By N. Fadi. State University of New York Institute of Technology at Utica/Rome.

Increased metabolism of warfarin and usually of doubtful benefit but with side effects cheap 10 mg deltasone amex, include phenytoin have been reported in alcoholics purchase deltasone 20mg mastercard. Alcohol enhances human chorionic gonadotrophin, growth hormone, caffeine, the gastric irritation caused by aspirin, indometacin and amphetamines, β-blockers and erythropoietin. They are Enhanced hypoglycaemia may occur following coadministra- claimed to enhance sexual pleasure and dilate the anus. Central effects are simi- euphoria, sedation, amnesia (implicated as ‘date rape’ drug), lar to alcohol. During withdrawal, convulsions are more often aggression, vomiting, coma, respiratory depression and seizure. Chloral hydrate and clomethiazole have similar potential for depend- Case history ence, and their use is difficult to justify. Laboratory tests reveal a raised mean corpuscular volume For more information on benzodiazepines, see Chapter 18. Solvents such as glues or paints are sniffed, Answer 1 often with the aid of a plastic bag to increase the concentration of Wernicke’s encephalopathy. Disinhibition can lead to excessively gregarious, aggressive or emotional behaviour. Cardiac Case history dysrhythmia can occur (as with hydrocarbon anaesthetics, A 20-year-old man is brought by the police to the Accident Chapter 24). Most deaths are associated with asphyxia as a result and Emergency Department unconscious. Excessive believe that he ingested condoms full of diamorphine prior to his arrest following a drugs raid. He had been in police chronic use is rare, but may lead to major organ failure, as custody for approximately one hour. There are no specific drug centrally cyanosed, breathing irregularly, with pinpoint therapies for solvent abusers and psychological and/or social pupils and no response to painful stimuli. Most synthetic anabolic steroids are derived Answer 2 Since naloxone is an effective antidote to diamorphine poi- from testosterone and are popular among body builders. The soning, close observation with repeated injections or infu- prevalence of anabolic steroid abuse among athletes is uncer- sion of naloxone, inhaled oxygen and bulk laxatives should tain. A handbook of drug and alcohol cal pharmacology of 3, 4-methylenedioxymethamphetamine. Self-poisoning creates 10% of the workload of Accident and The effects may be delayed. This list of agents that cause death from overdose does not testing) and biochemical determination of plasma electrolytes, reflect the drugs on which individuals most commonly over- Table 54. Benzodiazepines (often taken with alcohol) are commonly Symptoms/signs of Common poisons taken in an overdose, but are seldom fatal if taken in isolation. The majority of cases of self-poisoning fall into the psycho- logical classification of suicidal gestures (or a cry for help). Coma, pinpoint pupils, Opioids However, the prescription of potent drugs with a low therapeu- hypoventilation tic ratio can cause death from an apparently trivial overdose. Following an immediate assessment of vital functions, as oxidase inhibitors, mefenamic full a history as possible should be obtained from the patient, rel- acid, theophylline, atives, companions and ambulance drivers, as appropriate. A hypoglycaemic agents, lithium, knowledge of the drugs or chemicals that were available to the cyanide patient is invaluable. A psychiatric history, particularly of depressive ill- Tinnitus, overbreathing, Salicylates ness, previous suicide attempts or drug dependency, is relevant. If the patient is unconscious, protect airway with cuffed Suspected overdose Effect on management endotracheal tube. If semiconscious with effective gag reflex, Paracetamol Administration of antidotes – place the patient in the head-down, left-lateral position. An acetylcysteine or methionine anaesthetist with effective suction must be present Iron Administration of antidote – 2. Place the patient’s head over the end/side of the bed, so that desferrioxamine their mouth is below their larynx Methanol/ethylene glycol Administration of antidote – 3. Confirm that the tube is in the stomach (not the trachea) by without dialysis auscultation of blowing air into the stomach; save the first Lithium Dialysis sample of aspirate for possible future toxicological analysis Salicylates Simple rehydration or alkaline (and possible direct identification of tablets/capsules) diuresis or dialysis 5. Use 300 –600mL of tap water for each wash and repeat three Theophylline Necessity for intensive care unit to four times. Unless an oral antidote is to be administered, leave 50g of urea, creatinine, oxygen saturation and arterial blood gases. In these, emergency measurement An increasingly popular method of reducing drug/toxin of the plasma concentration can lead to life-saving treatment. To be effective, large amounts of char- overdoses are often asymptomatic, and although it only rarely coal are required, typically ten times the amount of poison causes coma acutely, patients may have combined paracetamol ingested, and again timing is critical, with maximum effec- with alcohol, a hypnosedative or an opioid.

As the indi- Adaptation of one’s behavior or beliefs to match viduals listened to the descriptions of others generic deltasone 40mg without a prescription, their an- those of the other members of a group discount 20 mg deltasone with mastercard. The power of social Conformity describes the adaptation of behavior norms was demonstrated even more strikingly when the that occurs in response to unspoken group pressure. It subjects continued to adhere to the norm later when they differs from compliance, which is adaptation of behavior were retested individually. Individuals conform to or strates one of the important conditions that produces comply with group behavior in an attempt to “fit in” or conformity: ambiguity. In most cases, swer to the question asked of the subjects, so they were conforming to social norms is so natural that people more vulnerable to reliance on a norm. However, each subject was Sigmund Freud viewed the conscience as one of tested in a room full of “planted” peers who deliberately two components of the superego, the other being the gave the wrong answer in some cases. In this scheme, the conscience prevents people fourths of the subjects tested knowingly gave an incorrect from doing things that are morally wrong, and the ego- answer at least once in order to conform to the group. This theory suggests that the conscience is Asch’s experiment revealed other factors—notably developed by parents, who convey their beliefs to their unanimity and size of the majority—that influence con- children. They in turn internalize these moral codes by a formity even when ambiguity isn’t an issue. Even one dissenter decreases the Other psychologists have proposed different theo- incidence of conformity markedly. People who follow the lead of an initial dissenter Further Reading may even disagree with that person and be dissenting Weissbud, Bernice. Although the ambiguity and unanimity of the situation are powerful contributors Consciousness to the incidence of conformity, they are not the sole de- Awareness of external stimuli and of one’s own terminants. Individuals who have a low status within a group or are unfamiliar Wilhelm Wundt’s investigations of consciousness, with a particular situation are the ones most likely to begun in 1879, were central to the development of psy- conform. Wundt’s approach, called members of a study or activity group, or new residents to structuralism, sought to determine the structure of con- a community are more likely to be affected by the pres- sciousness by recording the verbal descriptions provided sure to conform. Personality traits, such as concern by laboratory subjects to various stimuli, a method that with being liked or the desire to be right, also play a role. Certain cultures proach to the study of consciousness was the functional- are more likely than others to value group harmony over ism of William James,who focused on how conscious- individual expression. Behavior- ganization managers, and even parents can establish an ism,pioneered by John B. Watson in the early 1900s, atmosphere or “culture” that either fosters conformity or shifted interest from conscious processes to observable allows for dissension and individuality. Teaching Your Child to was at the heart of Sigmund Freud’s model of human Handle Peer Pressure. He also formulated the concept of the preconscious,which functions as an Conscience intermediate or transitional level of mind between the The moral dimension of human consciousness, the unconscious and the conscious. A preconscious thought means by which humans modify instinctual drives can quickly become conscious by receiving attention, to conform to laws and moral codes. In contrast, the re- In meditation, an altered state of consciousness is pressed material contained in the unconscious can only achieved by performing certain rituals and exercises. The collective unconscious con- widely used in the United States for purposes of relax- tains images and symbols, called archetypes, that Jung ation. It has been found that during this type of medita- found are shared by people of diverse cultures and tend tion, people consume less oxygen, eliminate less carbon to emerge in dreams,myths, and other forms. In Jung’s dioxide, and breathe more slowly than when they are in view, a thorough analysis of both the personal and col- an ordinary resting state. Although sleep suspends the voluntary exercise of stances as alcohol, tobacco, and coffee. The major cate- both bodily functions and consciousness, it is a much gories of psychoactive drugs include depressants, which more active state than was once thought. Delta waves demarcate the thought, memory, and perception, are particularly deepest levels of sleep, when heart rate, respiration, tem- known for their consciousness-altering properties. They perature, and blood flow to the brain are reduced and can produce distortion of one’s body image, loss of growth hormone is secreted. In the comes from the Greek word for sleep (hypnos), hypno- United States, for example, hallucinations are devalued tized people are not really asleep. Their condition resem- by mainstream culture as a bizarre sign of insanity, bles sleep in that they are relaxed and out of touch with whereas the youth counterculture of the 1960s viewed ordinary environmental demands, but their minds remain drug-induced hallucinations as enlightening, “mind-ex- active and conscious. In certain other societies, halluci- include lack of initiative, selective redistribution of at- nations are respected as an important therapeutic tool tention, enhanced ability to fantasize, reduced reality used by ritual healers. Also, hypnosis is often followed by post-hypnotic amnesia, in which the Further Reading person is unable to remember what happened during the Dennett, D.

Endogenous infection requires ■ a source Infection control 131 ■ means of transmission ■ means of entry trusted 5mg deltasone. Family and friends rarely move between patients deltasone 40mg cheap, but staff can easily transfer hospital (often resistant) pathogens between patients. Hygiene (especially handwashing) temporarily reduces numbers of skin-surface bacteria; particularly problematic pathogens may be targeted by specific treatments for staff (e. The use of gloves and no-touch techniques significantly reduces cross-infection, but handwashing remains the simplest and most important way to reduce infection; minimising movement of staff between patients also reduces risks. Airborne bacteria can also be transmitted through ■ dust ■ airborne skin scales ■ droplets (e. Taylor’s (1978) classic study of nurses’ handwashing techniques identified poor technique by qualified staff; student nurses fared better, possibly due to recent education or anxieties about their clinical assessment. Poor handwashing technique may be improved through continuing (in-service) education (Gould & Chamberlain 1994) and feedback (Mayer et al. Intensive care nursing 132 Taylor also found that while palms of hands were effectively cleaned when handwashing, thumbs, tips of fingers and backs of hands were poorly washed. Fingertips, the most likely part to touch patients, may harbour bacteria unless consciously washed— observing almost anyone washing their hands (in or outside hospital) supports Taylor’s observation. Hands should be dried thoroughly after washing; wet hands (and wet alcohol) provide ideal warm, moist environments for bacterial growth. Recontamination after handwashing can be reduced by ■ elbow-operated taps ■ disposable towels (not trailing in water) ■ foot-operated pedal bins. These should be accessible and maintained (tap levers blocked by other wall fittings, empty towel dispensers or broken pedal bins are counterproductive). Chlorhexidine causes a greater reduction in skin surface bacteria than soap (Doebbling et al. Alcohol rubs are as effective as handwashing, provided the alcohol is allowed to dry (Heinz & Yakovich 1988). Gowns/aprons reduce transmission of bacteria carried on staff clothing, while reminding staff to wash their hands (associations with ‘gowning up’) and discouraging unnecessary staff from visiting bed areas. Some units adopt colour codes for each bedspace; by limiting staff having direct patient contact to those wearing the apron colour for the bedspace ensures that staff change aprons (and wash hands) between patients. Inadequate hospital laundry supply or turnover and limited changing facilities at work encourages staff to wash uniforms at home. Hospital laundry washes of 71°C kill most microorganisms (Wilson 1997) (although not necessarily hepatitis B); while uniforms should withstand such temperatures, most casual clothing will not (see labels on clothing). Home washes are usually considerably cooler and domestic washing therefore seldom sterilises clothes. Staff from other areas in direct contact with patients should be encouraged to either change into unit clothing, or remove jackets and coats worn outside the unit (before washing their hands). Critical illness necessitates contact with many staff, but unnecessary staff should be discouraged from visiting, and movement of staff between beds minimised. Conflicts with educational Infection control 133 needs (particularly in teaching hospitals) need to be evaluated against risks to patients. Communication and teamwork between different multidisciplinary team members, including microbiologists and infection control teams, can proactively minimise infection risk; multidisciplinary audit should identify unit-specific issues; action research may develop solutions. Inadequate staffing (quantity and quality) increases cross-infection (Hanson & Elston 1990). Many invasive procedures and treatments are unavoidable with critical illness, but each may introduce infection into immunocompromised patients. Nurses can usefully question whether some may be avoided: alternative routes for drugs may be possible (e. Central vein cannulae remain the major cause of nosocomial septicaemia (Randolph 1998), and so should be replaced whenever practical. Unused cannulae (peripheral or central) create unnecessary risks and should be removed. Despite extensive research, time limits for replacing invasive equipment vary between equipment type, insertion site and researchers. Hospitals and units often provide evidence-based guidelines for replacement times, and manufacturers should state recommended times; staff extending manufacturers’ times should consider their legal liability (see Chapter 45). Insertion dates of all invasive equipment should be recorded so that they can be changed promptly. Improving gut perfusion with dopamine (McClelland 1993b) has proved disappointing; dobutamine may be more effective (Levy et al. Measuring intramucosal pH (pHi) indicates sepsis and mortality (Lavery & Clapham 1993), although benefits remain controversial. Enteral nutrition (see Chapter 9) remains the most effective way to enhance gut defences and reduce translocation of gut bacteria. Intensive care nursing 134 Isolation can halve nosocomial infection rates (Hanson & Elston 1990), but increase psychological stress (see Chapter 3) and delay discharge, thus exposing patients to prolonged risk of nosocomial infection (Teare & Barrett 1997). Staff screening has recently generated heated debate in the British Medical Journal, Lessing et al.