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Depending on a number of factors 20 mg levitra with amex, these conditions may be met in the operating room or the intensive care unit much later in the post-operative course discount 20 mg levitra amex. Cardiopulmonary interactions can exert important influences on the hemodynamics of the postoperative patient but must be evaluated critically and optimized for the specific patient situation generic 20 mg levitra mastercard. For example buy levitra 20mg with amex, while early extubation and spontaneous ventilation after Fontan operation is often thought to improve hemodynamics, if atelectasis or hypoventilation occurs, pulmonary vascular resistance will increase, and hemodynamics will be adversely affected. Monitoring of mechanical ventilation and pulmonary adequacy is accomplished via physical examination, non-invasive monitoring of oxygen saturation and end tidal carbon dioxide, attention to lung mechanics, blood gases, and chest radiographs. The need for tracheal suctioning and the quality and quantity of secretions should be followed as well. Once patients are weaned from mechanical ventilation, care must be taken to avoid atelectasis. Infants and young children typically will move and cry spontaneously, but older children and adolescents frequently will need assistance with sitting and standing, and will need - 63 - encouragement to deep breathe and move. Incentive spirometry and a guided program of progressive ambulation is essential and should be initiated as soon as physiologically safe. Cardiac Evaluation and Support The routine evaluation of the cardiovascular system after surgery depends on a combination of physical exam, non-invasive monitoring, and invasive monitoring. Repeated physical examination is an essential part of the evaluation following cardiac surgery. Although a vital part of patient assessment, physical examination remains the least quantifiable and most subjective. Distal extremity temperature, capillary refill and peripheral pulses suggest the adequacy of tissue perfusion. A prolongation of capillary refill greater than 3 - 4 seconds indicates poor systemic perfusion. Changes in the character of murmur or attenuation of a shunt murmur may reflect significant changes in the child’s condition. The child should (frequently) be examined for changes in cardio respiratory status. Cool extremities with normal or rising rectal temperature suggests decreasing and inadequate systemic cardiac output. Before invasive monitoring is planned, the risk-benefit ratio of catheter placement should be considered. Vascular catheters are commonly placed in the operating room, and include central venous catheters, right atrial catheters, left atrial catheters, pulmonary artery catheters, and arterial catheters. Central venous or right atrial catheters provide right-sided filling pressures, as well as information about tricuspid valve function. They enable indirect assessment of cardiac output by providing systemic venous oxygen saturation119, and they provide a site for infusion of pharmacologic agents. Because of their relative safety and extraordinary utility, most cardiac surgery patients will have a central venous/right atrial line. Central venous catheterization can be obtained by percutaneous cannulation of the internal jugular vein or by placing the catheter directly into the right atrial appendage at the time of surgery. Left atrial catheterization provides measurement of pressures in the left side of the heart, information about mitral valve function, and measurement of left atrial desaturation due to right- to-left shunting in the lung. The indications for left atrial catheter placement are abnormal mitral valve function, abnormalities of left ventricular diastolic and/or systolic function, and abnormal lung parenchyma. Left atrial catheter placement carries the serious risk of introduction of air into the systemic arterial circulation. This can be kept to a minimum by careful management of these lines, the use of air filters, and appropriate education of the care team. The recent introduction of intraoperative echocardiography has resulted in a more selective use of left atrial lines. Pulmonary artery catheters should be used in children whose postoperative pulmonary artery pressure is greater than 1/2 systemic arterial pressure and in children who are at a high risk for pulmonary artery hypertension (Table 22-6). Pulmonary artery catheters are placed during surgery through the right ventricular outflow tract and advanced into the main pulmonary artery.

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Watery fluids help keep food flowing through the digestive tract cheap levitra 10 mg with visa, and ensure that the movement of adjacent abdominal organs is friction free cheap 20mg levitra free shipping. Water also protects cells and organs from physical trauma 20 mg levitra mastercard, cushioning the brain within the skull generic levitra 20mg otc, for example, and protecting the delicate nerve tissue of the eyes. Water as a Heat Sink A heat sink is a substance or object that absorbs and dissipates heat but does not experience a corresponding increase in temperature. In the body, water absorbs the heat generated by chemical reactions without greatly increasing in temperature. Moreover, when the environmental temperature soars, the water stored in the body helps keep the body cool. This cooling effect happens as warm blood from the body’s core flows to the blood vessels just under the skin and is transferred to the environment. As the water evaporates into the air, it carries away heat, and then the cooler blood from the periphery circulates back to the body core. Water as a Component of Liquid Mixtures A mixture is a combination of two or more substances, each of which maintains its own chemical identity. In other words, the constituent substances are not chemically bonded into a new, larger chemical compound. The concept is easy to imagine if you think of powdery substances such as flour and sugar; when you stir them together in a bowl, they obviously do not bond to form a new compound. The room air you breathe is a gaseous mixture, containing three discrete elements—nitrogen, oxygen, and argon—and one compound, carbon dioxide. An important characteristic of solutions is that they are homogeneous; that is, the solute molecules are distributed evenly throughout the solution. If you were to stir a teaspoon of sugar into a glass of water, the sugar would dissolve into sugar molecules separated by water molecules. The ratio of sugar to water in the left side of the glass would be the same as the ratio of sugar to water in the right side of the glass. If you were to add more sugar, the ratio of sugar to water would change, but the distribution—provided you had stirred well—would still be even. Water is considered the “universal solvent” and it is believed that life cannot exist without water because of this. Water is certainly the most abundant solvent in the body; essentially all of the body’s chemical reactions occur among compounds dissolved in water. Because water molecules are polar, with regions of positive and negative electrical charge, water readily dissolves ionic compounds and polar covalent compounds. This is because sugar molecules contain regions of hydrogen-oxygen polar bonds, making it hydrophilic. Nonpolar molecules, which do not readily dissolve in water, are called hydrophobic, or “water-fearing. The concentration of a given solute is the number of particles of that solute in a given space (oxygen makes up about 21 percent of atmospheric air). In the bloodstream of humans, glucose concentration is usually measured in milligram (mg) per deciliter (dL), and in a healthy adult averages about 100 mg/dL. Another method of measuring the concentration of a solute is by its molarilty—which is moles (M) of the molecules per liter (L). The mole of an element is its atomic weight, while a mole of a compound is the sum of the atomic weights of its components, called the molecular weight. This is particularly useful in chemistry because of the relationship of moles 23 to “Avogadro’s number. Many substances in the bloodstream and other tissue of the body are measured in thousandths of a mole, or millimoles (mM). The solute particles consist of tiny clumps of molecules large enough to make the liquid mixture opaque (because the particles are large enough to scatter light). In the thyroid glands, the thyroid hormone is stored as a thick protein mixture also called a colloid. A suspension is a liquid mixture in which a heavier substance is suspended temporarily in a liquid, but over time, settles out.

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The production of energy for cellular activities requires oxygen and nutrients reaching the cell interior and carbon dioxide and other chemical wastes products be transferred to the environment 20 mg levitra free shipping. Extensive exchange between cells and immediate surroundings buy levitra 10mg on line, interstitial fluid purchase levitra 20 mg without prescription, occurs by diffusion based on a concentration gradient cheap levitra 10mg online. Diffusion causes adequate movement of dissolved nutrients, gases and metabolic end products to meet the active needs of the cell, if the distance is short. For the efficiency of diffusion, the diameter of individual cells is usually not more than a few tenths of a millimeter. In the circulatory system, blood rapidly moves between the respiratory system, where gases are exchanged; the kidney where wastes and excess of fluid and solutes are excreted; and the digestive system where nutrients are absorbed. These substances are rapidly transported by blood flow overcoming the diffusion limit on large body size. By maintaining a relatively constant internal environment, multicellular organisms are able to live freely in changing external environment. Responses tend to oppose the change and restore the variable to its set point value. All organ systems have regulatory processes for maintaining a delicate balance in a dynamic steady state. If external environment stresses are very severe beyond the homeostatic processes, the balance can be overwhelmed. Prolonged exposure to cold may lead to an intolerable reduction in the body temperature. Exercise in very hot environment, may result in fluid depletion and an increase in the core temperature, resulting in heat stroke. The cells are much adapted to a regulated core temperature that even a few degree of temperature variations may have fatal consequences. Without clothes and proper protection humans can tolerate only a narrow differences between body temperature and environmental temperature. Factors homeostatically maintained include: • Concentration of nutrient molecules • Concentration of oxygen and carbondioxide • Concentration of waste products • pH • Temperature • Concentration of water, salt, and other electrolytes • Volume (fluids), osmolality, and pressure Homeostasis is essential for survival of cells in that : • Cells need homeostasis for their own survival and for performing specialized function essential to survival of the whole body. Nervous System: Information from the external environment relayed through the nervous system. Nervous system acts through electrical signals to control rapid responses for higher functions e. Digestive system: Obtains nutrients, water and electrolytes from the external environment and transfers them into the plasma; eliminates undigested food residues to the external environment Muscular and Skeletal system: Supports and protects body parts and allows body movements; heat generated by muscular contraction are important in temperature regulation; calcium is stored in the bones Immune system: Defense against foreign invaders and cancer cells; paves way for tissue repair Integumentary system: 9 keeps internal fluids in and foreign materials out serves as a protective barrier between the external environment and the remainder of the body; the sweat glands and adjustment in blood flow are important in temperature regulation Cellular physiology Cells are the link between molecules and human. They have many molecules in a very complex organization and have the feature of interaction and represent a living entity. Cells are the living building blocks for the immense multicellular complicated whole body. Many cells share some common features despite diverse structure and functional specialization. Most cells have 3 subdivisions: the plasma membrane, the nucleus, and the cytoplasm. Plasma membrane/cell membrane: It is very thin membrane structure that enclose each cell, separating the cell’s contents from the surrounding. The nucleus: This is distinctly oval or spherical shaped central structure surrounded by a double-layered membrane. By monitoring these protein synthesis activity, the nucleus indirectly governs most cellular activities and serves as the cell’s master. The Cytoplasm: The cytosol is the material of cell interior not occupied by the nucleus, containing a number of distinct, highly organized membrane-enclosed structures- the organelles- dispersed within a complex jelly – like marrow called the ‘cytosol’. All cells contain six main types of organelles- the endoplasmic reticulum, Golgi complex, lysosomes, peroxisomes, mitochondria, and vacules. They are similar in all cells, but with some variations depending on the cell specialization. Each organelle is a separate compartment, containing different chemically setting for fulfilling a partial or cellular function.

Factors affecting bowel and bladder elimination: Age order levitra 20mg with visa, dietary intake purchase levitra 20 mg with mastercard, fluid intake purchase levitra 10 mg otc, physical activity levitra 10mg without prescription, psychological factors, position during defecation, pain, pregnancy, surgery, anaesthesia and diagnostic test. Common bowel elimination problems :Constipation, impaction, diarrhoea, incontinence, flatulence, haemorrhoids and bowel diversion. The normal amount of oxygen in the blood must be in the range of 80 to 100 mm (14) Oxygen can be administered by the ways of nasal catheter, B. Your report of observation is very valuable in helping the physician to arrive at proper diagnosis and treatment. Your observation and prompt actions may help patients from getting into serious complications such as haemorrhage and other similar problems. Skill in observation is acquired through careful training in using your senses namely, seeing, hearing, touching and smelling. It is through the sense of seeing you observe whether the patient is walking with difficulty, whether he is in pain and whether he has any other visible problems. From hearing the sound of his breathing you will able to understand whether the patient is having difficulty in breathing. Touching the patient reveals whether his body temperature is raised above normal or whether the skin is of normal texture or not. A nurse’s observation includes not only the physical condition of the patient, but also his psychological aspects. To come to clear interpretations of your observations, you have to question you patient so that you will be able to find out the problems experienced by the patient. Changes in colour of the skin, pulse, respiration, discharges from body cavities and changes in speech are some of the ex­ amples of objective symptoms. For example, some special techniques are needed to note changes in temperature, pulse, respiration and blood pressure; X­rays and laboratory tests are used for finding out changes in structure and functions of various systems of the human body. Physicians use methods such as inspection, palpation, percussion and auscultation for observation of patient’s condition. Whether there is swelling, discharge, abnormal watering, pain, burning, itching, photophobia or headache. Whether there is clubbing of fingertips, tremors of hands, swelling of extremities, pain in the joints or any other abnormality, all range of motions present 17) Lower extremities: Normal in shape and size,any deformity, all range of motions present. A nurse should be able to maintain records related to nursing and she should be able to understand the notes made by physicians and others. These measures indicate effectiveness of circulation, respiratory, neural and endocrine function because of their importance they are referred to as vital signs. Mechanisms are unable to keep pace with excess heat produc­ tion, resulting in an abnormal raise in body temperature Thermometer: (clinical thermometer): It is used for measuring body temperature Thermometer into two types: (1) Basing on the materials. The fever may subside suddenly (decline by crisis or gradually (decline by lysis) Crisis: Crisis is sudden return to normal temperature from a very high temperature within a few hours of days True crisis: The temperature falls suddenly within few hours and touches normal, accompanied by a marked improvement in the patents condition Subnormal temperature: When the body temperature falls below normal it is called subnormal temperature. It may be danger signal and not a sign of improvement Lysis: The temperature falls in a zig­zag manner for two of three days of a week before reaching normal during which time, the other symptoms also gradually disappear Constant fever or Continuous fever; Constant fever or Continuous fever is one in which the temperature varies not more then two degrees between morning and evening and it does nor reach normal for a period of days of weeks Remittent fever: Remittent fever is a fever characterized by variations of more than two degrees between morning and evening but does not reach normal level Intermittent or quotidian fever: The temperature is raises from normal or subnormal to high fever and back at regular intervals. Usually the temperature is higher in the evening than the morning Inverse fever: In this type the highest range of temperature is recorded in the morning hours and the lowest in the evening which is contrary to that found in the normal course of fever Hectic fever: When the difference between the high and low point is very great, the fever is called hectic or swinging fever. Relapsing fever: Relapsing fever is one in which there are brief febrile period followed by one or more days of normal temperature Irregular fever: When the fever is entirely irregular in its course, it cannot be classified under any one of the fevers described above and it is called irregular fever Rigor: Rigor is sudden severe attack of shivering in which the body temperature rises rapidly to a stage of hyperpyrexia as seen in malaria Low pyrexia: In low pyrexia the fever does not rise above 99 to 100°F or 37. The temperature is to be checked every 4 hours of even more frequently for those who are actually ill, who are having high fever, and post operative patients. It may vary with the nature of the diseases Respiratory system: Shallow and rapid breathing Circulatory system; Increased pulse rate and palpitation Alimentary system: Dry mouth, coated tongue, loss of appetite, nausea, vomiting, constipation, or diarrhea Urinary system: Diminished urinary output, burning micturition, high colored urine Nervous system: Headache, reslessness, irritability, insomnia, convulsions, delirium Musculo­skeletal system: Heavy sweating, hot flushes, goose flush, shivering or rigors. Integumentry system: Heavy sweating, hot flushes, goose flush, shivering or rigors Fever is not a disease but it is a sign. Fever if not too high hastens the destruction of bacteria by increasing phagocytes, and by producing immune bodies. A temperature of 104 to 105°F for several hours will destroy the organisms of syphilis and gonorrhoea. The range in the body temperature within which the cells can function efficiently is between 34 to 41°C (94 to 106°F). Irreversible changes may occur in the nervous system if the body temperature goes above 41°C or below 34°C Care in Fevers 1) Regulation of the body temperature : Care of the patients in fevers focuses on reducing the elevated body temperature. When the patients temperature is moderately elevated, various methods of reducing the temperature be started.

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