Benzac
By Q. Anktos. The Johns Hopkins University.
This reflects usual human use of senses: most input is usually through sight and hearing order 20gr benzac visa skin care professionals, with very limited inputs perceived from other senses cheap benzac 20 gr line skin care at 30. When finished, review your lists analysing how many of these inputs are ‘normal’ for you. Absence of vision may be caused by ■ periorbital oedema (preventing eye opening) ■ coverings to prevent corneal drying (see Chapter 11: Eyecare) Those able to see may be nursed supine: ceilings are usually visually unstimulating; overhead equipment may be frightening. Attempts to rationalise such sensory inputs, especially if unprepared for this environment before admission, are likely to cause bizarre interpretation. Watching overhead monitors detracts from eye contact (non-verbal communication), and becomes dehumanising. Windows (with beds placed to give patients a view) help maintain orientation to normality. Auditory input is too often confined to either instructions or others’ conversation (e. Both are detrimental; instructions, although valid in themselves, should be supplemented by quality conversation. Patients learning about their own condition and progress (or misinterpreting conversation as being about them) may become understandably anxious; half-heard discussions and misunderstood terms are likely to compound anxieties. Task-orientated touch is necessary, but reduces individuals to commodities, reinforcing their dehumanisation. Patients appreciate having their pillows turned and their head stroked in a comforting manner (affective touch). Factors such as culture and gender affect how touch is interpreted (Eastabrooks & Morse 1992); touching some body parts can suggest inappropriate intimacy (Lane 1989) or power (Davidhizer et al. Massage offers valuable opportunities for developing qualitative touch (see Chapter 47), but spontaneous affective touch can rehumanise care. Intubation largely bypasses this mechanism, but it remains intact and presumably functional, and so total absence should not be presumed. Hallucinations and psychosis are a form of psychological pain (stress), a response to a stimulus, and in humanistic nursing should receive similar attention to physiological pain. Responses depend on both reception (sensory stimuli) and perception (sensory transmission to, and interpretation by, higher centres). Healthy adults suffering eight hours sensory deprivation can experience acute psychotic reactions, delusions and severe depression for several days, and anxiety for several weeks (Hudak et al. Understanding patients’ perceptions and interpretations is not always possible, but it can make sense of hallucinations and bizarre actions—for instance, lying on alternating mattresses may resemble cross channel ferries. Reported experiences often suggest profound fear; nurses (and other healthcare professionals) can appear as devils/tormentors, so that nurses attempting to explore fears or reassure patients may meet resistance. Stress response Stress, however initiated, causes physiological responses to enable ‘fight or flight’. Catecholamine release and sympathetic stimulation make circulation hyperdynamic: ■ tachycardia ■ vasoconstriction ■ hypertension and so increase oxygen consumption. Neuroendocrine release includes ■ catecholamines (primarily adrenaline; also nor adrenaline): as above Intensive care nursing 18 ■ cortisol (immunosuppression, impaired tissue healing) ■ antidiuretic hormone: fluid retention, oedema (including pulmonary) ■ growth hormone: anabolism (tissue repair) ■ glucagon: hyperglycaemia (also peripheral insulin resistance from catecholamines) ■ insulin. Sodium and water retention, with plasma extravasation, cause oedema formation (including pulmonary). Barrie-Shevlin (1987) describes classic studies in which healthy volunteers, exposed to sensory deprivation, experienced hallucinations, impaired intelligence and psychomotor skills, and body water and electrolyte imbalance. For critically ill (hypoxic) patients, these demands may exceed homeostatic reserves, provoking myocardial infarction or other crises; even moderate hyperglycaemia aggravates immunocompromise (Torpy & Chrousos 1997). Reticular activating system This dense cluster of neurons between the medulla and posterior part of the midbrain selects which stimuli reach the cerebral cortex, preventing overload and so maintaining internal balance (biorhythm). Repetitive, familiar or weak signals are filtered out, and so loud, but unimportant, sounds may remain unnoticed (e. Quieter, meaningful noises may be noticed (parents sleeping through heavy traffic may waken with small noises from their children). As the reticular activating system filters out progressively more, or receives progressively fewer/abnormal sensory stimuli, the cortex attempts to rationalise remaining stimuli, resulting in hallucinations and progressively disorganised behaviour. The reasons behind nursing actions may appear mysterious to many patients (relevance deprivation), and explanations can reduce anxiety and psychological (and so physical) pain (Hayward 1975). Patients often quickly forget so that nurses should not assume patients will remember rationales given previously. Ashworth (1980) describes one patient interpreting a monitor as fluorescent light displays in Piccadilly Circus.
During this period generic benzac 20 gr acne out active, psychiatric inpatient treat- ment provided sufficient time to implement programs of ther- apy that were aimed at social rehabilitation 20gr benzac with amex acne and hormones. Currently, care in inpatient psychiatric facilities is shorter and more biologically based, limiting clients’ benefit from the socialization that occurs in a milieu as treatment program. Although strategies for mi- lieu therapy are still used, they have been modified to conform to the short-term approach to care or to outpatient treatment programs. Crises are precipitated by specific, identifiable events and are determined by an individual’s personal perception of the situa- tion. Crises occur when an individual is exposed to a stressor and previous problem-solving techniques are ineffective. They include disposi- tional crises, crises of anticipated life transitions, crises resulting from traumatic stress, maturational or developmental crises, cri- ses reflecting psychopathology, and psychiatric emergencies. Crisis intervention is designed to provide rapid assistance for individuals who have an urgent need. Aguilera (1998) suggests that the “focus is on the supportive, with the restoration of the individual to his precrisis level of functioning or possibly to a higher level of functioning. Nursing process is the vehicle by which nurses assist individuals in crisis with a short-term problem-solving approach to change. A four-phase technique is used: assessment/analysis, planning of therapeutic intervention, intervention, and evalua- tion of crisis resolution and anticipatory planning. Through this structured method of assistance, nurses assist individuals in cri- sis to develop more adaptive coping strategies for dealing with stressful situations in the future. Individuals under stress respond with a physiological arousal that can be dangerous over long periods. Indeed, the stress re- sponse has been shown to be a major contributor, either directly or indirectly, to coronary heart disease, cancer, lung ailments, accidental injuries, cirrhosis of the liver, and suicide—six of the leading causes of death in the United States. Relaxation therapy is an effective means of reducing the stress response in some individuals. The degree of anxiety that an individual experiences in response to stress is related to cer- tain predisposing factors, such as characteristics of temperament with which he or she was born, past experiences resulting in learned patterns of responding, and existing conditions, such as health status, coping strategies, and adequate support systems. Deep relaxation can counteract the physiological and be- havioral manifestations of stress. Various methods of relaxation include the following: Deep-Breathing Exercises: Tension is released when the lungs are allowed to breathe in as much oxygen as pos- sible. Deep-breathing exercises involve inhaling slowly and deeply through the nose, holding the breath for a few seconds, then exhaling slowly through the mouth, pursing the lips as if trying to whistle. Progressive Relaxation: This method of deep-muscle re- laxation is based on the premise that the body responds to anxiety-provoking thoughts and events with muscle tension. Each muscle group is tensed for 5 to 7 seconds and then relaxed for 20 to 30 seconds, during which time the individual concentrates on the difference in sensa- tions between the two conditions. A modified version of this technique (called passive progressive relaxation) involves re- laxation of the muscles by concentrating on the feeling of relaxation within the muscle, rather than the actual tens- ing and relaxing of the muscle. It brings on a special state of consciousness as attention is concentrated solely on one thought or object. During meditation, as the individual becomes totally pre- occupied with the selected focus, the respiration rate, heart rate, and blood pressure decrease. The frame of reference is very personal, based on what each individual considers to be a relaxing environment. The relaxing sce- nario is most useful when taped and played back at a time when the individual wishes to achieve relaxation. Biofeedback: Biofeedback is the use of instrumentation to become aware of processes in the body that usually go un- noticed and to help bring them under voluntary control. Biological conditions, such as muscle tension, skin surface temperature, blood pressure, and heart rate, are monitored by the biofeedback equipment. With special training, the individual learns to use relaxation and voluntary control to modify the biological condition, in turn indicating a modification of the autonomic function it represents. Bio- feedback is often used together with other relaxation tech- niques such as deep breathing, progressive relaxation, and mental imagery. Assertive behavior increases self-esteem and the ability to develop satisfying interpersonal relationships. This is ac- complished through honesty, directness, appropriateness, and respecting one’s own rights, as well as the rights of others.
A parallel exists between how partner relates to client and to staff discount 20gr benzac with mastercard acne regimen, based on the partner’s feelings about self and situation discount benzac 20gr without prescription acne yeast. This individual’s own identity may have been lost—he or she may fear self-disclosure to staff and may have difficulty giving up the dependent relationship. Because the family has been so in- volved in dealing with the substance abuse behavior, family members need help adjusting to the new behavior of sobriety/ abstinence. Incidence of recovery is almost doubled when the family is treated along with the client. Encourage involvement with self-help associations, such as Alcoholics Anonymous, Al-Anon, Alateen, and professional family therapy. Puts client and family in direct contact with support systems necessary for continued sobriety and assists with problem resolution. Family members demonstrate behaviors required to change destructive patterns of behavior that contribute to and enable dysfunctional family process. Categories Paranoid Schizophrenia Paranoid schizophrenia is characterized by extreme suspicious- ness of others and by delusions and hallucinations of a perse- cutory or grandiose nature. The individual is often tense and guarded and may be argumentative, hostile, and aggressive. Disorganized Schizophrenia In disorganized schizophrenia, behavior is typically regressive and primitive. Affect is inappropriate, with common characteristics being silliness, incongruous giggling, facial grimaces, and extreme social withdrawal. Catatonic Schizophrenia Catatonic schizophrenia manifests itself in the form of stupor (marked psychomotor retardation, mutism, waxy flexibility [posturing], negativism, and rigidity) or excitement (extreme psy- chomotor agitation, leading to exhaustion or the possibility of hurting self or others if not curtailed). Undifferentiated Schizophrenia Undifferentiated schizophrenia is characterized by disorganized behaviors and psychotic symptoms (e. The patient has a his- tory of at least one episode of schizophrenia in which psychotic symptoms were prominent. Schizoaffective Disorder Schizoaffective disorder refers to behaviors characteristic of schizophrenia, in addition to those indicative of disorders of mood, such as depression or mania. Brief Psychotic Disorder The essential features of brief psychotic disorder include a sud- den onset of psychotic symptoms that last at least 1 day but less than 1 month and in which there is a virtual return to the pre- morbid level of functioning. The diagnosis is further specified by whether it follows a severe identifiable stressor or whether the onset occurs within 4 weeks postpartum. Schizophreniform Disorder The essential features of schizophreniform disorder are identical to those of schizophrenia, with the exception that the duration is at least 1 month but less than 6 months. The diagnosis is termed “provisional” if a diagnosis must be made prior to recovery. Delusional Disorder Delusional disorder is characterized by the presence of one or more nonbizarre delusions that last for at least 1 month. Delusions of inflated worth, power, knowl- edge, special identity, or special relationship to a deity or famous person. Shared Psychotic Disorder (Folie à Deux) In shared psychotic disorder, a delusional system develops in the context of a close relationship with another person who already has a psychotic disorder with prominent delusions. Examples of general medical conditions that may cause psychotic symptoms include neurologic conditions (e. Substance-Induced Psychotic Disorder The essential features of this disorder are the presence of promi- nent hallucinations and delusions that are judged to be directly attributable to the physiological effects of a substance (i. Studies show that relatives of individuals with schizophrenia have a much higher probability of develop- ing the disease than does the general population. Whereas the lifetime risk for developing schizophrenia is about 1% in most population studies, the siblings or offspring of an identified client have a 5% to 10% risk of developing schizophrenia (Andreasen & Black, 2006). Twin and adop- tion studies add additional evidence for the genetic basis of schizophrenia. Jonsson and associates (1997) have suggested that schizophrenic disorders may in fact be a birth defect, occurring in the hippocampus region of the brain, and related to an influenza virus encountered by the mother during the second trimester of pregnancy. The studies have shown a “disordering” of the pyramidal cells in the brains of individuals with schizophrenia, but the cells in the brains of individuals without the disorder appeared to be arranged in an orderly fashion. Further research is required to determine the possible link between this birth defect and the development of schizophrenia.
Allow both swabs to air dry in a contamination-free environment for at least thirty minutes buy benzac 20gr line acne 9 dpo. Verify that the unique labeling and correct contents of the packet are documented; initial and date the seal for continuity purposes generic benzac 20gr online acne facial. Complete the chain-of-custody form and ship to the laboratory as directed, maintaining a cool, dry, ultraviolet-light-free environment wherever possible. Importantly, for these same reasons, rinsing or wiping before taking an oral swab should not be done if the subject is a sus- pected rape victim and oral copulation may have occurred. In this particular situation, the goal is not to obtain a reference sample for a donor but rather gain biological evidence of the attacker. As the popularity of this collection technique grows, an increas- ing number of laboratories are adopting a high-throughput platform that accommodates the swab samples. Tese programs include elaborate search algorithms that enable the investigator to scan hundreds or thousands of records quickly in search of a match between the questioned and known sets of records. Inevitably, following the generation of these best-possible matches, the asso- ciated records are retrieved in original hard copy or high-quality digital form and examined by a qualifed forensic odontologist to determine if the threshold for a dental identifcation has been achieved. Te laws governing sample collection and whether an individual must be convicted of a violent crime or simply arrested before uploading the profle varies from state to state. A match made within the Forensic Index may not lead immediately to the perpetrator’s name, but it can link crime scenes together and detect serial ofenders whose activities span several jurisdictions. In this way, police from all over the country can coordinate their independent investigations and share whatever leads they may have developed in an attempt to defeat criminal activity. Most odontologists will be familiar with the fundamentals of biology and biochemistry because of their own educational background. Te more alleles that naturally occur at a given locus in a given population increase the discriminating power of that locus. When paired (homologous) chromosomes each have the same allele at the same locus they are called homozygous. When the two alleles are diferent between the paired chromosomes, they are said to be heterozygous. Te raw data are then reviewed by the analyst, who uses his education, training, and experience to confrm the result and, when appropriate, compare sets of data, draw conclusions, and calculate statistical values. Some laboratories call the instrumentation portion of this process detection and reserve the word analysis for the fnal data review step by the analyst only. Nucleotides are ring-shaped molecules with various combi- nations of carbon, oxygen, hydrogen, and nitrogen with a phosphate group attached. In the successful pairing of two single strands, the opposing sequences must be complementary. Tis means that adenine will only align opposite thymine, and guanine will align exclusively with cytosine. Te separation of strands, or denaturation, can be accomplished by the addition of certain chemi- cals or by elevating the temperature to approximately 98°C. Te opposite of denaturing is annealing, which describes two complementary strands binding together. All are identical at the molecular level, but each varies in its protein-coding responsibilities and its location within the cell. Genotype versus phenotype: Te sum of genetic information in an organ- ism’s genome is its genotype. Te physical manifestation of that genetic information is called the organism’s phenotype. A locus can be described by using the chromo- some number, designating the short or long arm of the chromosome, and the band or subband on that arm. Mitochondria possess their own genome that is separate and distinct from the twenty-three pairs of chromo- somes inside the cell nucleus. Te human mitochondrial genome is 16,569 base pairs in length, carries 13 coding regions, and is inherited along maternal lines. It contains known regions of diversity that help forensic analysts to distinguish individuals of diferent maternal lineages from one another.
The problem is compounded when others are present generic 20gr benzac amex acne on buttocks, because when we are unsure how to interpret events we normally look to others to help us understand them buy generic benzac 20gr online skin care advice, and at the same time they are looking to us for information. The problem is that each bystander thinks that other people aren‘t acting because they don‘t see an emergency. Believing that the others know something that they don‘t, each observer concludes that help is not required. Even if we have noticed the emergency and interpret it as being one, this does not necessarily mean that we will come to the rescue of the other person. The problem is that when we see others around, it is easy to assume that they are going to do something, and that we don‘t need to do anything ourselves. Diffusion of responsibility occurs when we assume that others will take action and therefore we do not take action ourselves. The irony again, of course, is that people are more likely to help when they are the only ones in the situation than when there are others around. Perhaps you have noticed diffusion of responsibility if you participated in an Internet users group where people asked questions of the other users. Did you find that it was easier to get help if you directed your request to a smaller set of users than when you directed it to a larger number of [13] people? Markey (2000) found that people received help more quickly (in about 37 seconds) when they asked for help by specifying a participant‘s name than when no name was specified (51 seconds). Of course, for many of us the ways to best help another person in an emergency are not that clear; we are not professionals and we have little training in how to help in emergencies. People who do have training in how to act in emergencies are more likely to help, whereas the rest of us just don‘t know what to do, and therefore we may simply walk by. On the other hand, today many people have cell phones, and we can do a lot with a quick call; in fact, a phone call made in time might have saved Kitty Genovese‘s life. Aggression may occur in the heat of the moment, for instance, when a jealous lover strikes out in rage or the sports fans at a university light fires and destroy cars after an important basketball game. Or it may occur in a more cognitive, deliberate, and planned way, such as the aggression of a bully who steals another child‘s toys, a terrorist who kills civilians to gain political exposure, or a hired assassin who kills for money. Aggression also occurs in nonphysical ways, as when children exclude others from activities, call them names, or spread rumors about them. Paquette and [14] Underwood (1999) found that both boys and girls rated nonphysical aggression such as name- calling as making them feel more “sad and bad‖ than did physical aggression. The Ability to Aggress Is Part of Human Nature We may aggress against others in part because it allows us to gain access to valuable resources such as food, territory, and desirable mates, or to protect ourselves from direct attack by others. If aggression helps in the survival of our genes, then the process of natural selection may well [15] have caused humans, as it would any other animal, to be aggressive (Buss & Duntley, 2006). One of the primary functions of the amygdala is to help us learn to associate stimuli with the rewards and the punishment that they may provide. The amygdala is particularly activated in our responses to stimuli that we see as threatening and fear-arousing. When the amygdala is stimulated, in either humans or in animals, the organism becomes more aggressive. Neither people nor animals are always aggressive; they rely on aggression only when they feel that they absolutely need to (Berkowitz, Attributed to Charles Stangor Saylor. The prefrontal cortex serves as a control center on aggression; when it is more highly activated, we are more able to control our aggressive impulses. Research has found that the cerebral cortex is less active in murderers and death row inmates, suggesting that violent crime may be caused at least in part by a failure or reduced ability to regulate aggression (Davidson, [17] Putnam, & Larson, 2000). Most important in this regard is the male sex hormone testosterone, which is associated with increased aggression in both males and females. Research conducted on a variety of animals has found a positive correlation between levels of testosterone and aggression. This relationship seems to be weaker among humans than [18] among animals, yet it is still significant (Dabbs, Hargrove, & Heusel, 1996). Consuming alcohol increases the likelihood that people will respond aggressively to provocations, and even people who are not normally aggressive may react with aggression when [19] they are intoxicated (Graham, Osgood, Wells, & Stockwell, 2006). Alcohol reduces the ability of people who have consumed it to inhibit their aggression because when people are intoxicated, they become more self-focused and less aware of the social constraints that normally prevent them from engaging aggressively (Bushman & Cooper, 1990; Steele & Southwick, [20] 1985). Negative Experiences Increase Aggression If I were to ask you about the times that you have been aggressive, I bet that you would tell me that many of them occurred when you were angry, in a bad mood, tired, in pain, sick, or frustrated. And you would be right—we are much more likely to aggress when we are experiencing negative emotions.
If pregnancy doesn’t occur purchase benzac 20 gr on-line the skincare shop, the corpus luteum normally breaks down and disappears 20 gr benzac sale acne 7 dpo. If this does not happen and fluid builds up in the cor- pus luteum, it can form a cyst. These cysts can grow to almost 10 cm and may cause bleeding or twist the ovary and cause pain. Other types of cysts include: Cystadenomas: Cysts that develop from cells on the outer surface of the ovary. They are often filled with a watery fluid or thick, sticky gel and can become large and painful. Endometriomas: A type of cyst that develops in women with endometriosis, a condi- tion where tissue from the lining of the uterus grows outside of the uterus. Polycystic ovarian syndrome: Multiple cysts appear on the ovaries due to hormonal imbalance and high insulin levels. Many women have ovarian cysts at some time during their lives and most ovarian cysts are benign (non-cancerous) and disappear without treatment. For this reason, knowing the signs and symptoms and having regular pelvic exams is important to preserving ovarian health. If you develop sudden and severe abdominal or pelvic pain along with fever or vomiting, O seek immediate medical attention. Follicular and corpus luteum cysts are usually just monitored by the doctor and go away on their own. Oral contraceptives or progesterone cream are sometimes given to women who get frequent cysts as a way of controlling hormone levels and preventing cyst growth. Surgery is usually considered as a last resort for women with malignant cysts, those who have very large cysts that do not go away, and those with severe symptoms or infertility. Foods to avoid: • Meat and dairy products may contain saturated fat, hormones, and chemicals that can affect ovarian health and trigger inflammation. O Top Recommended Supplements There is limited research on supplements for the prevention and/or treatment of ovarian cysts. The supplements outlined here may play a role in minimizing symptoms and support- ing hormone balance and liver health. Calcium D-glucarate: Helps the liver detoxify and eliminate excess hormones, particularly estrogen. Chasteberry: Balances estrogen to progesterone ratio and may help normalize ovulation. Indole-3-carbinol: A compound found naturally in cruciferous vegetables that aids in de- toxification of estrogen, protects liver function, and may protect against hormonal cancers. Complementary Supplements Evening primrose oil: Helps reduce pain and inflammation. Some are harmless and even beneficial for health and others can cause illness and disease. A parasite is an organism that lives on or in a host organism and gets its food from or at the expense of its host. There are two main classes of parasites that can cause intestinal disease in humans: Helminths: Derived from the Greek word for “worms,” these large, multicellular organisms are generally visible to the naked eye. The three main groups of helminths that are human parasites are flatworms (tapeworms), P thorny-headed worms, and roundworms (hookworms and pinworms). Protozoa: Microscopic, one-celled organisms that can be free-living or parasitic in nature. They can multiply in humans, which contributes to their survival and also permits serious infections to develop from just a single organism. When the organisms are swallowed, they move into the intestine, where they can reproduce and cause disease. You can also contract parasites from intimate contact (oral-anal) with someone who has them. In some people, intestinal parasites do not cause any symptoms or the symptoms may be mild. In others they can cause horrible gastrointestinal problems, weight loss, irritability, and more.
Sedation cheap benzac 20gr fast delivery skin care coconut oil, a valuable adjunct to promote comfort buy benzac 20 gr acne and pregnancy, is usually limited to a few hours, and so rapidly cleared drugs (e. Neurological complications Potentially fatal thrombi (and emboli) may be from ■ cardiopulmonary bypass ■ air emboli ■ thrombotic vegetations (chronic preoperative atrial fibrillation). Neurological deficits can cause ■ impaired peripheral nerve function ■ cerebral/cognitive deficits ■ uncontrollable hypertension (injury to vital centres). Neurological assessment is a priority, but cerebrovascular accidents may remain undetected until patients show deficits or fail to wake normally. Postoperatively, mood is often labile, euphoria (induced by opiates and survival) being followed (day 2–4) by reactive depression. Stress provokes tachycardia, hypertension and hyperglycaemia (see Chapter 3), all impairing recovery in patients least able to tolerate such insults. Providing information, achieving optimum pain control, relieving anxieties and minimising sensory imbalance are therefore important aspects of holistic nursing care. Skin care Wound breakdown or skin ulceration may occur from (Waterlow 1996; Lewicki et al. On regaining consciousness, pain and anxiety often make patients reluctant to move. Sternal instability can cause ‘clicking’ sounds; although not painful, external stabilisation with hands or a cushion helps deep breathing and coughing. Wound dressings are usually removed within 24 hours, and then left exposed unless oozing. Perfusion of graft sites (especially radial artery grafts; also arteriovenous shunts) should be protected, and so pressure (e. Normalisation Nurses can experience considerable satisfaction from assisting rapid postoperative recovery following cardiac surgery. Normalisation should be urged, and families and friends encouraged to visit, as they would on a surgical ward. Cardiac surgery 303 Early mobilisation should be supported, musculoskeletal complications and pulmonary emboli being the main causes of delayed discharge (Johnson & McMahan 1997). Transplantation issues The severing of the sympathetic and parasympathetic pathways causes loss of vagal tone, resulting in resting rates of about 100 beats/minute (Adam & Osborne 1997). Denervation also (usually) prevents angina, increasing risk of silent infarction (12 per cent of patients do experience pain (Tsui & Large 1998)). A loss of sympathetic tone impairs cardiac response to increased metabolic demands, making atropine ineffective (Adam & Osborne 1997). Surgery preserves recipients’ right atrium, resulting in two P waves (one intrinsic, one graft) (Adam & Osborne 1997). Although not pathologically significant, the reasons for the presence of two P waves should be explained to patients, families and junior nurses. Many possible postoperative complications result from the necessities of intraoperative procedures; increasing percutaneous surgery may significantly reduce numbers of open heart operations. Clinical scenario Peter Da Silver is a 48-year-old man with a history of angina, hypertension and insulin dependent diabetes. Review causative factors for this complication and propose a plan of care to stabilise sternum, promote healing and recovery (evaluate various treatment approaches, pharmacological/surgical interventions, equipment used to stabilise sternum, appropriate nutrition). Haemostasis has four phases: ■ smooth muscle contraction (vasoconstriction; myogenic reflex) ■ formation of platelet plugs ■ formation of fibrin clot (blood clotting/coagulation), followed by retraction of fibrin clots ■ fibrinolysis. The most effective diagnostic tests are D-dimer tests, platelet counts, anti-thrombin-3 levels and fibrin monomers (Jørgensen et al. Proteolysis stimulates further coagulation and fibrinolysis, causing disseminated generation of thrombin and plasmin. Excessive fibrin production and deposition consume clotting factors (hence ‘consumptive coagulopathy’) and cause inappropriate clotting. Consumption of clotting factors leaves insufficient supply for homeostasis so that patients bleed readily (typically from invasive cannulae and trauma, such as endotracheal suction).
