer positions because of the type of restraint used by the police. The concept of “restraint asphyxia,” albeit in a specific set of cir- cumstances, was born. Since the description of deaths in the prone hog-tied position, Reay’s original concepts have been extended to account for many deaths of indi- viduals simply under restraint but not in the hog-tied position. The term restraint asphyxia has been widened to account for these sudden and unex- pected deaths during restraint. Considerable pathological and physiological controversy exists regarding the exact effects of the prone position and hog- tieing in the normal effects upon respiration. Although the physiological controversy continues, it is clear to all those involved in the examination and investigation of these deaths that there is a small group of individuals who die suddenly and apparently without warning while being restrained. Recent physiological research on simulated restraint (33,34) revealed that restraint did produce reductions in the ventilatory capacity of the experimental subjects but that this did not impair cardiorespiratory function. In two of the eight healthy subjects, breath holding after even moderate exercise induced hypoxia-related dysrhythmias, and it was noted that arterial oxygen saturation fell rapidly even with short breath hold times, especially if lung volume was reduced during exhalation. The problem that currently faces the forensic pathologist is the determi- nation of the cause or causes of these deaths.

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Resistance is usually caused by how change is introduced rather than by the change itself (Closs 1996) generic elavil 50mg without prescription. Change purchase elavil 50 mg free shipping, and the unknown order elavil 50mg without a prescription, are threatening; people fearing they will not cope seek refuge in, and defend, the status quo. Motivation for resistance should therefore be acknowledged and respected; belittling resisters increases the threat, damages morale, and may cause them to leave. As their confidence develops, resisters may share ownership of change, gain a sense of achievement and join the (very) later majority. Change is not always beneficial; enthusiasm can blind change agents to any faults. Opposition can stimulate healthy debate, possibly even finding better ways forward. Change agents unwilling to consider that the change they have made might subsequently need changing become tyrants; resistance can usefully moderate misplaced enthusiasm (Wright 1998). If change proves beneficial, and becomes the norm, continuing resistance may prove destructive. Once other avenues are exhausted, persistent resisters may leave; their resignation may be the best compromise for everyone. Lewin’s strategy Lewin’s (1952) classic work on change management includes: ■ field theory ■ stages of change Lewin’s field theory suggests that opposing forces both drive and restrain change. Habit, often enshrined in rituals (Walsh & Ford 1989; Ford & Walsh 1994) is a major restraining force. More widely cited is Lewin’s three stages of change: Intensive care nursing 452 ■ unfreezing (destabilising) ■ moving (changing) ■ refreezing (re-establishing) Unfreezing, breaking habits and rituals, creates motivation for change. Wright (1998) suggests that unfreezing may occur when: ■ expectations have not been met ■ staff have uncomfortable feelings about something ■ obstacles to change are removed (‘psychological safety’) Moving occurs when change is planned and initiated. Stability may have been possible when Lewin published his ideas in 1952, but if change and instability are now the norm (Toffler 1970), unfreezing may be unnecessary and refreezing impossible; change agents may only have to plan the moving stage. Human needs Change causes stress for everyone, including (often especially) change agents. Failed initiatives can leave change agents physically and emotionally exhausted, while ‘shifting sand’ quickly buries their ideas. Familiarity breeds contempt (the ‘wallpaper effect’ (Wright 1998): we cease to notice familiar problems); change agents may become conservative, defending their own change against any subsequent developments. However, safety needs should be balanced against the benefits of taking risks; this does not mean turning off ventilators each shift to see whether patients can breathe on their own, but it does include taking calculated risks when the likely benefits appear to outweigh the possible dangers. Nursing has inherited a culture of negative criticism, which undermines the confidence of nurses who usually only receive feedback when they have done something wrong. Pressures should be recognised, and Managing change 453 planned for; actions should be specific and timetabled, with achievable targets for everyone to work towards. It is necessary therefore to plan: who will achieve something by what date how all staff will be made aware of changes how they will be achieved, and where specific events will occur Plans which remain flexible and adaptable are more likely to succeed (Wilkinson 1994); targets may need modification later. Evaluation However good ideas may sound, their effects in practice, together with their strengths and weaknesses, should be evaluated and, if necessary, the ideas should be modified, developed further, or even abandoned. Evaluations may be achieved through questionnaires, interviews, or more informal approaches. Beyond change Having successfully seen through changes, staff should gain satisfaction (boosting morale) from positively contributing to practice. Experience may be disseminated within the hospital, and beyond—for instance, are there hospital-wide forums where you work? If not, consider the mounting of study sessions/days, or the publication of articles. Extending practice should be part of each nurse’s professional development, and so relevant material, with written reflections on the process, can provide valuable additions to professional profiles. 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.

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Lloyd (1990) is worth reading buy elavil 25mg amex, but does make some questionable assumptions and statements discount 75 mg elavil amex. Clinical scenario James Smith is 45 years old and works as an air traffic controller at London’s Heathrow Airport discount elavil 10mg on line. James is known to wear non-gas permeable contact lenses and has recently received treatment for conjunctivitis. Consider how this affected his recovery in relation to his perceptions, vision, communication interactions and pain. Traditionally, pressure sores were equated with bad nursing, and this created a culture of guilt and denial in nursing. This chapter revises pressure sore development, identifies some assessment systems available, and describes some ways of preventing pressure sores. Emphasis remains on prevention, and so wound dressings are not discussed—the rapid changes in practice and availability of dressings makes their inclusion in this book impractical. Much of the literature on skincare originates, or is sponsored/promoted by, people and companies with vested interests and so should be treated especially critically. Necrotising fasciitis, a dermatological condition that can often prove fatal, is included here. Intensive care nursing 104 Pressure sores A pressure sore is localised tissue necrosis (Reid & Morison 1994b). Waterlow (1995) suggests that pressure sores can be caused by both extrinsic factors: ■ unrelieved pressure ■ shearing ■ friction and intrinsic factors: ■ age ■ malnutrition ■ dehydration ■ incontinence ■ medical condition ■ medication. The supply of tissue oxygen and nutrients and the removal of waste products of metabolism require capillary perfusion; initial damage causes cellular microtrauma (Lowthian 1997), and so supporting microcirculation and the provision of adequate nutrition are fundamental to pressure sore prevention. Capillary perfusion depends on various forces (see Chapter 33), including external pressure. The pressure needed to prevent capillary flow is called capillary occlusion pressure. Currently, measurement of patients’ capillary pressures is impractical, but aids and equipment to prevent pressure sore development or progression should not exert continuous pressures above likely capillary occlusion pressures (20–25 mmHg—this is probably over-conservative, as the spread of pressure enables tolerance of higher pressures with deeper tissue (up to 35–40 mmHg in health), but until occlusion pressure can be safely measured, hypoperfusion of critical illness necessitates caution). Shearing forces, pushing the walls of capillaries together by folding the skin over, increases the (blood) pressure needed to open capillaries (Matlhoko 1994). Urine, which may leak around urinary catheters, is a weak acid and so excoriates skin. Waterlow (1995) suggests that patients should be reassessed every day; critical illness may necessitate more frequent assessment. In 1993 the Department of Health instructed that incidence of pressure sores in hospitals must be reduced by 5 per cent each year. Assessment Although there is no nationally recognised classification of pressure sores (Waterlow 1996), a 1992 consensus conference produced the ‘Stirling’ scale (Reid & Morison 1994a) (see Table 12. Whichever classification system is used, all staff on the unit should be familiar with it (a wall poster is often helpful). However, classification only describes current problems; risk assessment and prevention requires an additional risk assessment tool. Tools relying on colour codes can also be difficult to use if black and white photocopies are made (copyright status should be checked before making photocopies). A handful of assessment tools have been designed specifically for use in intensive care. Birtwistle’s study (1994) found it easy to use and appropriate for critically ill patients; while visually clear and simple, the absence of a score necessitates incorporating the whole tool with Intensive care nursing 106 each record in nursing documentation, and the tool does not appear to have been widely adopted. Stage Partial-thickness skin loss or damage involving epidermis 2 and/or dermis 2. Stage Full-thickness skin loss involving damage or necrosis of 3 subcutaneous tissue but not extending to underlying bone, tendon or joint capsule 3. Until debrided it is not possible to observe whether damage extends into muscle or involves damage to bone or supporting structures. Stage Full thickness skin loss with extensive destruction and 4 tissue necrosis extending to underlying bone, tendon or joint capsule 4. Like Waterlow’s scale, Cubbin and Jackson’s scale is an aid, not a substitute, for more detailed assessment. Lowery (1995) reports successfully adapting Cubbin and Jackson’s scale (the ‘Sunderland’ scale); Sollars’ (1998) single- patient study supports this adaptation. A revised version of Cubbin and Jackson’s scale was published in 1999 (Jackson 1999). This was also published following a pilot study, although the sample size was 51 patients. While based on substantial research, its presentation appears (rather than is) unnecessarily complicated; the proposed ‘next stage’ for the scoring system does not appear to have been published yet, and the system has not been widely adopted. Units dissatisfied with their current system should pilot other tools and consider adapting them through action research. For all patients, pressure on skin can be decreased either by changing position or increasing the surface area over which pressure is spread. Two-hourly pressure area care owes more to ritual than logic; prevention strategies need to be individually planned following individual assessment of risk factors. Intensive care nursing 108 Many aids have been marketed; bedding includes: ■ mattress overlays ■ alternating pressure mattresses ■ tilting beds ■ fluidised beds Booth (1993) lists many available mattresses, although others have been marketed since his article. In addition, the lack of airflow from prolonged immobility allows the accumulation of perspiration. Alternating pressure mattresses assist healing provided the capillary occlusion pressure remains below the minimum mattress inflation pressure. Some alternating pressure mattresses have static head areas to prevent seasickness; this exposes cranial skin to constant high pressures, and so checking for back-of-head sores should not be neglected. Various tilting and turning beds have been developed for spinal injury units (Waterlow 1995). Kinetic therapy can assist ventilation (see Chapter 27), and also prevent pressure sores; it enables rotation through 124°, but hard mattresses and pressure from straps can often cause, rather than heal, sores (Dobson et al. Fluidized silicone beds have proved popular in many units, although difficulties in maintaining upright positions are frequently identified by nurses. The beds are useful for patients with burns (Waterlow 1995) or large exposed wounds as they enable drainage of exudate; this can prevent the need for traumatic dressings. With the choice of commercial aids available, improvised aids are best avoided in view of the increasing levels of litigation and the professional individual accountability of nurses. For example, latex gloves filled with water can easily be overfilled (Waterlow 1995), thus exerting excessive (unmonitored) pressure on a single concave point and exposing patients’ heels to greater pressure than if left on hospital mattresses. Although talc dries perspiration and masks odours, so providing comfort and reducing the risk of breakdown from dampness, some patients are allergic to it. Waterlow recommends gel, head and elbow pads and 30° tilts for pillows (Waterlow 1995). Skincare 109 Cost Pressure sores increase ■ human suffering ■ recovery time (1,000 kcal may be needed each day to replace exudate protein loss and promote healing) ■ mortality ■ financial costs (prolonged stay, additional treatments, litigation). The cost of treating just one severe pressure sore can be £40,000 (Waterlow 1995). Tingle (1997a) cites costs ranging between £4,500 and £12,500 in recent cases where pressures sores contributed to mortality, but no records exist of nursing pressure area assessment. Necrotising fasciitis Necrotising fasciitis, an extension of cellulitis, is caused by aerobic and anaerobic soft tissue infection (Neal 1994). Necrotising fasciitis usually follows minor trauma or surgery (Neal 1994), beginning as cellulitis unresponsive to antibiotics. Tissue necrosis causes gas production (hydrogen, methane, hydrogen sulphide, nitrogen) and putrid discharge (Neal 1994)—although purely streptococcal infections have no odour (Neal 1994). The smell (and grey colour) of rotting flesh, distressing enough for staff, will probably cause profound anxiety to patients and visitors. Air fresheners can help mask the smell, although chemicals should not be allowed to enter exposed wounds. Gross swelling of flesh (oedematous) may make patients almost unrecognisable so that visitors need to be carefully prepared. Early stages of the disease are acutely painful (Neal 1994), but with progressive destruction of superficial nerve endings the later stages are often painless (Lipman 1997). The culture of guilt surrounding pressure sores is unhelpful to everyone; despite good nursing, sores will occur, and so nurses should assess and minimise risk factors in order to reduce the incidence. Further reading General nursing journals frequently carry articles on skincare; some journals specialise in the topic; regular library scans can identify new material. Following up at least one article on the assessment scale used by your unit can identify its strengths and limitations.

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