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Management of patients with cellulitis continued on page 28 Wound Care Advisor · July/August 2013 · Volume 2 antiviral nhs buy medex 5mg cheap, Number 4 A prospective antiviral zdv order medex 5mg line, randomized how long after hiv infection will symptoms appear buy 5 mg medex mastercard, controlled double-blind study of a moisturizer for xerosis of the feet in pa- tients with diabetes hiv infection rates by state cheap medex 5mg on-line. A three-hour test for rapid comparison of effects of moisturizers and active constituents (urea) hiv infection rate uganda purchase medex 1mg without prescription. Measurement of hydration hiv infection quiz order medex 5mg without prescription, scaling, and skin surface lipidization by non-invasive techniques. Nancy Morgan, cofounder of the Wound Care Education Institute, combines her expertise as a Certified Wound Care Nurse with an extensive background in wound care education and program development as a nurse entrepreneur. Robyn Bjork is a physical therapist, a certified wound specialist, and a certified lymphedema therapist. She is also chief executive officer of the International Lymphedema and Wound Care Training Institute, a clinical instructor, and an international podoconiosis specialist. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Thomas A. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Library of Congress Cataloging-in-Publication Data Phillips, Lynn Dianne, 1947- author. The fee code for users of the Transactional Reporting Service is: 978-0-8036-3846-4/14 0 + $. I want to dedicate this edition of the Manual to the supportive, loving friends I have had the good fortune to know through the Infusion Nurses Society: Mary Alexander, Michelle Berreth, Ann Corrigan, Beth Fabian, Lisa Gorski, Roxanne Perucca, Ofelia Santiago, Marvin Siegel, and Mary Walsh. You have been an excellent author, and this edition is better than ever because of you! Lynn Phillips First of all, I want to thank Lynn for asking me to co-author this edition of the Manual-it was a joy to work together! I dedicate this book to my husband John, my parents John and Audrey Morrill, and my children Ben and Amanda Gorski, who have loved me and have supported me in all my professional endeavors. And also to my colleagues in the Infusion Nurses Society, who make a difference every day by supporting our Standards of Practice to ensure that our patients receive the best possible care. Therapeutics: Evidence-Based Practice for Infusion Therapy, Sixth Edition, provides comprehensive information on infusion therapy for the nursing student and practicing nurse. The sixth edition continues to address pediatric and the older adult patients in a separate section in each chapter. This self-paced, comprehensive text presents information ranging from a simple to a complex format, incorporating theory into clinical application. The skills of recall, nursing process, critical thinking, and patient education are covered, along with detailed summaries, providing the foundation one needs to become a knowledgeable practitioner. The psychomotor skills associated with infusion therapy are presented in step-by-step procedures with rationales based on standards of practice at the end of the chapters. Each chapter includes accompanying objectives, defined glossary terms that are bolded within the text, a post-test, a summary of chapter highlights, and a critical thinking case study. Icons and special boxes are used throughout each chapter to key the reader to websites, patient education, home care issues, cultural considerations, and standards of practice. Skill Checks, 100 test questions, PowerPoint presentations, and math calculations tests are included in the DavisPlus faculty ancillaries and can be used in the educational setting, as well as in agencies, for validating competencies of nurses in infusion skills. The first three foundations chapters are designed to provide information to the reader on nursing practice related to infusion therapy (nursing process applied to infusion therapy, legal and ethical responsibilities, evidence-based practice background, and performance improvement), infection prevention and occupational hazards, and fundamentals of fluid and electrolyte balance. The subsequent seven chapters provide the essential solid foundation in infusion therapy practices, including parenteral solutions, infusion equipment, peripheral and central vascular access techniques and management, complications, medication infusion, and infusion calculations. This sixth edition has incorporated recurring displays for cultural and ethnic-related issues. Key concepts for nursing practice are identified as "Nursing Fast Facts," and "Note>" identifies an important theory concept. The last two chapters encompass the additional topics of transfusion therapy and parenteral nutrition. It includes guidelines for discussion and answers to the case studies, and additional math calculations problems and answers. It also provides the learner with web-based ancillaries, an additional 50 interactive flash cards for learning terminology, interactive case studies, and web links for further research. We hope this new edition provides you, whether you are a practicing healthcare professional or a student, with valuable insights into the safe practice of infusion therapy and a reference for this rapidly advancing field. Davis: Tom Ciavarella, Nursing Acquisitions Editor, who assisted in the final development of this manual. Echo Gerhart, Project Editor, Nursing, who as project consultant helped bring this vision to reality. Sam Rondinelli, Production Manager, for guiding this manuscript through the production process. Cassie Carey, Senior Production Editor at Graphic World Inc Appreciation is also expressed to the following companies who provided product information, pictures, and illustrations: 3M Medical Division, St. Fluids 216 Common Colloid Volume Expanders 227 Smart Pump Features 294 Infusion Pump Risk Reduction Strategies for Clinicians 297 Comparison of Artery and Vein 315 Selecting an Insertion Site for Superficial Veins of Dorsum of Hand and Arm 318 xiii xiv Tables 6-3 6-4 6-5 6-6 6-7 6-8 6-9 6-10 6-11 6-12 6-13 6-14 7-1 7-2 7-3 8-1 8-2 8-3 8-4 8-5 8-6 9-1 9-2 9-3 9-4 9-5 9-6 9-7 9-8 10-1 10-2 10-3 10-4 10-5 11-1 11-2 11-3 Phillips 16-Step Peripheral-Venipuncture Method 320 Tips for Selecting Veins 327 Phillips Multiple Tourniquet Technique 330 Transillumination 331 Techniques to Assist with Difficult Venous Access 333 Recommended Gauges 337 Conversion Chart: Rate Calculation 351 Summary of Steps in Initiating Peripheral l. It is not for the sake of piling up miscellaneous information or curious facts, but for the sake of saving life and increasing health and comfort. Discuss the use of competency-based education programs in the practice of infusion therapy. Identify the components of the nursing process and how they are applied to infusion practice. Expert testimony Witness from the same professional specialty who examines evidence, reviews pertinent nursing literature, gives depositions, and potentially testifies in court. The practice of infusion nursing encompasses nursing management and coordination of care (Corrigan, 2010) to the patient in accordance with: 1. Most nurses at some point of, or throughout, their career will be involved in infusion care. The patient populations served by this specialty practice range from neonates to elderly patients. However, there are risks, and some complications are serious and life threatening. Regardless of the setting, the nurse must have a thorough understanding and knowledge of the appropriate type of access device being utilized, the appropriateness of the selected device for the prescribed therapy, care and maintenance of the device, potential complications related to the device and infusion solutions, and safe infusion administration. Competence and competency are two frequently used terms that sound similar and may be used interchangeably; however, they do have different meanings. Nursing competence refers to the potential ability to perform at an expected level of practice, whereas competency focuses on actual performance. Competence is required before one can expect competency (National Board for Certification of Hospice and Palliative Nurses, 2011). Competency integrates the following aspects of performance related to patient care: 1. Competency may be reviewed through information obtained from past and current employers, peer recommendations, validating specialty certifications, testing, ongoing performance data collection, and/or skills observation, either separately on in partnership with customers. The need to validate competency may be identified through clinical outcome data. When the healthcare organization chooses to measure or validate specific competencies, it should do so in a thorough and ongoing fashion, including looking at new, significant, and/or high-risk practices, interventions, or activities that are unfamiliar to staff members. A variety of methods are used, including written tests and direct observation of a skill, whether in the work setting, in a skills laboratory, or through use of simulation. Competency-Based Educational Programs Competency-based educational programs establish specific goals, accountability, individualization, and behaviors for practitioners by defining clear expectations for levels of performance. The health-care organization has the responsibility of ensuring a competent staff. A framework for developing staff competencies and ensuring that the institution is delivering safe care includes: Development of standards Development of criteria for performance of skills Assessment of learning needs Establishment of a plan of educational programs Presentation of educational programs Evaluation of learning outcomes Three-Part Competency Model A three-part competency model includes: 1. Domains of learning criteria: Cognitive criteria (knowledge base) and performance criteria (psychomotor skills: observed behaviors) 3. Evaluation and learning outcomes: Written tests, return demonstrations, and clinical demonstration of skill to nurse preceptor All professional nurses are accountable and responsible for all parts of the tasks associated with infusion therapy and for tasks that are delegated to the licensed practical nurse or technician for care rendered to the patient while under care. The three-part competency model is an effective tool for ensuring competent practice. There are 33 specific nursing competencies in the program, which can be used for procedural validation skills. Certification is a mark of excellence, validates nursing knowledge and skills, and protects the public (Altman, 2011). Other certifications that include components of infusion therapy are as follows: 1. Based on initiatives for certification from across the country, the American Association of Critical Care Nurses identified five themes of best practices in creating a culture for nursing certification: commitment to excellence, a supportive and encouraging environment, goal-directed evaluations, availability of educational resources, and celebrations for rewarding excellence (Fleischman, Meyer, & Watson, 2011). You have used povidone iodine (Betadine) for skin antisepsis prior to port access. There is now strong evidence that chlorhexidine/alcohol solution is a superior agent and is preferred for skin antisepsis; you also know that povidone iodine is still considered an acceptable agent. This patient does not want to switch antiseptic agents because he has never had a problem. Each time a new device or technique is introduced, new practices must be considered. Questions must be asked when new technology is introduced, such as: Are there studies supporting the benefits of the technology? Between the ongoing safety initiatives being introduced into health-care settings and the increasing presence of practice guidelines, it is imperative that the infusion nurse use evidence to support infusion practice. There are 68 Standards, which are broad statements that describe expectations of practice applicable to infusion therapy in all settings. The Standards address areas such as the need for organizational policies and nurse competency. The Practice Criteria provide specific guidance on the implementation of each Standard. New to the 2011 document, each Practice Criterion is rated as reflecting the strength of the body of evidence. Although evidence that is research based is preferred, evidence may come from a variety of sources (Table 1-2). The following is an example of a Standard and a Practice Criterion from Standard 35: Vascular access site preparation and placement. One percent to two percent tincture of iodine, iodophor, and 70% alcohol may also be used. As with many areas of nursing practice, there are unanswered questions, there often is limited research, and there is a constant influx of newly published studies to read and review. Numerous evidence-based models are available; however, all share certain steps as follows: 1. Unresolved issue: Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists. These Standards provide each nurse with a framework to utilize when working with a patient. The nursing diagnosis provides the basis for selecting nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnoses are validated with the patient, family, and other health-care providers. Standardized terminology is also critical in increasing visibility of nursing interventions and greater adherence to the standards of practice. Nursing diagnoses related to infusion therapy are included in each chapter of this textbook. Ineffective protection related to inadequate nutrition Collaborative problems are physiological complications that nurses monitor to detect onset or changes in status. Nurses manage collaborative problems using physician-prescribed as well as nursing-prescribed interventions (Ackley & Ladwig, 2011). It is also an essential step that the nurse collaborate with the patient, family, and other health-care providers (including the physician and other health-care disciplines) in developing expected outcomes. Patient values and ethical and cultural considerations should be incorporated into the process of identifying expected outcomes. All care plans must be individualized; the tables in the chapters are suggestions for use with the patient who receives infusion therapy. Planning sets the stage for writing nursing actions by establishing the plan of care. Implementation of Interventions/Nursing Actions Implementation is the "action plan" and the fifth step of the nursing process. The interventions are the concepts that link specific nursing activities and actions to expected outcomes. Independent activities are actions performed by the nurse, using his/her own discretionary judgment. Collaborative activities are actions that involve mutual decision making between two or more health-care practitioners. The care must be coordinated within and across all types of health-care settings for patients who transition to another setting. Specific examples of implementation of infusion therapy related nursing actions include: 1.
These viruses are made up of four distinct families: arenaviruses hiv infection rates scotland discount medex 5 mg with visa, filoviruses antiviral group order medex 5 mg, bunyaviruses process of hiv infection at the cellular level quality medex 1 mg, and flaviviruses stages of hiv infection pdf purchase medex 5mg without prescription. Severely ill patient cases may also show shock hiv infection impairs humoral immunity discount 1 mg medex fast delivery, nervous system malfunction antiviral zanamivir order medex 1 mg otc, coma, delirium and seizures. Examples of reservoir hosts include the multimammate rat, cotton rat, deer mouse, house mouse and other field rodents. Rodents or insectivores via direct contact with the animal, or inhalation of or contact with materials contaminated with rodent droppings. Vectorborne transmission via mosquito or tick bites or by crushing infected ticks. Currently, only vaccines for yellow fever and Argentine hemorrhagic fever are available. Because many of the hosts that carry hemorrhagic fever viruses are rodents, disease prevention efforts include: · controlling rodent populations · discouraging rodents from entering or living in homes or workplaces · encouraging safe cleanup of rodent nests and droppings For hemorrhagic fever viruses spread by ticks or mosquitoes, prevention efforts often focus on community-wide insect control. In addition, people are encouraged to use insect repellent, proper clothing, bed nets, window screens and other insect barriers to avoid being bitten. Strategies include creating tools for more rapid disease diagnosis, to study how the viruses are transmitted and exactly how the disease affects the body, and to better understand how the environment interacts with these viruses and their hosts in order to offer preventive public health advice for avoiding infection. Adapted from the Centers for Disease Control and Prevention and the World Health Organization. K Geospatial Imaging & Information Research Group,Faculty Geionformation and Real Estate, Universiti Teknologi Malaysia, Malaysia zulkeplimajid@utm. Typical examples of these modifications include impoundments, dams, irrigation systems, landfills and so on that provide enabled environment for the transmission of Hemorrhagic fever such as malaria, dengue, avian flu, Lassa fever etc. Furthermore, contemporary urban dwelling pattern appears to be associated with the prevalence of Hemorrhagic diseases in recent years. These observations are not peculiar to the developing world, as urban expansion also contributes significantly to mosquito and other vectors habitats. The key to disease control is developing an understanding of the contribution of human landscape modification to vector-borne pathogen transmission and how a balance may be achieved between human development, public health, and responsible urban land use. A comprehensive review of urban land use Pattern Analysis for Hemorrhagic fever risk has been conducted in this paper. A relational model for investigating the influence of urban land use change pattern on the risk of Hemorrhagic fever has been proposed in this study. The rate of transmission of the parasite increases with the quest for speedy urbanization. Again, the actual process of rapid urbanization is associated with various ecological, social, and economic changes, in both the urban area, and the adjacent natural environment. Consequently, the continuous degradation of the ecosystem poses a threat to the present and future dwelling sustainability. Also, literature affirms that urbanization takes place in both developed and developing countries (Al-shalabi et al. However, speedy urbanization, especially the urban land expansion, and the associated problem of unemployment, poverty, poor sanitary condition and environment degradation pose a formidable challenge in some developing countries (Basnet, 2011; Hove et al. Be that as it may, the developing countries lack adequate implementation policies to address dwelling and Hemorrhagic risks as a result of speedy urbanization. Nevertheless, adequate insight into the available dwelling patterns and their impact on the spread of Hemorrhagic diseases could fast-track decision making progress for sustainable urbanization. For example, Lassa is limited to rural areas of West Africa where rats and mice carry the virus. Bulks of these studies were conducted in America, Asia and Australia with much emphasis on mosquito borne diseases such as dengue and malaria fevers. A greater proportion of shrub or grass land cover was found to be the most important contributor to their model, which predicts highest levels of risk around the Black Sea, Turkey, and some parts of central Asia. It was affirmed that Sub-Saharan Africa shows more localized areas of risk throughout the Sahel and the Cape region. However, studies on land use/land cover classification and other non-mosquito borne Hemorrhagic diseases such as Lassa fever, Ebola, Marburg etc. It is therefore, essential to conduct a comprehensive review of the existing literature on urban dwelling pattern and the risks of Hemorrhagic diseases in order to establish the relationship that may exist between them as well as to benchmark the variations in literature on continental basis. This may be remarkable for predicting the spread of such diseases and providing decision support system for health management institutions. Therefore, this paper presents a review on urban dwelling pattern analysis for Hemorrhagic fever risks. The results and findings of the paper are discussed in Section 4 while Section 5 wraps up the paper with conclusion. The outcome is fatal in a high proportion of cases sometimes more than 50%, (Dzotsi et al. Ebola and malaria, dengue haemorrhagic fevers and Lassa fever occur in parts of subSaharan Africa. Crimean-congo haemorragic fever occurs in the steppe regions of central Asia and in central Europe, as well as in tropical and southern Africa (Lai et al. Ecosystem changes resulting from natural phenomena or human interventions, on a local or global scale, can alter the ecological balance and context in which vectors and their parasites develop and transmit the disease (Patz et al. For the consequences at local and regional levels, the spatial patterns of land use change are as relevant as the aggregate volume of change. Today, there are various approaches to urban studies such as ground survey, photogrammetry and remote sensing. Remote sensing as a major source of data, is used in the study of areas with urban or manmade characteristics, landscapes and natural environments (Peled and Gilichinsky, 2013; Ye and Fang, 2011; Pelorosso et al. The definition given by Colwell (1997) to remote sensing as the art, science and technology of obtaining reliable information about physical objects and the environment, through a process of recording, 2. In general, the term "viral hemorrhagic fever" is used to describe a severe multisystem syndrome (meaning that multiple organ systems in the body are affected). While some types of hemorrhagic fever viruses can cause relatively mild illnesses, many of these viruses like Ebola or Marburg cause severe, life-threatening disease and death (Ajayi et al. For Ebola and Marburg viruses, humans have been infected from contact with tissues of diseased non-human primates (monkeys and apes) and other mammals, but most human infections have resulted from direct contact with the body fluids or secretions of infected patients. Lassa fever virus is carried by rodents and transmitted by excreta, either as aerosols or by direct contact. Some viral haemorrhagic fevers have been amplified in hospitals by nosocomial transmission resulting from unsafe procedures, use of contaminated medical devices (including needles and syringes) and unprotected exposure to contaminated body fluids (Kigozi et al. Land cover concerns the physical material observed at the earth surface (such as forests, water bodies and bare rock); Land use is related to the human use of the land and integrates socio-economic and cultural functions (such as agriculture and housing). Such classification procedures range from totally unsupervised approach to a full visual interpretation of the images and highly depend on the availability of the remotely sensed data, the availability of experts of the application domain, the adequacy of the data for the question addressed and the competence of the technicians, engineers and/or researchers that perform the image processing. As a result, a wide variety of Land use/Land cover typologies and methodologies can be found in the literature. Furthermore, in a bid to create comfortable dwelling for man, urban environment have been modified in various ways. These human modifications of the natural environment continues to provide habitats in which vectors of a wide variety of human and animal pathogens thrive with an enormous potential to negatively affect public health if left unchecked. This underscores the need for numerous studies on urban land use classification and diseases hazard risks found in current literature (see Table 1). The queries were defined by the conjunction of two or more key words and/or expressions. A total of 15 recently published articles from 2011 to 2016 were identified on the subject matter. Table 1a and 1b shows the summary of the articles in accordance to their classification. Variable studies exist for different hemorrhagic fevers in different part of the world. This could be attributed to the variations in government response to cases of endemic diseases, cultural differences and the nature of urban life style. This will help to identify the risk factors from the set of possible environmental parameters. Landscape composition (the number and types of patches) and configuration (the spatial relationships among patches) must be considered alongside the set of highly localized biotic and abiotic features. This raises questions of objectivity, relevance and adequacy when carrying out environmental characterization. Some studies have therefore tried to standardize and evaluate the effectiveness of the characterization methods (Tischendorf et al. Also, a study on mapping a Knowledge-Based Malaria Hazard Index Related to Landscape Using Remote Sensing has been conducted by Li et al. A set of normalized landscape-based hazard indices was developed by computing and combining landscape metrics. Through empirical selection of the best index, the index that successfully represents the current knowledge about the role played by landscape patterns in malaria transmission within the study area was identified. Furthermore, a handful of literature on urban land use pattern analysis for malaria risk over Africa also exists. Extensive georeferenced database and geographical information systems was used to highlight transmission patterns, knowledge gaps, trends and changes in methodologies over time, and key differences between land use, population density, climate, and the main mosquito species. Investigating the contribution of agricultural insecticide use to increasing insecticide resistance in African malaria vectors, Reid and McKenzie, (2016) found that higher resistance in mosquito populations across Africa was associated with agricultural insecticide use. This association appears to be affected by crop type, farm pest management strategy and urban development. Nevertheless, similar efforts over Europe and Asia have revealed that there are relatively few studies (Al-Eryani et al. This may be due, in part to strong economic growth in many countries of Europe and Asia, and improved housing standards and control programs (TapiaConyer et al. Large volume of extensive literature on the risks, distribution and mapping of the spread of dengue fever in relation to urban land use pattern has been well reported over Asia than any continent of the world (Wesolowski et al. Furthermore, the spatial distribution of risks of dengue fever have been recently studied (Kikuti et al. While identifying poor geographic access to health services as a possible barrier to identifying both dengue and non-dengue cases, further spatial studies that could account for such potential source of bias have been recommended in these studies. Therefore, utilising urban land use metrics in addition to socioeconomics may be a pointer to the desired goal. This is evident by the virtually none existence of any specific article in the current literature discussing the land used pattern analysis for families of the non-mosquito borne Hemorrhagic fever risks. Typical among them are Ebola and Lassa fevers whose recent outbreaks has posed serious health challenges in the world especially in sub-Sahara Africa. For instance, it has been reported in medical literature that rats are the key vectors of lassa virus (Yun and Walker, 2012). The short incubation period of these diseases, their high infectious characteristics and high mortality rate associated with the spread has led to their classification as high risk health issue (Ibekwe et al. The challenge therefore, is to determine the link between these diseases and urban land use pattern. Therefore, the critical questions to be addressed in subsequent studies include: (i) Is there any relationship between urban land use pattern and non-mosquito borne Hemorrhagic fevers? In order to address these issues and establish the desired relationship, there is the need to first, construct a relational framework. This will help in understanding the relationship between land use characteristics and the incidences of hemorrhagic fevers; Figure 1 depicts the relational framework. This relational framework as shown in Figure 1 indicates a possible relationship between hemorrhagic fevers and land use change pattern. Similarly, majority of the available literature on malaria emerged from the Caribbean (particularly, Brazil) followed by sub-Saharan Africa, while Asia has the most studies on dengue Hemorrhagic fevers. This framework can be said to have provided a preliminary answer to the questions raised in Section 4. The authors would also like to thank Innovative Engineering Alliance, Universiti Teknologi Malaysia, for providing the fund from vote number 4L149 to enable this study to be carried out. Molecular Diagnostics For Lassa Fever At Irrua Specialist Teaching Hospital, Nigeria: Lessons Learnt From Two Years Of Laboratory Operation. Spatial Distribution Of the Risk Of Dengue And the Entomological Indicators In Sumarй, State Of Sгo Paulo, Brazil. Changes In Land Use/Land Cover And Ecosystem Services In Central Asia During 1990-2009. Analysis Of Reported Cases Of Lassa Fever In Plateau State And the Need For Strategic Action Plan. Epidemiological Analysis Of Spatially Misaligned Data: A Case Of Highly Pathogenic Avian Influenza Virus Outbreak In Nigeria. Containing A Lassa Fever Epidemic In A Resource-Limited Setting: Outbreak Description And Lessons Learned From Abakaliki, Nigeria (JanuaryMarch 2012). Entomological Aspects And the Role Of Human Behaviour In Malaria Transmission In A Highland Region Of the Republic Of Yemen. A Multi-Criteria Decision Analysis Approach To Assessing Malaria Risk In Northern South America. Spatial Analysis Of Dengue And the Socioeconomic Context Of the City Of Rio De Janeiro (Southeastern Brazil). Baseline Malaria Vector Transmission Dynamics In Communities In Ahafo Mining Area In Ghana. Coupling Of Remote Sensing Data And EnvironmentalRelated Parameters For Dengue Transmission Risk Assessment In Subang Jaya, Malaysia. Modeling Sprawl Of Unauthorized Development Using Geospatial Technology: Case Study In Kuantan District, Malaysia. Thirty Years Of Use And Improvement Of Remote Sensing, Applied To Epidemiology: From Early Promises To Lasting Frustration. The Urban Crisis In Sub-Saharan Africa: A Threat To Human Security And Sustainable Development. Malaria Parasite Carriage And Risk Determinants In A Rural Population: A Malariometric Survey In Rwanda. The Multiplicity Of Malaria Transmission: A Review Of Entomological Inoculation Rate Measurements And Methods Across Sub-Saharan Africa.
As a nurse initiating infusion therapy hiv infection long term symptoms purchase 5mg medex mastercard, be aware of these standards as well as those of your own institution hiv symptoms days after infection buy 5mg medex. Attention to pain management Catheter selection Gloving Site preparation Vein entry hiv infection by oral buy discount medex 5 mg on line, direct versus indirect Catheter stabilization and dressing management Postcannulation 12 antiviral drug for herpes discount medex 5mg without prescription. Labeling Equipment disposal Patient education Rate calculations Documentation Precannulation Before initiating the I hiv infection rate dominican republic medex 1 mg otc. It is also essential that the nurse understand the rationale for the order before proceeding hiv infection symptoms in hindi medex 5mg free shipping. Step 2: Hand Hygiene Appropriate and adequate hand hygiene is one of the most important steps in reducing the risk for vascular access device-related infections. Note that glass systems are used infrequently and primarily with medications that can be absorbed by plastic. To check the glass system: Hold the container up to the light to inspect for cracks as evidenced by flashes of light. Gently squeeze the soft plastic infusate container to check for breaks in the integrity of the plastic; squeeze the system to detect pinholes. For the closed glass system, a vented administration set must be used; for the plastic system, a nonvented set should be used (see Chapter 5 for more detailed information on I. Step 4: Patient Identification, Patient Assessment, and Psychological Preparation Before assessing the patient, patient identification is critical. Examples of patient identifiers include name, an assigned identification number, and birth date. Selection of the vascular access device and insertion site requires integration and synthesis of data obtained from the patient assessment and the specific infusion therapy prescribed. It is important to use step 4 to gather the necessary information needed to perform a successful venipuncture and infusion therapy. The nurse should consider aspects such as autonomy, handedness, and independence along with invasion of personal space when I. Often the patient has a fear of pain associated with venipuncture or the memory of a previously negative encounter related to necessity of the therapy. Make sure to assess and document fears and preferences related to pain management. In alternative care settings, such as the home, creating a good environment can be challenging. Often, the kitchen table works well because there is often good lighting and the surface can be cleaned for placement of supplies. It is important to remember that certain therapies are not appropriate for peripheral-short catheters. In adults, veins that should be considered include those on the dorsal and ventral surfaces of the upper extremities. Routinely initiate venipuncture in the distal areas of the upper extremities; subsequent cannulation should be made proximal to the previously cannulated site. Consideration should be given to use of visualization technologies that aid in vein identification, such as transillumination or near infrared technology (discussed later in this chapter and also in Chapter 5). Veins of the lower extremities; these should not be used in the adult population because of risk of embolism and thrombophlebitis b. Veins in the lateral surface of the wrist above the thumb for approximately 45 inches because of the potential for nerve damage f. The ventral surface (inner aspect) of wrist because of pain on insertion and possible nerve damage g. The affected extremity when there is evidence of cellulitis, presence of an arteriovenous fistula, history of lymph node dissection. Additional information must be considered before initiation of infusion therapy and is part of step 4 in completing a thorough assessment. The following factors help nurses make appropriate choices for site selection and should be part of step 1 in the nursing process- assessment. Type of solution: When administering irritating fluids, such as certain antibiotics and potassium chloride, select a large vein in the forearm to initiate this therapy. Condition of the vein: A soft, straight vein is the ideal choice for venipuncture. Palpate the vein by moving the tips of the fingers down the vein to observe how it refills. The dorsal metacarpal veins in elderly patients are a poor choice because blood extravasation. When a patient is hypovolemic, peripheral veins collapse more quickly than larger veins. Avoid: Bruised veins Red, swollen veins Veins near previous site of phlebitis and infiltration Sites near a previously discontinued site 3. Duration of therapy: Long courses of infusion therapy make preservation of veins essential. Perform venipuncture distally, with each subsequent puncture proximal to previous puncture and alternate arms. Cannula size: Small-gauge catheters take up less space in the vein, allowing for blood flow around the catheter; they also cause less trauma when inserted. If a larger-gauge catheter is required, as in emergency situations or blood transfusions, a larger vein should be chosen. For more viscous solutions such as blood, an 18- to 20-gauge catheter may be selected, although smaller catheters are used with children. For neonates, 24-gauge catheters are used; for children, 22- to 24-gauge catheters are most often used (Frey & Pettit, 2010). Veins in the hands, feet, and antecubital region may be the only accessible sites. Veins in elderly persons are usually fragile, so approach venipuncture gently and evaluate the need for a tourniquet. Patient activity: Ambulatory patients who use crutches or a walker will need cannula placement above the wrist so that the hand can still be used. Presence of disease or previous surgery: Patients with vascular disease or dehydration may have limited venous access. If a patient has a condition with poor vascular venous return, the affected side must be avoided. Examples of such conditions are cerebrovascular accident, mastectomy, amputation, orthopedic surgery of the hand or arm, and plastic surgery of the hand or arm. Patients receiving anticoagulation therapy: these patients have a propensity to bleed. Local ecchymoses and major hemorrhagic complications can be avoided if the nurse is aware that the patient is taking anticoagulant drugs. Use the smallest catheter that will accommodate the vein and deliver the ordered infusate. On discontinuation of infusion therapy for patients on anticoagulation therapy, direct pressure should be applied over the site for at least 10 minutes. If the veins are fragile or if the patient is taking anticoagulants, avoid using a tourniquet; constricted blood flow may overdistend fragile veins, causing vein damage, vessel hemorrhages, or subcutaneous bleeding. For example, iodine allergies must be identified because iodine is contained in some products used for skin antisepsis (povidone iodine). Other allergies of concern to delivery of safe patient care include allergies to lidocaine, medications, foods, animals, latex, and environmental substances. Always question the patient regarding allergies before administering medications, especially those given by intravenous route. Debilitated patients and those taking corticosteroids have fragile veins that bruise easily. Patients who require frequent infusions are often knowledgeable about which of their veins are good for venipuncture. A formal assessment tool, the TransCultural Nursing Assessment Tool, is available online ( It organizes an assessment into six cultural phenomena that are evident in all cultural groups: 1. Communication: Language, voice quality, pronunciation, use of nonverbal communication 2. Social organization: Ethnicity, family role function, work, leisure, church, friends 4. Environmental control: Health practices, values, definition of health and illness 6. Encourage the patient to share cultural interpretations of health, illness, and health care. Factors affecting the capacity for dilation are blood pressure, presence of valves, sclerotic veins, and multiple previous I. Stroking the vein: Lightly stroke the vein downward or use light tapping with index finger to cause dilation of vein. Another randomized controlled trial involving outpatient oncology patients compared dry heat to moist heat, finding that dry heat was 2. Phillips multiple tourniquet technique: Apply additional tourniquets to increase the oncotic pressure and bring deep veins into view. This technique is useful for patients with extra adipose tissue, although ultrasonography is becoming more prevalent and is very useful for obtaining successful venous access in obese patients. Table 6-5 lists the steps for the technique, and Figure 6-6 shows a picture of a multiple tourniquet. Visualization technology (transillumination): Transillumination is simply defined as shining a light through tissues (Hadaway, 2010b). A small, portable battery-operated device is available for imaging subsurface veins and some structures; this side-transillumination method shines light into the skin from outside the field of view so that the light is pointed toward the center at a depth of approximately 2 cm. The depth of visualization of veins is between 3 and 6 mm depending on the color of the light used. Advantages to such a device include vein location in darker-skinned and obese patients and in children. Explain reasons for use of multiple tourniquet technique and that some pressure discomfort may be felt for a short period of time. After 2 minutes, place a second tourniquet at midarm just below the antecubital fossa for 2 minutes. By increasing the oncotic pressure inside the tissue, blood is forced into the small vessels of the periphery. If soft collateral veins do not appear in the forearm, a third tourniquet may be placed near the wrist. Use Phillips multiple tourniquet technique: If the peripheral vessels are hard and sclerosed because of a disease process, personal misuse, or frequent drug therapy, venous access is difficult. Note: the Phillips multiple tourniquet technique helps novices learn the differences between collateral veins and sclerosed vessels. Usually, veins appear in the basilic vein of the forearm and the hands when this approach is used. Advantages include a hands-free device and the ability to better view veins in patients who are darker-skinned or obese and have compromised veins. Visualization technology (ultrasound): Ultrasonography uses sound waves to locate human bodily structures. A, Tangential lighting using flashlight to illuminate veins of dark skin individual. Patients with altered skin integrity are often photosensitive and need additional protection of their already damaged tissue. Although most of the literature addresses use by emergency department nurses, use in other hospital units is increasing. Venous access is generally difficult in obese patients, and use of ultrasound is associated with improved success rate in this special patient population (Houston, 2013) (see also Chapter 5). The technique can be effectively performed by nurses, physicians, and emergency department technicians. Instead, use side lighting, which can add contour and "shadowing" to highlight the skin color and texture and allow visualization of the vein shadow below the skin. When caring for patients with highly pigmented skin, establish the baseline color with good lighting. Cannulation Cannulation involves steps 6 through 11: Paying attention to pain management, selecting the appropriate catheter, gloving, preparing the site, direct or indirect entry into the vein, stabilizing the catheter, and managing the dressing. Expected outcomes in relation to appropriate site placement include the following: the site must tolerate the rate of flow. Obesity: Use ultrasonography to locate and cannulate veins, use 2-inch catheter and lateral veins, and/or consider Phillips multiple tourniquet technique. Patient satisfaction is maximized and fear and anxiety are reduced when pain management is addressed. Additional interventions include cognitive behavioral strategies such as distraction and positioning. The benzyl alcohol is an opium alkaloid that possesses antiseptic and anesthetic properties. Although often used as an inexpensive anesthetic, bacteriostatic normal saline was found to be inferior in terms of local anesthesia compared with lidocaine in two randomized controlled trials led by nurses (Burke et al. Lidocaine has been used in clinical practice since 1948 and is one of the safest anesthetics. The anesthetized site is numb to pain, but the patient perceives touch and pressure and has control of his or her muscles. The anesthetic becomes effective within 15 to 30 seconds and lasts 30 to 45 minutes. Lidocaine can cause a slight burning sensation with initial needle insertion; when the lidocaine is buffered with sodium bicarbonate, this discomfort is reduced. However, buffered lidocaine is not commercially available and must be compounded by the pharmacy, which makes it more costly (Ganter-Ritz, Speroni, & Atherton, 2012).
Antimicrobial lock solutions as a method to prevent central line-associated bloodstream infections: a meta-analysis of randomized controlled trials hiv infection guidelines purchase medex 5mg line. Prophylactic antibiotics for preventing gram positive infections associated with long-term central venous catheters in oncology patients foods with antiviral properties generic medex 1mg free shipping. Adverse effects associated with ethanol catheter lock solutions: a systematic review hiv infection vaccine cheap medex 5 mg with visa. Ethanol locks in the prevention and treatment of catheter-related bloodstream infections hiv infection rates global medex 5mg lowest price. Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis hiv infection rate malawi generic medex 5 mg free shipping. Taurolidine lock solutions for the prevention of catheter-related bloodstream infections: a systematic review and meta-analysis of randomized controlled trials hiv gum infection cheap medex 1mg otc. Emergence of gentamicin-resistant bacteremia in hemodialysis patients receiving gentamicin lock catheter prophylaxis. Inspect the infusion system for clarity of the infusate; integrity of the system (ie, leakage, luer connections secure) and of the dressing; correct infusate; accurate flow rate; and for expiration dates of the infusate and administration set. Recognize the risk of contamination with each manipulation of the infusion system (refer to Standard 36, Add-on Devices; Standard 40, Flushing and Locking). Short peripheral catheters: assess minimally at least every 4 hours; every 1 to 2 hours for patients who are critically ill/sedated or have cognitive deficits; hourly for neonatal/pediatric patients; and more often for patients receiving infusions of vesicant medications. Take this measurement 10 cm above the antecubital fossa; identify the location and other characteristics, such as pitting or nonpitting. Allow any skin antiseptic agent to fully dry prior to dressing placement; with alcoholic chlorhexidine solutions, for at least 30 seconds; for iodophors, for at least 1. Use chlorhexidine with care in premature infants and infants under 2 months of age due to risks of skin irritation and chemical burns. For pediatric patients with compromised skin integrity, remove dried povidone-iodine with sterile 0. Anticipate potential risk for skin injury due to age, joint movement, and presence of edema. If gauze is used to support the wings of a noncoring needle in an implanted port and does not obscure the insertion site, it is not considered a gauze dressing. Secure dressings to reduce the risk of loosening/ dislodgment, as more frequent dressing changes due to dislodgment are associated with increased risk for infection; more than 2 dressing changes for disruption were associated with a greater than 3-fold increase in risk of infection. Change the dressing immediately to closely assess, cleanse, and disinfect the site in the event of drainage, site tenderness, other signs of infection, or if dressing becomes loose/dislodges. Perform dressing changes on short peripheral catheters if the dressing becomes damp, loosened, and/or visibly soiled and at least every 5 to 7 days. Use chlorhexidine-impregnated dressings with caution in premature neonates and among patients with fragile skin and/or complicated skin pathologies; contact dermatitis and pressure necrosis have occurred. Consider use of chlorhexidine-impregnated dressings with peripheral arterial catheters as an infection reduction intervention. Reduction in catheter-related infections after switching from povidone-iodine to chlorhexidine for the exit-site care of tunneled central venous catheters in children on hemodialysis. Observational study on preoperative surgical field disinfection: povidone-iodine and chlorhexidine-alcohol. Chlorhexidineimpregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Chlorhexidine gluconateimpregnated central access catheter dressings as a cause of erosive contact dermatitis: a report of 7 cases. Chlorhexidine gluconate-impregnated central-line dressings and necrosis in complicated skin disorder patients. Chlorhexidine bathing and health care-associated infections: a randomized clinical trial. Chlorhexidine bathing to reduce central venous catheter-associated bloodstream infection: impact and sustainability. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Evaluation of a no-dressing intervention for tunneled central catheter exit sites. Check the packaging of administration sets for latex and avoid use of a latex-containing set for patients with a latex allergy (refer to Standard 14, Latex Sensitivity or Allergy). Label administration sets used for medications that are administered via specialized access devices (ie, intraspinal, intraosseous, subcutaneous) to indicate the correct administration route and device, and place the label near the connection to the device. Replace primary and secondary continuous administration sets used to administer solutions other than lipid, blood, or blood products no more frequently than every 96 hours. There is strong evidence that changing the administration sets more frequently does not decrease the risk of infection. There is an absence of studies addressing administration set changes for intermittent infusions. Aseptically attach a new, sterile, compatible covering device to the male luer end of the administration set after each intermittent use. Do not attach the exposed male luer end of the administration set to a port on the same set ("looping"). Change the transfusion administration set and filter after the completion of each unit or every 4 hours. If more than 1 unit can be infused in 4 hours, the transfusion set can be used for a 4-hour period (refer to Standard 62, Transfusion Therapy). Replace the disposable or reusable transducer and/ or dome and other components of the system, including the administration set, continuous flush device, and flush solution used for invasive hemodynamic pressure monitoring every 96 hours, immediately upon suspected contamination, or when the integrity of the product or system has been compromised. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Replacement of administration sets (including transducers) for peripheral arterial catheters: a systemic review. Control blood sampling procedures to prevent errors in the preanalytic phase before the sample reaches the laboratory. These errors delay treatment decisions due to spurious lab values, enhance the potential for patient harm, and increase costs of care. A centralized phlebotomy service for hospitalized patients has been shown to reduce preanalytic errors, such as hemolysis and specimen labeling. Assess the patient for fasting prior to collection of blood samples, if appropriate for the requested laboratory values. Use the same unique numbers for both patient identification and specimen labeling to reduce preanalytic errors and enhance patient safety. Use multiple process improvement methods such as staff engagement, transparency of data on mislabeled and unlabeled specimens, process changes, root cause analysis, and accountability measures. An electronic system (eg, bar-code or radio-frequency technology) for patient identification and sample container labeling has been shown to reduce these errors. Perform all infection prevention practices including hand hygiene, appropriate use of gloves, singlepatient tourniquets, single-use venipuncture and sampling devices, use of safety-engineered devices, and appropriate skin antisepsis (see Standard 16, Hand Hygiene; Standard 18, Medical Waste and Sharps Safety). Hemolysis causes spurious values for many tests (eg, electrolytes, glucose, cardiac biomarkers, coagulation times). Contact the clinical laboratory about parameters for the free hemoglobin level that would cause a sample to be rejected. Employ blood conservation strategies to reduce phlebotomy-associated blood loss, which is a significant cause of hospital-acquired anemia in patients of all ages. This blood loss often results in the need for blood transfusion and its inherent risks. Collaborate with the laboratory about the minimum volume of blood required for each test. Place all blood specimens in a closed, leakproof container and dispatch to the laboratory immediately using an appropriate delivery method; or if delivery must be delayed (eg, home-drawn specimens), properly store and control the temperature to reduce the risk for inaccurate laboratory values and the potential for hemolysis. If phlebotomy must be performed on the extremity with infusing solutions, a vein below or distal to the site of infusion should be used. Avoid venipuncture on upper extremities with lymphedema, compromised circulation associated with radiation therapy, paralysis, or hemiparesis from a cerebrovascular accident. When possible, restrict venipuncture to the dorsum of the hand in patients with an actual or planned dialysis fistula or graft. Evidence for avoiding all venipuncture on the side of axillary node dissection comes from conflicting studies; however, there remains a recommendation to avoid all venipuncture procedures on these upper extremities (refer to Standard 27, Site Selection). Perform venipuncture for phlebotomy with a straight or winged needle on veins in the antecubital fossa (eg, median cubital, cephalic, and basilic veins) due to the lower rates of hemolysis associated with these devices and sites. Excessive alcohol on the skin has previously been thought to cause hemolysis; however, 1 study has shown this to not be a cause (see Standard 33, Vascular Access Site Preparation and Device Placement). Consider use of a standardized sterile blood culture collection kit to reduce sample contamination. Draw a quantity of blood that is sufficient for isolating organisms (ie, 20-30 mL for adults; no more than 1% of the total blood volume for infants and children). Discard the initial blood sample (eg, 5 mL) when drawing from a direct venipuncture. Avoid tight fist clenching or repetitively opening and closing the fist to prevent pseudohyperkalemia. Use a straight or winged needle instead of obtaining the sample during the procedure to insert a short peripheral catheter. If a tourniquet is required, limit tourniquet time to less than 1 minute to reduce the risk of hemolysis and inaccurate chemistry lab values caused by changes in vascular endothelium from increased venous pressure and hypoxia. Immediately release the tourniquet when the blood begins to flow into the collection container. For coagulation studies, do not discard the initial sample except when a winged needle with an attached extension set is used. Air in the extension set prevents the correct ratio of blood to anticoagulant additive in the tube. Perform venipuncture in neonates by a skilled phlebotomist instead of heel lance methods due to the increased pain from the heel lance. No studies of these specific techniques are found for peripheral or midline catheters. Discard volumes of 6 mL from nontunneled catheters and 9 mL from tunneled cuffed catheters were sufficient to remove infused glucose, although the discard volume for implanted ports could not be established. These studies do not provide consensus on the required number of push-pull cycles or the volume of blood to be pulled; however, 5 cycles is the most common. Consider obtaining a blood sample from an indwelling short peripheral catheter for pediatric patients, adults with difficult venous access, presence of bleeding disorders, and the need for serial tests. Infusing solutions should be stopped for at least 2 minutes prior to obtaining the blood sample; waste 1 to 2 mL of blood before obtaining the sample. Sampling of blood from indwelling short peripheral catheters is reliable for many routine blood tests, including coagulation studies. Obtaining blood cultures from short peripheral catheters at insertion or during the dwell is not recommended. Obtaining a blood sample during the insertion of a short peripheral catheter is associated with higher rates of hemolysis and spurious lab values, regardless of whether the sample was drawn directly from the catheter hub or from an attached extension set. However, short peripheral catheters inserted for infusion into veins of the antecubital fossa are not recommended due to higher catheter complication rates in areas of joint flexion (see Standard 27, Site Selection). Lengthy tourniquet time and difficult catheter insertion can produce inaccurate lab values. For midline catheters, no evidence is available regarding obtaining blood samples. For therapeutic drug monitoring, draw the blood sample from a dedicated lumen not used for infusion of the drug being monitored. Retesting via a direct venipuncture is required when questionable results are obtained. Research has not established the length of time for stopping fluid flow or the amount of flush solution. One study suggests a wait time of 10 minutes after stopping the infusion before drawing the sample. One study suggests larger volumes (10-20 mL) of flush solution provide more accurate peak levels of antibiotics when compared to smaller volumes (3 mL). Remove and discard the used needleless connector prior to drawing a blood sample to reduce risk of a falsepositive blood culture result. Review medical history (eg, trauma, previous radial artery cannulation, radial artery harvesting); assess presence of anticoagulants; and perform a physical examination of hand circulation such as assessing radial and ulnar pulses, Allen test, pulse oximetry, or Doppler flow study. Because palpation is needed to feel the arterial pulsation, use sterile gloves for puncture and catheter insertion into any artery (refer to Standard 33, Vascular Access Site Preparation and Device Placement). For arterial blood gases, expel air from the syringe immediately after obtaining the sample, and place the syringe on ice for immediate transport to the lab. Do not use solutions containing glucose in adults as this results in falsely elevated glucose levels, possible overtreatment with insulin, and dangerously low serum levels of glucose. Store solutions intended for arterial infusion in a location different from solutions intended for venous infusion. Ensure that the label on the solution container is visible and not obscured by the presence of a pressurized device. Use a closed loop system to reduce hospital-acquired anemia and subsequent need for transfusion. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. Hemolyzed specimens: a major challenge for emergency departments and clinical laboratories. Reduction in specimen labeling errors after implementation of a positive patient identification system in phlebotomy. A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.
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