By U. Eusebio. Meredith College.

Alteplase may be used if repeat doses of streptokinase are contraindicated (Weston 1996; McDonald 1997) purchase norvasc 5mg visa blood pressure 7040, such as following heparin quality 10 mg norvasc pulse pressure equivalent. Although thrombolysis has reduced complications during recovery, following thrombolysis nurses should observe for: ■ allergic reaction/hypotension ■ haemorrhage Revascularisation dysrhythmias (especially ventricular) are common but usually benign, one-half of all patients experiencing a degree of left ventricular failure (Thompson 1990); reperfusion injury may progress to ventricular fibrillation, and 5 per cent of patients develop cardiogenic shock (Thompson 1990. The risk of major haemorrhage following thrombolysis is small (less than 5 per cent), but triples if patients have had previous vascular/cardiac procedures (deBono 1990), and so intramuscular injections should be avoided with all patients. Rest Rest, with bedrest for 48 hours (Hockings & Donovan 1997), promotes recovery. Rest and adequate sleep (quality as well as quantity) promote physical and psychological healing (see Chapter 3): planned care should include minimal interventions overnight and rest periods during the day, with active assessment of benefits. Prognosis Within the first weeks, up to one-tenth of patients suffer a second infarction (Hockings & Donovan 1997), while only one-tenth recover without further complications (Nowak & Handford 1994). Oedema may subside, enabling reperfusion and recovery, or progress to further infarction. The British Heart Foundation produces a range of useful booklets that are available in most hospitals. Nursing care of patients with myocardial infarctions should focus on prevention and close monitoring of further complications. Medical material can usefully be supplemented by whatever current textbooks readers have access to. Clinical scenario Howard Gray is a 52-year-old insurance broker with a history of angina. Review your role in administering and monitoring the effectiveness of this therapy (note frequency and type of investigation/assessment, identification of potential adverse effects). Chapter 25 Shock Fundamental knowledge Cellular pathology (see also Chapter 23) Pericardial anatomy Baroreceptors and chemoreceptors Renin-angiotensin-aldosterone cascade Normal inflammatory responses (increased capillary permeability, leucocyte migration, vasoactive mediators release) Introduction Traditional labels of shock, by causal mechanisms, have some value: resolving the cause should relieve problems. However caused, shock impairs tissue oxygen delivery, and causes microcirculatory maldistribution and metabolic complications (Shoemaker & Beez 1996), with life-threatening cellular hypoxia progressing to whole system dysfunction. Urgent microcirculatory resuscitation is needed to prevent the complications of shock. Perfusion pressure (mean arterial pressure) is the sum of: ■ total capacity of blood vessels ■ total blood volume ■ local factors (e. Prolonged hypoperfusion damages tissues, with shock becoming irreversible once reperfusion is unachievable. Renal hypotension causes renin release, increasing systemic pressure via the renin-angiotensin-aldosterone cascade. Cellular dysfunction aggravates electrolyte imbalances (especially hypercalcaemia and hyperkalaemia), impairing cardiac conduction, so causing dysrhythmias. Anaerobic metabolism and metabolic acidosis (from systemic hypoperfusion) stimulates tachypnoea. Severe shock, therefore, increases the work of breathing without improving tissue oxygenation (Wheeler & Bernard 1999). However, prolonged hypoperfusion, reduced colloid osmotic pressure and increased vascular permeability from critical illnesses cause excessive fluid shifts into interstitial spaces, resulting in oedema and raised interstitial pressure (causing further resistance to perfusion), without sustaining perfusion pressure. Anaerobic metabolism accelerates metabolic acidosis, and hypoxia damages cell walls, causing inappropriate movement of ions across cell membranes (see Chapter 23). Hyperglycaemia may occur from ■ cortisol ■ growth hormone ■ catecholamines Inhibited glucose transport into cells impairs intracellular energy production, compounding cell (then organ) failure (see Chapter 23). The liver has many functions (metabolic, digestive, immune, homeostatic), and so hepatic dysfunction causes many problems, including coagulopathies and immunocompromise. Compensatory tachycardia may restore blood pressure, but increased myocardial oxygen consumption can cause ischaemia, dysrhythmias and infarction. Compensatory tachycardia may increase myocardial oxygen supply, but it also increases consumption. Damage to over 70 per cent of the left ventricle is rapidly fatal (Hinds & Watson 1996). Treatment attempts to increase systemic perfusion pressure while limiting myocardial hypoxia. Artificial ventilation and removing the work of breathing with paralysing agents (Nimmo & Nimmo 1993) optimises tissue oxygen availability. Inotropes may be necessary to increase cardiac output, but will aggravate myocardial ischaemia (Nimmo & Nimmo 1993). Mortality from cardiogenic shock varies between 30 and 90 per cent, survival being lower with aggressive treatment (Califf & Bengston 1994).

A child who feels that his or her parents are forcing him to eat his asparagus may react quite vehemently with a strong refusal to touch the plate order norvasc 2.5mg overnight delivery hypertension 1 and 2. And an adult who feels that she is being pressured by a car salesman might feel the same way and leave the showroom entirely buy norvasc 2.5mg overnight delivery heart attack grill nyc, resulting in the opposite of the salesman‘s intended outcome. The tendency to help others in need is in part a functional evolutionary adaptation and in part determined by environmental factors. Some helping is based on reciprocal altruism, the principle that if we help other people now, those others will return the favor should we need their help in the future. The result of this learning is norms about helping, including the reciprocity norm and the social responsibility norm. The typical outcome of conformity is that our beliefs and behaviors become more similar to those of others around us. The important influence of the social situation on conformity was demonstrated in the research by Sherif, Asch, Milgram, and others. New evolutionary perspectives on altruism: Multilevel-selection and costly-signaling theories. Some neo-Darwinian decision rules for altruism: Weighing cues for inclusive fitness as a function of the biological importance of the decision. My sibling’s but not my friend’s keeper: Reasoning about responses to aggressive acts. Altruism on American television: Examining the amount of, and context surrounding, acts of helping and sharing. Effects of violent video games on aggressive behavior, aggressive cognition, aggressive affect, physiological arousal, and prosocial behavior: A meta-analytic review of the scientific literature. Gender differences in young adolescents’ experiences of peer victimization: Social and physical aggression. Dysfunction in the neural circuitry of emotion regulation—A possible prelude to violence. Hot and crowded: Influence of population density and temperature on interpersonal affective behavior. Catharsis, aggression, and persuasive influence: Self-fulfilling or self-defeating prophecies? Chronic violent video game exposure and desensitization to violence: Behavioral and event-related brain potential data. Relation of threatened egotism to violence and aggression: The dark side of high self-esteem. Proactive and reactive aggression among school bullies, victims, and bully- victims. Relational and physical victimization within friendships: Nobody told me there’d be friends like these. Insult, aggression, and the southern culture of honor: An “experimental ethnography. Field experiments examining the culture of honor: The role of institutions in perpetuating norms about violence. A focus theory of normative conduct: Recycling the concept of norms to reduce littering in public places. Self-monitoring without awareness: Using mimicry as a nonconscious affiliation strategy. Strength of identification and intergroup differentiation: The influence of group norms. Summarize the advantages and disadvantages of working together in groups to perform tasks and make decisions. Just as our primitive ancestors lived together in small social groups, including families, tribes, and clans, people today still spend a great deal of time in groups. We study together in study groups, we work together on production lines, and we decide the fates of others in courtroom juries. A rock band that is writing a new song or a surgical team in the middle of a complex operation may coordinate their efforts so well that it is clear that the same outcome could never have occurred if the individuals had worked alone. But group performance will only be better than individual performance to the extent that the group members are motivated to meet the group goals, effectively share information, and efficiently coordinate their efforts.

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