Archive | September 2010

Trendelenburg’s position

A supine position with the patient inclined at an angle of 45 degrees; so that the pelvis is higher than the head, used during and after operations in the pelvis or for shock.

Work Smart, Not Hard

 
Many caregivers never had the opportunity to learn essential time-management skills that result in working smart, not hard. You may find the following helpful:

Create specific goals for personal and professional development. Parse your annual goals into monthly goals. Break up your weekly goals into daily goals. Ask yourself, “What do I want to accomplish this year, this month, this week, this day?” Planning each day can give you a road map to getting to your destination!

Do one thing at a time. Caregivers are notorious for trying to do and be all things to all people and all projects all the time. Quality always suffer when you try to do too many things at once.

End the day by planning for tomorrow’s projects whenever possible. That way, you’ll not only waste less time getting started the following morning, you’ll arrive at work feeling more in control of the day ahead.

Protect yourself from constant interruptions. When you’re working on a task, nothing will sabotage you more than interruptions. Block out the necessary time to complete tasks.

Work when you work best. We all have certain natural peak hours of performance. Pay attention to your inner clock. Are you a morning person or a night person? Does a brief nap recharge you?

Focus and reject. This is a reminder to stay focused on the task at hand. Learn to “switch off” those things that prevent you from accomplishing desired tasks. Sometimes this means delaying or returning calls and correspondence. If you always “stay available” you won’t have time to accomplish what you may really want and need to.

When all else fails, retreat to a hideout. When working on project development, you may need to find a “Skinner Box”: a place where you can hole up with no interruptions. Tell only those who truly need to know where you are. You’ll be amazed at what you get done.

When you know your energy level is dropping, take a break. After a 10-minute walk or a short nap, you may be able to accomplish much more than you could have otherwise.

Delegate tasks whenever possible. Watch out for “busy work” that might be done more efficiently by someone else.

Throughout the day ask yourself, “What’s the best use of my time right now?” Focus on those tasks that need to be done first.

Wolfelt, Alan. 2007. The Bereavement Caregiver’s Self Care Guidelines. Center for Loss and LIfe Transitions. Retrieved September 26, 2010 from http://griefwords.com/index.cgi?action=page&page=articles%2Fguidlines.html&site_id=3.

Total Parenteral Nutrition (TPN)

Administration of a nutritionally adequate solution through a catheter directly into the blood stream. This method bipasses the gastrointestial tract providing only the nutritional basics – typically dextrose, amino acids, essential vitamins and mineral components.

Indications: TPN may be the only feasible option for patients who do not have a functioning GI tract or who have disorders requiring complete bowel rest, such as the following:

  • In cases of severe exacerbations of Crohn’s disease or ulcerative colitis
  • Bowel obstruction
  • Certain pediatric GI disorders (eg, congenital GI anomalies, prolonged diarrhea regardless of its cause)
  • Short bowel syndrome due to surgery
  • In cases where the gastrointestinal tract requires respite to heal after trauma.

Administration technique:

Through a central venous catheter. 

The catheter and the skin around the catheter must cared for using sterile technique.

 The central line catheter may have 2-3 ports.  The TPN line should not be used for any other purpose.

External tubing should be changed q 24 h with the first bag of the day. In-line filters have not been shown to decrease complications.

Dressings should be kept sterile and are usually changed q 48 h using strict sterile techniques.

Assessments:

  • Weight
  • CBC
  • electrolytes
  • BUN
  • Plasma glucose should be monitored q 6 h until patients and glucose levels become stable.
  • Fluid intake and output should be monitored continuously.
  • Liver function tests.
  •  Plasma proteins (eg, serum albumin, possibly transthyretin or retinol-binding protein)
  • prothrombin time
  • plasma
  • urine osmolality
  • Ca
  • Mg
  • phosphate

Self Care Guidelines

We who care for the bereaved and the dying have a wondrous opportunity: to help others embrace and grow through grief-and to lead fuller, more deeply-lived lives ourselves because of this important work.

But our work is draining-physically, emotionally and spiritually. We must first care for ourselves if we want to care well for others. This manifesto is intended to empower you to practice good self-care.

1. I deserve to lead a joyful, whole life.

No matter how much I love and value my work, my life is multi-faceted. My family, my friends, my other interests and my spirituality also deserve my time and attention. I deserve my time and attention.

2. My work does not define me. I am a unique, worthy person outside my work life. While relationships can help me feel good about myself, they are not what is inside me. Sometimes I need to stop “doing” and instead focus on simply “being.”

3. I am not the only one who can help dying and bereaved people. When I feel indispensable, I tend to ignore my own needs. There are many talented caregivers in my community who can also help the dying and the bereaved.

4. I must develop healthy eating, sleeping and exercise patterns. I am aware of the importance of these things for those I help, but I may neglect them myself. A well-balanced diet, adequate sleep and regular exercise allow me to be the best I can be.

5. If I’ve been overinvolved in my caregiving for too long, I may have forgotten how to take care of myself. I may need to rediscover ways of caring for and nurturing myself. I may need to relearn how to explore my own feelings instead of focusing on everybody else’s.

6. I must maintain boundaries in my helping relationships. As a death caregiver, I cannot avoid getting emotionally involved with dying and bereaved people. Nor would I want to. Active empathy allows me to be a good companion to them. However, I must remember I am responsible to others, not for others.

7. I am not perfect and I must not expect myself to be. I often wish my helping efforts were always successful. But even when I offer compassionate, “on-target” help, the recipient of that help isn’t always prepared to use it. And when I do make mistakes, I should see them as an integral part of learning and growth, not as measurements of my self-worth.

8. I must practice effective time-management skills. I must set practical goals for how I spend my time. I must also remember Pareto’s principle: twenty percent of what I do nets eighty percent of my results.

9. I must also practice setting limits and alleviating stresses I can do something about. I must work to achieve a clear sense of expectations and set realistic deadlines. I should enjoy what I do accomplish in helping others but shouldn’t berate myself for what is beyond me.

10. I must listen to my inner voice. As a caregiver to the dying and the bereaved, I will at times become grief overloaded. When my inner voice begins to whisper its fatigue, I must listen carefully and allow myself some grief down-time.

11. I should express the personal me in both my work and play. I shouldn’t be afraid to demonstrate my unique talents and abilities. I must also make time each day to remind myself of what is important to me. If I only had three months to live, what would I do?

12. I am a spiritual being. I must spend alone time focusing on self-understanding and self-love. To be present to those I work with and to learn from those I companion, I must appreciate the beauty of life and living. I must renew my spirit.

Center for Loss and LIfe Transition. 2007. Self-care for Caregivers. Retrieved September 24, 2010 from http://griefwords.com/index.cgi?action=page&page=articles%2Fguidlines.html&site_id=3

Kernicterus

A form of brain damage caused by excessive jaundice in infancy.

Etiology:

damage to the brain centers of infants caused by increased levels of unconjugated bilirubin in the tissues.

Bilirubin builds up in the body to toxic levels and precipitates into tissues as the liver fails to metabolize it and the kidneys fail to excrete it from the body.

Pathophysioogy:

Pathologic diagnosis is characterized by bilirubin staining of the brainstem nuclei and cerebellum. Called bilirubin encephalopathy.

Manifestations:

Infant presents with yellowed skin tone and yellow discolouration to sclera of eyes.

In addition to the mild symptoms of jaundice listed above, severe brain damaging jaundice presents as follows:

  1. Excessively lethargy –  The infant is too sleepy, and they are difficult to arouse – either they don’t wake up from sleep easily like a normal baby, or they don’t wake up fully, or they can’t be kept awake.
  2. They have a high-pitched cry
  3. decreased muscle tone, becoming hypotonic or floppy)
  4. have episodes of increased muscle tone (hypertonic) and arching of the head and back backwards.
  5. As the damage continues, they may develop fever, may arch their heads back into a very contorted position known as opisthotonus or retrocollis.
Health promotion and prevention of hyperbilirubinemia
  1. Promote and support successful breastfeeding
  2. Establish protocols for the assessment of hyperbilirubinemia
  3. Measure total serum bilirubinemia or trancutaneous bilirubinemia of jaundiced infants within 24hrs
  4. Visual estimation of jaundice degree can lead to inaccurate assessment
  5. Interpret labs results of hyperbilirubinemia with respect to infant’s age in hours old
  6. Infants <38 weeks gestation, particularly those with inadequate milk intake in poor breastfeeding, those with congenital defects and infections such as hepatitis are at higher risk, requiring heightened monitoring.
  7. Perform a systematic assessment on all infants before discharge for severe hyperbilirubinemia risk.
  8. Educate parents to assess for newborn jaundice
  9. Provide follow-up and home visits for those at higher risk
  10. Treat newborns with severe hyperbilirubinemia with phototherapy and or exchange blood transfusion.

Management and Treatment:

Phototherapy. Light of the blue coloured wavelength in visible light alters the bilirubin chemical structure transforming it from a toxic form to a water soluble, non-toxic form that can be eliminated easily by the body.

At higher, more dangerous levels of bilirubin, or in certain situations where the bilirubin is expected to rise very rapidly, such as Rh or other hemolytic diseases of the newborn, exchange transfusions may be performed, to rapidly remove toxic bilirubin from the blood.

American Academy of Pediatrics, Clincical Practice Guideline, Subcommittee on Hyperbilirubinemai. (2004). Management of Hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 114 (1) 297-316.

Sharpiro, Steven. 2007. Jaundice and Kernicterus. Retrieved September 23, 2010 from http://www.kernicterus.org/

Otosclerosis

A condition causing fixation of the ear bones in the middle ear typically involving the stapes.

Etiology:

Genetic predisposition involving mutation in five collagen genes. Has a viral trigger and autoimmune component.

Manifestations:

Conductive hearing loss results as the natural pattern of osseous remodelling becomes dysfunctional. Bone resorption occurs normally, however bone building or hyperosteoblast activity occurs and the stapes becomes hyperossified eventually impairing movement of the stapes and resultantly impairing sound conduction.

Treatment:

Stapedotomy using a CO2 Lazer.

A hole is created in the stapes to secure a prosthetic

This allows sound to bypass the fused stapes and transmit sound through to the oval window.