Showing posts with label medical surgical nursing. Show all posts
Showing posts with label medical surgical nursing. Show all posts

Saturday, October 8, 2011

The 4 Cs of Cardiac Arrest Care

The 4 Cs of Cardiac Arrest Care according to the 2010 A.H.A Guidelines

Field JM, Hazinski MF, Sayre MR, et al
Circulation. 2010;122:S640-S656
The year 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR). During these past 50 years, tremendous research has been conducted to evaluate techniques, medications, and devices designed to advance the care of victims of cardiac arrest. The American Heart Association (AHA) developed the first CPR guidelines in 1966 and since that time has published frequent updates of the guidelines to help educate the public and medical establishment about optimal care for patients with cardiac arrest and other emergency cardiovascular conditions.
This past November, the newest set of guidelines pertaining to CPR and emergency cardiovascular care were published by the AHA in a supplement issue of Circulation. The guidelines consist of 16 parts. They address not only cardiac arrest, but also post-arrest care, dysrhythmias, acute coronary syndromes, stroke, cardiac arrest in special situations (eg, pregnancy, pulmonary embolism, etc), pediatric considerations, and ethics. Part I is a summary statement of the major changes in cardiac arrest and emergency cardiovascular care since the previous set of guidelines, which were published in 2005. The highlights of this "Executive Summary" are summarized below. For purposes of brevity, this discussion will focus on adult patients with acute cardiac conditions (cardiac arrest and dysrhythmias), excluding acute coronary syndromes, stroke, and pediatric considerations. The reader should note that the bulk of guideline recommendations, as in past years, are concentrated on victims of primary cardiac arrest and are not necessarily relevant to victims of pulmonary arrest (eg, drowning, drug overdose, etc).

Study Summary

Change from "A-B-C" to "C-A-B." A major change in basic life support is a step away from the traditional approach of airway-breathing-chest compressions (taught with the mnemonic "A-B-C") to first establishing good chest compressions ("C-A-B"). There are several reasons for this change.
  • Most survivors of adult cardiac arrest have an initial rhythm of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), and these patients are best treated initially with chest compressions and early defibrillation rather than airway management.
  • Airway management, whether mouth-to-mouth breathing, bagging, or endotracheal intubation, often results in a delay of initiation of good chest compressions. Airway management is no longer recommended until after the first cycle of chest compressions -- 30 compressions in 18 seconds. The 30 compressions are now recommended to precede the 2 ventilations, which previous guidelines had recommended at the start of resuscitation.
  • Only a minority of cardiac arrest victims receive bystander CPR. It is believed that a significant obstacle to bystanders performing CPR is their fear of doing mouth-to-mouth breathing. By changing the initial focus of resuscitation to chest compressions rather than airway maneuvers, it is thought that more patients will receive important bystander intervention, even if it is limited to chest compressions.
Basic life support. The traditional recommendation of "look, listen, and feel" has been removed from the basic life support algorithm because the steps tended to be time-consuming and were not consistently useful. Other recommendations:
  • Hands-only CPR (compressions only -- no ventilations) is recommended for the untrained lay rescuers to obviate their fears of mouth-to-mouth ventilations and to prevent delays/interruptions in compressions.
  • Pulse checks by lay rescuers should not be attempted because of the frequency of false-positive findings. Instead, it is recommended that lay rescuers should just assume that an adult who suddenly collapses, is unresponsive and not breathing normally (eg, gasping) has had a cardiac arrest, activate the emergency response system, and begin compressions.
  • Pulse checks by healthcare providers have been de-emphasized in importance. These pulse checks are often inaccurate and produce prolonged interruptions in compressions. If pulse checks are performed, healthcare providers should take no longer than 10 seconds to determine if pulses are present. If no pulse is found within 10 seconds, compressions should resume immediately.
  • The use of end-tidal CO2 (ETCO2) monitoring is a valuable adjunct for healthcare professionals. When patients have no spontaneous circulation, the ETCO2 is generally ≤ 10 mm Hg. However, when spontaneous circulation returns, ETCO2 levels are expected to abruptly increase to at least 35-40 mm Hg. By monitoring these levels, interruptions in compressions for pulse checks become unnecessary.
CPR devices. Several devices have been studied in recent years, including the impedance threshold device and load-distributing band CPR. No improvements in survival to hospital discharge or neurologic outcomes have been proven with any of these devices when compared with standard, conventional CPR.
Electrical therapies
  • Patients with VF or pulseless VT should receive chest compressions until a defibrillator is ready. Defibrillation should then be performed immediately.
  • Chest compressions for 1.5-3 minutes before defibrillation in patients with cardiac arrest longer than 4-5 minutes have been recommended in the past, but recent data have not demonstrated improvements in outcome.
  • Transcutaneous pacing of patients who are in asystole has not been found to be effective and is no longer recommended.
Advanced cardiac life support. Good basic life support, including high-quality chest compressions and rapid defibrillation of shockable rhythms, is again emphasized as the foundation of successful advanced cardiac life support. The recommendations for airway management have undergone 2 major changes: (1) the use of quantitative waveform capnography for confirmation and monitoring of endotracheal tube placement is now a class I recommendation in adults; and (2) the routine use of cricoid pressure during airway management is no longer recommended.
As they did in 2005, the AHA acknowledges once again that as of 2010, data are "still insufficient ...to demonstrate that any drugs improve long-term outcome after cardiac arrest."
Several important changes in recommendations for dysrhythmia management have occurred:
  • For symptomatic or unstable bradydysrhythmias, intravenous infusion of chronotropic agents (eg, dopamine, epinephrine) is now recommended as an equally effective alternative therapy to transcutaneous pacing when atropine fails;
  • As noted above, transcutaneous pacing for asystole is no longer recommended; and
  • Atropine is no longer recommended for routine use in patients with pulseless electrical activity or asystole.
Post-cardiac arrest care. Post-cardiac arrest care has received a great deal of focus in the current guidelines and is probably the most important new area of emphasis. There are several key highlights of post-arrest care:
  • Induced hypothermia, although best studied in survivors of VF/pulseless VT arrest, is generally recommended for adult survivors of cardiac arrest who remain unconscious, regardless of presenting rhythm. Hypothermia should be initiated as soon as possible after return of spontaneous circulation with a target temperature of 32°C-34°C.
  • Urgent cardiac catheterization and percutaneous coronary intervention are recommended for cardiac arrest survivors who demonstrate ECG evidence of ST-segment elevation acute myocardial infarction regardless of neurologic status. There is also increasing support for patients without ST-segment elevation on ECG who are suspected of having acute coronary syndrome to receive urgent cardiac catheterization.
  • Hemodynamic optimization to maintain vital organ perfusion, avoidance of hyperventilation, and maintenance of euglycemia are also critical elements in post-arrest care.

Viewpoint

The AHA 2010 guidelines represent significant progress in the care of victims of cardiac arrest. Most important is the stronger emphasis on post-cardiac arrest care. Induced hypothermia is underscored, and perhaps the most important advance is the recommendation for urgent percutaneous coronary intervention in survivors of cardiac arrest. The wealth of data thus far indicate that post-arrest percutaneous coronary intervention may be the most significant advance toward improving survival and neurologic function since defibrillation was first introduced decades ago.
In reviewing these guidelines, I must admit, however, that I was disappointed that AHA hesitated to adopt the concepts of "cardiocerebral resuscitation" (CCR). CCR also promotes the "C-A-B" approach to resuscitation, but it fosters even further delays in airway intervention -- withholding any form of positive pressure ventilations, in favor of persistent chest compressions, for as long as 5-10 minutes after the cardiac arrest. The current guidelines recommend withholding positive pressure ventilation for a mere 18 seconds. First described in 2002,[1] CCR has been studied more recently as well and demonstrated marked improvements in rates of resuscitation and neurologic survival.[2-4] I think that CCR should be incorporated into basic life support protocols for victims of primary cardiac arrest as quickly as possible to further improve outcomes.
Optimal management of cardiac arrest in the current decade can be summarized simply by "the 4 Cs": Cardiovert/defibrillate, CCR, Cooling, and Catheterization.


Thursday, January 13, 2011


"Importance of having Breakfast"
Breakfast can help prevent strokes, heart attack and sudden death. Advice on not to skip breakfast! Healthy living. For those who always skip breakfast, you should stop that habit now! You've heard many times that "Breakfast is the most important meal of the day. Now, recent research confirms that one of the worst practices you can develop may be avoiding breakfast. Why?


 Because the frequency of heart attack, sudden death, and stroke peaks between 6: 00a.m. and noon, with the highest incidence being between 8: 00a.m. and 10:00a.m.What mechanism within the body could account for this significant jump in sudden death in the early morning hours? We may have an Answer. Platelet, tiny elements in the blood that keep us from bleeding to Death if we get a cut, can clump together inside our arteries due to Cholesterol or plaque buildup in the artery lining. It is in the morning hours that platelets become the most activated and tend to form these internal blood clots at the greatest frequency.
However, eating even a very light breakfast prevents the morning platelet activation that is associated with heart attacks and strokes. Studies performed at Memorial University in St.Johns,   Newfoundland found that eating a light, very low-fat breakfast was critical in modifying the morning platelet activation. Subjects in the study consumed either low-fat or fat-free yogurt, orange juice, fruit, and a source of protein coming from yogurt or fat-free milk. So if you skip breakfast, it's important that you change this practice immediately in light of this research. Develop a simple plan to eat cereal, such as oatmeal or Bran Flakes, along with six ounces of grape juice or orange juice, and perhaps a piece of fruit. This simple plan will keep your platelets from sticking together, keep blood clots from forming, and perhaps head off a potential Heart Attack or stroke. So never ever skip breakfast

Thursday, December 9, 2010

Nursing Diagnosis: Ineffective Coping

NANDA Definition: Inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources

Defining Characteristics: Lack of goal-directed behavior or resolution of problem, including inability to attend; difficulty with organized information; sleep disturbance; abuse of chemical agents; decreased use of social support; use of forms of coping that impede adaptive behavior; poor concentration; fatigue; inadequate problem solving; verbalized inability to cope or ask for help; inability to meet basic needs; destructive behavior toward self or others; inability to meet role expectations; high illness rate; change in usual communication patterns; risk taking

Related Factors: Gender differences in coping strategies; inadequate level of confidence in ability to cope; uncertainty; inadequate social support created by characteristics of relationships; inadequate level of perception of control; inadequate resource availability; high degree of threat; situational crises; maturational crises; disturbance in pattern of tension release; inadequate opportunity to prepare for stressor; inability to conserve adaptive energies; disturbance in pattern of appraisal of threat; chronic conditions; alteration in body integrity; cultural variables


Client Outcomes

1. Verbalize ability to cope and ask for help when needed
2. Demonstrate ability to solve problems related to current needs
3. Remain free of destructive behavior toward self or others
4. Communicate needs and negotiate with others to meet needs
5. Discuss how recent life stressors have overwhelmed normal coping strategies
6. Demonstrate new effective coping strategies
7. Have illness and accident rates not excessive for age and developmental level


Nursing Interventions and Rationales

  • Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation. 
  • Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. 
  • Assess the risk of the client's harming self or others and intervene appropriately.
  • Help the client set realistic goals and identify personal skills and knowledge. 
  • Use empathetic communication and encourage the client and family to verbalize fears, express emotions, and set goals. 
  • Encourage the client to make choices and participate in the planning of care and scheduled activities. 
  • Provide mental and physical activities within the client's ability (e.g., reading, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games). 
  • If the client is physically able, encourage moderate aerobic exercise.
  • Provide information regarding care before care is given. Adequate information and training before and after treatment reduces anxiety and fear (Herranz and Gavilan, 1999).
  • Discuss changes with the client before making them. 
  • Discuss the client's and family's power to change a situation or the need to accept a situation. 
  • Use active listening and acceptance to help the client express emotions such as sadness, guilt, and anger (within appropriate limits). 
  • Encourage the client to describe previous stressors and the coping mechanisms used. 
  • Be supportive of coping behaviors; allow the client time to relax. 
  • Help the client to define what meaning his or her symptoms might have for the client. 
  • Encourage the use of cognitive behavioral relaxation (e.g., music therapy, guided imagery). 
  • Use distraction techniques during procedures that cause the client to be fearful. Distraction is used to direct attention toward a pleasurable experience and block the attention to the feared procedure (DuHamel, Redd, and Johnson-Vickberg, 1999).
  • Use systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping. Fear of new things diminishes with repeated exposure (DuHamel, Redd, and Johnson-Vickberg, 1999).
  • Provide the client and/or family with a video of any feared procedure to view before the procedure. Ensure that the video shows a client of similar age and background. Videos provide the client and/or family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, and Johnson-Vickberg, 1999).
  • Refer for counseling as needed. 
    Geriatric
  • Engage the client in reminiscence. Reminiscence activates positive memories and evokes well-being (Puentes, 2002).
  • Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use of medications with known cognitive and psychotropic side effects). 
  • Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. An older individual's responses to age-related stress will depend on the balance of personality strengths and weaknesses. 
  • Increase and mobilize the support available to the elderly client. Encourage interaction with family and friends.
    Multicultural
  • Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of effective coping. 
  • Assess for intergenerational family problems that can overwhelm coping abilities. 
  • Encourage spirituality as a source of support for coping. 
  • Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. 
  • Identify which family members the client can count on for support. 
  • Use an empowerment framework to redefine coping strategies. 
  • Assess the influence of fatalism on the client's coping behavior. 
  • Assess the influence of cultural conflicts that may affect coping abilities.

    Home Care Interventions

    • The interventions described previously may be adapted for home care use.
    • Observe the family for coping behavior patterns. Obtain family and client history as possible. 
    • Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal. Ineffective coping can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope for a solution. A suicidal client is not safe in the home environment unless supported by professional help.
    • Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others.
    • Refer to medical social services for evaluation and counseling, which will promote adequate coping as part of the medical plan of care. If no primary medical diagnosis has been made, request medical social services to assist with community support contacts. If the client is involved with the mental health system, actively participate in mental health team planning. Based on knowledge of the home and family, home care nurses can often advocate for clients. These nurses are frequently requested to monitor medication use and therefore need to know the plan of care.
    • Refer the client and family to support groups. 
    • If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver. Prepouring of medications may be helpful with some clients. Caregivers in the home benefit from interventions that promote self-efficacy and provide a nurse for support (Dibartolo, 2002).
    • Institute case management for frail elderly clients to support continued independent living. Difficulties in coping with changes in health care needs can lead to increasing needs for assistance in using the health care system effectively. Case management combines the nursing activities of client and family assessment, planning and coordination of care among all health care providers, delivery of direct nursing care, and monitoring of care and outcomes. These activities are able to address continuity of care, mutual goal setting, behavior management, and prevention of worsening health problems (Guttman, 1999).
    • If the client is homebound, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. Psychiatric home care nurses can address issues relating to the client's ability to adjust to changes in health status. Behavioral interventions in the home can help the client to participate more effectively in the treatment plan (Patusky, Rodning, and Martinez-Kratz, 1996).
    • NOTE: All of the previously mentioned interventions may be applied in the home setting. Home care may offer psychiatric nursing or the services of a licensed clinical social worker under special programs. Traditionally, insurance does not reimburse for counseling that is not related to a medical plan of care unless it falls under one of the programs just described. Public health agencies generally do not have the clinical support needed to offer psychiatric nursing services to clients. Clients are usually treated in the ambulatory mental health system.

    Client/Family Teaching

  • Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options. 
  • Provide the seriously ill client and his or her family with needed information regarding the condition and treatment. 
  • Teach relaxation techniques. 
  • Work closely with the client to develop appropriate educational tools that address individualized needs. 
  • Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups). 

 Toy Story 3

Wednesday, December 1, 2010

Medical Mnemonics

HYPERNATREMIA                                               
FRIED SALT
F - Fever (low), flushed skin
R - Restless (irritable)
I - Increased fluid retention & increased BP
E - Edema (peripheral and pitting)
D - Decreased urinary output, dry mouth

SALT
S - Skin flushed
A - Agitation
L - Low-grade fever
T - Thirst

HYPERKALEMIA - Signs & Symptoms
MURDER
M - Muscle weakness
U - Urine, oliguria, anuria
R - Respiratory distress
D - Decreased cardiac contractility
E - ECG changes
R - Reflexes, hyperreflexia, or areflexia (flaccid)

HYPERKALEMIA - Causes
MACHINE
M - Medications - ACE inhibitors, NSAIDS
A - Acidosis - Metabolic and respiratory
C - Cellular destruction - Burns, traumatic injury
H - Hypoaldosteronism/ hemolysis
I - Intake - Excessive
N - Nephrons, renal failure
E - Excretion - Impaired

HYPOCALCEMIA
CATS
C - Convulsions
A - Arrhythmias
T - Tetany
S - Spasms and stridor

BLEEDING - S/Sx
BEEP
B - Bleeding gums
E - Ecchymoses (bruises)
E - Epistaxis (nosebleed)
P - Petechiae (tiny purplish spots)

RESPIRATORY DEPRESSION - inducing drugs

STOP breathing
S - Sedatives and hypnotics
T - Trimethoprim
O - Opiates
P - Polymyxins

PNEUMOTHORAX - S/Sx
P-THORAX
P - Pleuretic pain
T - Trachea deviation
H - Hyperresonance
O - Onset sudden
R - Reduced breath sounds (& dypsnea)
A - Absent fremitus
X - X-ray shows collapse

PNEUMONIA - risk factors
INSPIRATION
I - Immunosuppression
N - Neoplasia
S - Secretion retention
P - Pulmonary oedema
I - Impaired alveolar macrophages
R - RTI (prior)
A - Antibiotics & cytotoxics
T - Tracheal instrumentation
I - IV dug abuse
O - Other (general debility, immobility)
N - Neurologic impairment of cough reflex, (eg NMJ disorders)

CROUP - S/Sx
SSS
S - Stridor
S - Subglottic swelling
S - Seal-bark cough

SHORTNESS OF BREATH - Causes
AAAA PPPP
A - Airway obstruction
A - Angina
A - Anxiety
A - Asthma
P - Pneumonia
P - Pneumothorax
P - Pulmonary Edema
P - Pulmonary Embolus

Tuesday, November 30, 2010

50 Interesting Facts

hi everyone!! I have here some interesting facts that I hope would amaze you.. The site where I got this is posted at the bottom of this info.

1. If you are right handed, you will tend to chew your food on your right side. If you are left handed, you will tend to chew your food on your left side.

2. If you stop getting thirsty, you need to drink more water. For when a human body is dehydrated, its thirst mechanism shuts off.
--akala ko the other way around?

3. Chewing gum while peeling onions will keep you from crying.
--ma-try nga!

4. Your tongue is germ-free only if it is pink. If it is white, there is a thin film of bacteria on it.
--go check your tongue in the mirror!

5. The Mercedes-Benz motto is “Das Beste oder Nichts” meaning “The Best or Nothing”.
--

6. The Titanic was the first ship to use the SOS signal.
--ahh.

7. The pupil of the eye expands as much as 45 percent when a person looks at something pleasing.
--dilates and contracts.

8. The average person who stops smoking requires one hour less sleep a night.
--really?

9. Laughing lowers levels of stress hormones and strengthens the immune system. Six-year-olds laugh an average of 300 times a day. Adults only laugh 15 to 100 times a day.
-- oh ano pa hinihintay nyo? tawa na!

10. The roar that we hear when we place a seashell next to our ear is not the ocean, but rather the sound of blood surging through the veins in the ear.

11. Dalmatians are born without spots.

12. Bats always turn left when exiting a cave.

13. The ‘v’ in the name of a court case does not stand for ‘versus’, but for ‘and’ (in civil proceedings) or ‘against’ (in criminal proceedings).

14. Men’s shirts have the buttons on the right, but women’s shirts have the buttons on the left.

15. The owl is the only bird to drop its upper eyelid to wink. All other birds raise their lower eyelids.

16. The reason honey is so easy to digest is that it’s already been digested by a bee.

17. Roosters cannot crow if they cannot extend their necks.

18. The color blue has a calming effect. It causes the brain to release calming hormones.

19. Every time you sneeze some of your brain cells die.
-- lagot. cx

20. Your left lung is smaller than your right lung to make room for your heart.

21. The verb “cleave” is the only English word with two synonyms which are antonyms of each other: adhere and separate.
-- ....processing. xDD

22. When you blush, the lining of your stomach also turns red.
--yun pla yung sinasabi nilang butterflies in the stomach

23. When hippos are upset, their sweat turns red.
-- bloody sweat.!

24. The first Harley Davidson motorcycle was built in 1903, and used a tomato can for a carburetor.

25. The lion that roars in the MGM logo is named Volney.
--haha, pineke yan ng Tom and Jerry Show ee.

26. Google is actually the common name for a number with a million zeros.
--yah.

27. Switching letters is called spoonerism. For example, saying jag of Flapan, instead of flag of Japan.

28. It cost 7 million dollars to build the Titanic and 200 million to make a film about it.

29. The attachment of the human skin to muscles is what causes dimples.
--abnormality daw yan.

30. There are 1,792 steps to the top of the Eiffel Tower.
-- ansipag nung nagmeasure.

31. The sound you hear when you crack your knuckles is actually the sound of nitrogen gas bubbles bursting.
-- Uo.

32. Human hair and fingernails continue to grow after death.
-- ang gulo, ang sabi dun sa isang libro hindi na daw. after death, magiging rigid daw yung whole body a process called Rigor Mortis. this is the reason why we mistakenly interpret that hair and nails grow after death.

33. It takes about 20 seconds for a red blood cell to circle the whole body.

34. The plastic things on the end of shoelaces are called aglets.
--first ko nalaman to sa Phineas and Ferb! do u watch that?

35. Most soccer players run 7 miles in a game.

36. The only part of the body that has no blood supply is the cornea in the eye. It takes in oxygen directly from the air.
-- Oo, whew, buti nakikinig ako nun sa Bio Class.

37. Every day 200 million couples make love, 400,000 babies are born, and 140,000 people die.
--Oh my.

38. In most watch advertisements the time displayed on the watch is 10:10 because then the arms frame the brand of the watch (and make it look like it is smiling).

39. Colgate faced big obstacle marketing toothpaste in Spanish speaking countries. Colgate translates into the command “go hang yourself.”
-- waah, tlga?!

40. The only 2 animals that can see behind itself without turning its head are the rabbit and the parrot.
--Uo.

41. Intelligent people have more zinc and copper in their hair.
--sandamak2 na zinc siguro ang nasa utak ko ngayon...ay este kang Einstein pla!

42. The average person laughs 13 times a day.
--lampas na siguro ako nyan ng dahil sa triviang ito.

43. Do you know the names of the three wise monkeys? They are: Mizaru (See no evil), Mikazaru (Hear no evil), and Mazaru (Speak no evil)

44. Women blink nearly twice as much as men.
--napablink 2loi ako.

45. German Shepherds bite humans more than any other breed of dog.
-- Felines Rule!!! meow.

46. Large kangaroos cover more than 30 feet with each jump.

47. Whip makes a cracking sound because its tip moves faster than the speed of sound.

48. Two animal rights protesters were protesting at the cruelty of sending pigs to a slaughterhouse in Bonn. Suddenly the pigs, all two thousand of them, escaped through a broken fence and stampeded, trampling the two hapless protesters to death.
--how ironic.

49. If a statue in the park of a person on a horse has both front legs in the air, the person died in battle; if the horse has one front leg in the air, the person died as a result of wounds received in battle; if the horse has all four legs on the ground, the person died of natural cause.
-- dko napansin eun aah. haha. nice.

50. The human heart creates enough pressure while pumping to squirt blood 30 feet!
-- so if I poke my heart while lying down, i'll have this really cool blood fountain?



http://symbianize.com/showthread.php?t=119020

Tuesday, November 2, 2010

Ways on how to easily remember clinical facts

1. To remember the difference between
transudate and exudate
, focus on
the prefixes …
• Trans- means “across,” as in the
transcontinental railroad
• Ex- means “out of,” as in exhale.

2. To remember the difference between
aerobic and anaerobic, think of jogging …

• When you jog, an aerobic activity, your
body needs oxygen, or air— aerobic means
oxygen is required.
• Anaerobic means without oxygen.

3. To remember what allergies to ask your
patient about before a CT scan that
requires contrast medium, think of SIC …

Shellfish
Iodine
Contrast media (prior sensitive reaction).

4. To remember the signs and symptoms
of a hypersensitivity reaction to contrast
media, think PURR …

Pruritus
Urticaria
Rash
Respiratory distress.

5. To remember what to assess when
evaluating a skin lesion, think of A, B, C, D …

A for asymmetry
B for border
C for color and configuration
D for diameter and drainage.

6. To remember that cones are cells in
the eyes that respond to color, think of
brightly colored ice cream cones.


7. To remember which direction to move
the syringe when you want to slow down
the flow through the tube, think of …

• lower is slower, or …
• slow DOWN.

8. To remember the meaning of myasthenia
gravis …

think of grave muscle weakness.

9. To remember the progression of ARDS,
think of …

Assault to the pulmonary system
Respiratory distress
Decreased lung compliance
Severe respiratory failure.

10. To remember the progression of
signs and symptoms of Lyme disease,
remember LIME …

Lesions, lymph node swelling, like the flu (Stage 1)
Innervation problems, such as meningitis and
peripheral neuropathy (Stage 2)
Movement problems, such as arthritis (Stage 3)
Everything else, such as myocarditis and
arrhythmia (Stage 3).

11. To remember the difference between
depolarization and repolarization, think of …
the R in repolarization as standing for Rest.

Repolarization is the resting phase of the
cardiac cycle.

12. When performing an assessment, remember
this CAUTION from the American Cancer
Society…

Change in bowel or bladder habits
A sore that doesn’t heal
Unusual bleeding or discharge
Thickening or lump
Indigestion or difficulty swallowing
Obvious changes in a wart or mole
Nagging cough or hoarseness.

13. To remember the four causes of cell injury,
think of how the injury tipped (or TIPD)
the scale of homeostasis …

Toxin or other lethal (cytotoxic) substance
Infection
Physical insult or injury
Deficit or lack of water, oxygen, or nutrients.

14. When combining insulins, to remember
which to draw first, think of

“clear before cloudy.”
Who doesn’t prefer a clear day to a cloudy one?

15. Remember this jingle when
converting inches to centimeters …
“ 2.54, that’s 1 inch and no more.”


16. Remember that X factor is often used to
describe a person or event that could cause
uneXpected, or unknown, outcomes.

Keep this in mind when performing dosage
calculations and you’ll remember that X
represents the unknown part of a ratio or fraction.

17. To remember the conditions that affect
the length of patient stay, think of FOCUS …

Functional skills (and disabilities)
Other diseases
Chronicity
Urgency of needs
Support of systems.

18. To remind yourself of the need to
check and adjust flow rates, remember
the following tongue twister …

Fight fickle flow with frequent follow-up.

19. To remember which drugs can be given
safely through an endotracheal tube, think
of ALE…

Atropine
Lidocaine
Epinephrine.

20. To remember which drug should be
inhaled FIRST, think about your ABCs…

A Bronchodilator comes before a Corticosteroid.

21. When using an IN-LINE nebulizer,
remember to…
connect it to the IN-SPIRATORY side
of the ventilatory circuit.

Wednesday, October 27, 2010

Top Ten Ways to Get Better Grades and to Get More Out of School

Many of you would like to get better grades but aren't sure exactly what will help raise your marks. You may have trouble focusing or you may get bored easily. You may think it takes too much effort to get better grades. That isn't necessarily the case. There are some very simple techniques that can help you to focus so that you'll remember things better, make your studying more efficient, get more studying done in less time, retain more information and to actually get better grades.

10. Actually go to every Class.

This technique is often overlooked. Some students might have trouble waking-up in the morning. Others may skip class to go shopping. For most students skipping an hour of class will require several hours of catching-up.

9. Sit in the Front of the Class

We know sitting in the front of the class makes it harder to play footsie with the person next to you. But sitting in the front will help you to focus and pay attention while helping you to retain more information. It will also help the professor to get to know your face, which may lead to more charitable feelings when grading time comes. Professors are sometimes more lenient on students they know than the faceless students in the back of the class.

8. Ask Questions and Volunteer Answers in Class

Not only does this get more attention from the instructor, but also it helps to keep you from getting bored or falling asleep. The added benefit is that some Instructors give you extra credit for class participation whether they tell you so or not.

7. Finish Your Assignments On Time

This often proves to be difficult due to conflicts with other classes, work and your social life. Students who manage to read their assignments on time retain longer and require less studying for exams. We know of a few students who kept up with all of the assignments and were able to skip cramming for final exams, much to the dismay of their fellow students. We're not saying this is easy.

6. Choose Classes that you like and find interesting in the first place

Of course if you like a class and find it interesting, you're more likely to pay attention without getting bored. You are more likely to remember the lectures and the readings. Choose to take classes with interesting lecturers, who help interest and motivate you.

5. Study a Little Bit Every Day

It's much easier to study a little bit every day than trying to get all of your studying done in one 10-hour study session each week. You may find that you have more free time to do other things without feeling guilty about a big pile of work waiting for you at home.

4. Know your Strengths and Weaknesses in Testing Types.

People vary in how they respond to various types of testing. Some do best at essays, while others do better with multiple choice or short answers. If you are given a choice of testing types choose the ones in which you excel. If you have a weakness in one of these areas, we suggest you learn what it takes to do better. Also make sure you clearly understand what criteria your professor uses in grading.

3. Start or Join a Study Group

When you have classes that involve complicated materials or have large volumes of reading, you should consider forming a study group with your peers. Quiz each other and explain things to each other. If there is a large amount of material you may want divide up the research and report back to each other. If you find that you are the one person in the group who knows much more than the others, You may still gain much from the study session. You will be practicing formulating your ideas. So even if you help bring your classmates from a C to a B, you may bring yourself from a B to an A. However, if the tests are highly competitive and graded on a curve, then you need to weigh the value of your study group. Make sure you leave yourself time to study on your own.

2. When You Study Set Goals and Take Breaks.

Figure out how much work you need to do and how long it will take to do it. Set yourself the goal of completing a certain amount of work and then taking a study break. When you are studying, be very focused on studying. When you take your breaks, get up, walk around, get the blood flowing in your body and brain. If you are studying with a friend, hang out, talk, and socialize. Its harder to take breaks if you leave all of your studying to the last minute hand find yourself cramming like crazy in a 7 hour study session, but it still helps to clear your head. Measured study with break gets the most done without burning you out.

1. Study in a Chair at a Table

Do all your reading, writing and studying at a table, sitting upright in chair. Be sure to have good lighting, fresh air and fluids nearby. This is the number one most important technique to getting more out of studying and getting better grades. So many people lay on the floor to study, sit on a bed to study or recline on the sofa to study. If you are lying down, chances are, you'll get sleepy and fall asleep. When you are lounging, your mind drifts out of focus. When you are sitting upright, in a well-lit room, your studying will be the most focused. Every hour of studying this way could be worth two hours of studying on the bed or sofa. That means more time for fun.

Good Luck. People we know with good study habits are less stressed and require less cramming before exams. They tend to get better grades too.

Sunday, October 24, 2010

Top 10 Strangest Diets Ever

From time to time we need to shed a few pounds and for most people the solution is to reduce calorie intake – eat less than you burn and you are guaranteed to lose weight. This is the principle behind the reason that the majority of French people are slim: they eat butter, cream, chocolate, and other delicious things, but in small quantities. Unfortunately there is a lot of money to be made in diets and so we are surrounded by bizarre ideas for weight loss. This list looks at ten of the strangest diets around. We have only included diets which are widely-spread; this means that individuals with bizarre eating habits are not included (they will have their own list).


10. Macrobiotic Diet

The macrobiotic diet is actually quite ancient. It involves eating grains as a staple food supplemented with other foodstuffs such as vegetables and beans, and avoiding the use of highly processed or refined foods. This is probably the least bizarre diet on the list, but it does have one noticeable quirk: some leaders in the field of macrobiotics advocate smoking for good health, claiming that it is the non-macrobiotic foods that cause cancer, not smoking. Michio Kushi, who introduced macrobiotics to the US, had surgery on his colon in 2004. His son said: “[I]n spite of years of his smoking, a fact well-known to many, recent x-rays of Michio’s lungs were surprisingly clean, like that of a twenty year old (remarked his physician)”.


9. Cabbage Soup Diet

The Cabbage soup diet is a radical weight loss diet designed around heavy consumption of a low-calorie cabbage soup over the time of seven days. The diet is actually surprisingly popular and has spawned a whole slew of similar fads. The origins of the diet are unknown but it gained popularity as a word of “faxlore” in the 1980s, because it spread virally through people sharing it via fax machines. The diet is almost universally condemned by doctors as it lacks any substantial nutrition and the weight loss it causes is mostly water-loss not fat-loss, and is, therefore, not permanent. Along with the cabbage soup recipe, the diet is usually touted as being used in hospitals to dramatically reduce weight in patients needing heart surgery; this is not true. Most people trying this diet lose energy and experience light-headedness. The most common side effect is flatulence – a lot of it.


8. Paleolithic Diet

This diet harkens back to the cavemen and their eating habits. It is based on the presumed ancient diet of wild plants and animals that various human species habitually consumed during the Paleolithic—a period of about 2.5 million years duration that ended around 10,000 years ago with the development of agriculture. Proponents of the diet say that paleolithic men were free of diseases known in modern times and, therefore, following their diet should keep us free from sickness. Centered around commonly available modern foods, the “contemporary” Paleolithic diet consists mainly of lean meat, fish, vegetables, fruit, roots, and nuts; and excludes grains, legumes, dairy products, salt, refined sugar, and processed oils. So now, from a diet based on evolution, to a diet based on creationism:


7. Fruitarianism

Fruitarianism is a diet of nothing but fruit, though some people whose diet is not 100% fruit, consider themselves fruitarian, if their diet is 75% or more fruit. Some fruitarians believe fruitarianism was the original diet of mankind in the form of Adam and Eve based on Genesis 1:29: “And God said: Behold I have given you every herb bearing seed upon the earth, and all trees that have in themselves seed of their own kind, to be your meat”. They believe that a return to an Eden-like paradise will require simple living and a holistic approach to health and diet. A fruitarian diet can cause deficiencies in calcium, protein, iron, zinc, vitamin D, most B vitamins (especially B-12), and essential fatty acids. Additionally, the Health Promotion Program at Columbia reports that food restrictions in general may lead to hunger, cravings, food obsessions, social disruptions and social isolation. Gandhi followed a fruit-only diet from time to time, but eventually gave it up due it being unsustainable. Now, if you didn’t think that was weird enough, how about the Bible Diet?


6. Bible Diet

The Bible Diet (or Maker’s Diet) is based on the idea that certain foods are either forbidden (”unclean”) or acceptable (”clean”) to God. The main promoter of the Bible diet is Jordan S. Rubin, who claims that the diet was responsible for his recovery from Crohn’s disease at the age of 19. In 2004 the United States Food and Drug Administration ordered Rubin’s company, Garden of Life, Inc., to stop making unsubstantiated claims about eight of its products and supplements. The diet begins and ends each day with prayers of thanksgiving, healing, and petition. The individual should perform exercises of “Life Purpose” for two to five minutes before the day gets too stressful. To achieve the utmost spiritual benefits from the partial fast days, it is suggested to pray each time hunger is experienced. The diet is broken up into three phases. Phase One restricts meats such as pork, bacon, ostrich, ham, sausages, emu and imitation meat. Fish and sea foods such as fried fish, breaded fish, eel, shark, crab, clams, oyster, mussels, lobster, shrimp, scallops, and craw fish are prohibited.


5. Shangri-La Diet

For people who love to eat, the Shangri-La diet is a godsend. Basically, you can eat what you like. The principle behind this diet is that the body has a set point (the weight that it wants to sustain) and appetite is moderated by the body to ensure that you stay at your set point. The inventor of the diet, Seth Roberts, says that you can lower your set point using his method, thereby lowering appetite and eventually weight. The method? Every day you must drink 100-400 calories of extra light olive oil or sugar water in a two hour window in which you must experience no flavors (including cigarette smoke). It is the consumption of extra flavorless calories which supposedly lowers the set point. While there are some critics of the method (which earned Roberts a spot on the New York Times bestseller list), most doctors consider that the diet, while lacking scientific evidence, is benign. [Image copyright (c) Erik Sansom: source]


4. Fletcherizing

“Nature will castigate those who don’t masticate.” These are the words used by Horace Fletcher at the turn of the 20th century to market his new diet: Fletcherizing. In this diet, a person must chew each mouthful 32 times whilst keeping their head tilted forward. After the chewing is complete, the dieter tilts their head back, allowing the contents of their mouth to slide down the throat. Any food that did not naturally slip down, was to be spat out. In addition, Fletcher advocated chewing liquids, and said that one must not eat when angry or sad. Fletched died a millionaire at 69 – with the majority of his money having come from promoting his diet which was wildly popular.


3.Breatharianism

Breatharianism consists of eating: nothing. That’s right, it is called Breatharianism because you are surviving on nothing but your breath. There are some elements of esotericism in this diet and some of practitioners believe that they are sustained by energy from the sun or a “vital life force” called prana. The Breatharian Institute of America promote the diet and offer a workshop to help you get started for the low price of just $10,000, which, according to their website: “is not a misprint”. These courses are run by Wiley Brooks who previously charged up to 25 million dollars for his courses. Occasionally Wiley eats a cheeseburger and a diet coke claiming that when he’s surrounded by junk culture and junk food, consuming them adds balance. At least three people have died whilst on this “diet”. If you have tried this diet and are not dead yet, be sure to tell us about it in the comments.


2. Sleeping Beauty Diet

As its name implies, this diet involves sleep – a lot of it. The principle behind this diet is: “if you aren’t awake, you aren’t eating”. Consequently, advocates take heavy sedation and sleep for days at a time in order to lose weight. Obviously the diet works but it is such an unhealthy approach to weight loss that it is insane to try it. The diet was originally formulated in the 1970s and was reportedly popular with Elvis Presley who was beginning to have difficulty bending down to tie up his blue suede shoes.


1. Tapeworm Diet

This diet is as disgusting as its name. In this diet, you eat a tapeworm in a cyst and let it grow in your body until it is fully mature. You then worm yourself and poop out the worm. Advocates of this insane diet assure people that they can lose 1 – 2 pounds per week using their method. Because it is illegal to import tapeworms into the US, some organizations run tapeworm farms in Africa and Mexico which tourists can visit to get infected “safely”. On these farms, cows are intentionally infected with tapeworm for harvesting for human consumption. This diet is alleged to work because once ingested, the worm attaches in the intestinal tract and absorbs nutrients from the food you eat.


Bonus
Last Chance Diet

This is not so much a diet as a fast, so it is added as a bonus item. Under this program, developed by Dr. Robert Linn in the 1970s, people ate nothing at all. But several times a day the fast was broken by a small drink of the concoction that Linn had invented called Prolinn. It was a liquid protein that provided fewer than 400 calories a day, consisted of ground-up and crushed animal horns, hooves, hides, tendons, bones and other slaughterhouse byproducts that were treated with artificial flavors, colors and enzymes to break them down. [Source: CBC News]

Not all diet programs work for everybody but there are those that work for specific cases.

via:strangesports

Thursday, September 30, 2010

Pregnancy Ultrasound- Is it necessary?

The journal, Obstetrics and Gynecology, estimated that over half of all pregnant women in 1990 had undergone diagnostic ultrasound, yet research published in the New England Journal of Medicine suggest that 80 percent of all pregnant women are very low risk and do not need ultrasounds. The unnecessary ultrasounds cost about $1 Billion per year.

Any woman who is told she needs an ultrasound should ask about the potential benefits of the test and the risks of the procedure. She should ask if the results of the ultrasound will affect her care she would otherwise receive and how. If the result of the ultrasound will not affect her care, she may question the need for the test at all. Only after being completely informed about the need for the test, the benefits, and the risks, should she sign a consent for the procedure.

USES OF ULTRASOUND

According to the ACOG patient education flier, "Ultrasound is not necessary for every woman or in every pregnancy." It is, however, being used more often as a standard procedure for every pregnant woman. Some common uses include diagnosing and detecting uterine or ectopic pregnancy, noting pelvic inflammatory disease, cysts, tumors uterine cancer, endometriosis and congenital abnormalities.

Ultrasound may compare fetal age and weight, note the placement of the placenta, amount of amniotic fluid that is present and diagnose certain birth defects such as neural tube defects. Ultrasound is used during an amniocentesis to verify the baby's position to be sure that the needle is placed properly. Some physicians use ultrasound for estimating the fetal weight. This is not a very accurate measurement unless numerous criteria and scans are checked. Head circumference is one measurement. However, incases of gestational diabetes, it is inaccurate because these babies gain the additional weight on their bodies only.

Ultrasounds are frequently used to date pregnancies. According to Otto and Platt, 1991, in the first trimester the error range is +5 days, in the second trimester it increases to +8 days and if done in the final trimester it is +22 days.


Sunday, September 26, 2010

FORENSIC NURSING

It was in 1992 when the term Forensic nursing was first heard. But what is it exactly? Forensic nursing is a specialty field that deals with the care of crime victims, collecting evidences and providing health care services  in the prison system. It is a combined health care and judicial system profession to be precise. International Association of Forensic Nurses (IAFN) is the official association of forensic nurses established in 1992 by a team of nurses who specialize in sexual assault examination.

1. A Day In The Life

Contrary to popular belief forensic nurses don't spend their day hanging around with corpses. Examining victims of sexual assault and training colleagues how to treat violently injured patients eat up most of these nurses days. Another related job for a forensic nurse is providing counsel to schoolchildren who fired guns.

2. Training

Training as a Sexual Assault Nurse Examiner is the entry-level position you need to obtain in order to break into forensic nursing. The nurse should be a Registered Nurse (RN) before being able to complete the specialized training needed to meet the standards of the IAFN. Forty hours of didactics and forty hours of clinical work are also needed. The nurse should be trained in handling and collecting evidences like hairs, fibers and swabs of fluids for DNA testing.

Forensic nursing is not limited to helping rape victims. Forensic nurses also work with other types of interpersonal abuse such as domestic violence, child and elderly abuse, neglect and physiological, as well as psychological abuse. They could also examine victims of near-fatal or fatal traumas like shooting or stabbing.

A lot of forensic nurses work as nurse examiners in the emergency rooms in the hospitals. In cases like shooting or stabbing, the forensic nurse works in collecting bullets and other debris left in the body that will help in the investigation. Removing the clothes the victim is wearing and storing them in a special bags are also some of their duties. They also have to photograph and measure the wounds of the patients. In case the victim dies, the nurse has to work with the medical examiner (ME).


3. Other Considerations

Forensic nurses are qualified to testify in court as an expert witness or a fact witness. As an expert witness, the nurse is allowed to give his or her opinions while on the witness stands in order to shed light on the case. On the other hand, as a fact witness, the nurse is only to state the details and answer the questions. A forensic nurse should state the information in an objective manner. It means that he or she should not speak for or against either the victim or the accused. As the duty calls for it, the nurse only has to state the information he or she obtained, not make conjecture about what he or she thinks happened.

4. Tools of the Trade

A forensic nurse should also know how to use different tools in order to document what he or she has gathered during the examination or treatment process.

- A digital camera
- An Omnichrome
- A Coloscope

To date, specialty areas are being related to forensic nursing. This includes a Forensic Nurse Specialist, Forensic Nurse Investigator, Nurse Coroner or what is known as Death Investigator, Sexual Assault Nurse Examiner (SANE), Legal Nurse Consultant, Forensic Gerontology Specialist, Forensic Psychiatric Nurse and a Correctional Nursing Specialist. Forensic nursing is a growing industry in the field of nursing. More and more nurses are being drawn to it. Nursing schools are also taking notice of this need. Forensic Nurse Programs are now being offered in nursing schools.


Monday, September 13, 2010

New Guidelines Issued for Insomnia and Other Sleep Disorders












News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD


September 2, 2010 — The British Association for Psychopharmacology (BAP) has issued a consensus statement on evidence-based treatment of insomnia, parasomnias, and circadian rhythm disorders. The new recommendations, intended to guide psychiatrists and clinicians caring for those with sleep problems, are published online September 2 in the Journal of Psychopharmacology.
"Sleep disorders are common in the general population and even more so in clinical practice, yet are relatively poorly understood by doctors and other health care practitioners," write Sue J. Wilson, from the Psychopharmacology Unit, University of Bristol, Bristol, United Kingdom, and colleagues. "These ...BAP guidelines are designed to address this problem by providing an accessible yet up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. We limited ourselves to discussion of sleep problems that are not regarded as being secondary to respiratory problems (e.g. sleep apnoea – see NICE Guidance TA139), as these fall outside the remit of the BAP."
These guidelines also do not cover neuropsychiatric disorders, such as narcolepsy and restless legs, for which recent sets of guidelines already exist. The new recommendations were developed after a consensus meeting in London in May 2009 of BAP members, as well as clinicians, experts, and advocates in sleep disorders, based on literature reviews and a description of standard of evidence.
Recommendations for Diagnosis and Treatment
Specific evidence-based recommendations for diagnosis and treatment of insomnia and other sleep disorders, and their accompanying level of evidence rating, are as follows:
  • The diagnosis of insomnia is primarily based on complaints provided in the clinical interview by the patient, family, and/or caregiver, ideally corroborated by a patient diary (level of evidence, A).
  • Referral to a specialist sleep center may be indicated for other tests in some cases, such as actigraphy for differential diagnosis of circadian rhythm disorder (level of evidence, A), polysomnography for suspected parasomnia or other primary sleep disorder (level of evidence, A), or in the case of treatment failure (level of evidence, D).
  • Insomnia should be treated because it impairs quality of life and many areas of functioning and is associated with an increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A). Treatment goals are to reduce distress and to improve daytime function. Choice of treatment modality is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
  • For chronic insomnia, cognitive behavioral therapy (CBT)-based treatment packages are effective and should be offered to patients as a first-line treatment (level of evidence, A). CBT, which may include sleep restriction and stimulus control, should be made available in more settings.
  • When prescribing hypnotic drug treatment, clinicians need to consider efficacy, safety, and duration of action (level of evidence, A). Other issues to consider may include previous efficacy or adverse effects of the drug and history of substance abuse or dependence (level of evidence, D).
  • Recommendations for long-term hypnotic drug treatment are to use it as clinically indicated (level of evidence, A). To discontinue long-term hypnotic drug therapy, intermittent use should first be attempted if feasible. Depending on ongoing life circumstances and patient consent, discontinuation should be attempted every 3 to 6 months or at regular intervals (level of evidence, D). During taper of long-term hypnotic drug treatment, CBT improves outcome (level of evidence, A).
  • When using antidepressants, clinicians should apply their knowledge of pharmacology (level of evidence, A). When there is a comorbid mood disorder, antidepressants should be used at therapeutic doses (level of evidence, A). However, clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
  • Because of frequent adverse effects of antipsychotic drugs, as well as a few reports of abuse, there is no indication for use as first-line treatment of insomnia or other sleep disorders (level of evidence, D).
  • Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia (level of evidence, D).
Recommendations for Certain Populations
Specific evidence-based recommendations for management of insomnia and other sleep disorders in special populations and conditions are as follows:
  • After menopause, the incidence of sleep-disordered breathing increases, and the clinical presentation is different in women vs men and often includes insomnia. Informed, individualized treatment of symptoms is needed for use of hormone therapy, considering risks and benefits clarified in recent studies.
  • Behavioral strategies are recommended for children with disturbed sleep (level of evidence, A). In children with attention-deficit/hyperactive disorder not treated with stimulant drugs, melatonin administration may help advance sleep onset to normal values (level of evidence, A).
  • For children and adults with learning disabilities, clinical evaluation should describe the sleep disturbance and triggering and exacerbating factors (level of evidence, A). Recommended first-line therapy includes environmental, behavioral, and educational strategies (level of evidence, A). Melatonin is effective in improving sleep (level of evidence, A). The treatment plan should be based on a capacity/best-interests framework.
  • For management of circadian rhythm disorders, clinical evaluation is essential in delayed sleep-phase syndrome and free-running disorder (level of evidence, A/B). In delayed sleep-phase syndrome, free-running disorder, and jet lag, melatonin may be useful (level of evidence, A), but other strategies such as behavioral regimens and scheduled light exposure (in sighted individuals) can also be used (level of evidence, B/C).
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The costs of the meeting were partly defrayed by unrestricted educational grants from Lundbeck and GlaxoSmithKline. All attendees completed conflict-of-interest statements held at the BAP office.
J Psychopharmacol. Published online September 2, 2010.
Additional Resource

The National Institutes of Health, National Heart, Lung, and Blood Institute's Web site has more information online about sleep disorders.

Clinical Context


Sleep disorders are common in the general population and even more so in clinical practice, yet they are relatively poorly understood by physicians and other healthcare practitioners. One of the most frequent complaints is insomnia. In the general population, one third of adults in Western countries experience difficulty with sleep initiation or maintenance at least once a week. Prevalence is between 1.5 and 2 times higher in women vs men. Approximately half of all diagnosed insomnia is related to a psychiatric disorder. The symptom prevalence of insomnia changes with age.
The BAP guidelines are designed to address this problem by providing an accessible up-to-date and evidence-based outline of the major issues, especially those relating to reliable diagnosis and appropriate treatment. A consensus meeting was held in London in May 2009. The aim of this report was to discuss the diagnosis and treatment of insomnia as well as circadian rhythm disorders and the more common parasomnias.

Study Highlights


  • Insomnia is a subjective disorder and is usually long term.
  • The diagnosis of insomnia is primarily based on patient-derived and family or caregiver complaints, as determined by the clinical interview, ideally with a patient diary (level of evidence, A).
  • In some circumstances, referral to a specialist sleep center may be necessary for other investigations, such as diagnosis of circadian rhythm disorder (actigraphy; level of evidence, A) or parasomnia (polysomnography; level of evidence, A), or in the case of treatment failure (level of evidence, D).
  • Circadian rhythm disorders are sleep disorders in which there is a mismatch between circadian rhythms and required sleep-wake cycle.
  • Parasomnias are unusual episodes or behaviors occurring during sleep, which disturb the patient or others such as night terrors, sleepwalking, nightmares, and rapid eye movement behavior disorder.
  • It is important to treat insomnia because the condition causes decreased quality of life; is associated with impaired functioning in many areas; and leads to increased risk for depression, anxiety, and possibly cardiovascular disorders (level of evidence, A).
  • The goal of treatment is to lessen anguish and improve daytime function.
  • Choice of treatment modality is patient guided and is based on the particular pattern of problem, such as sleep-onset insomnia or sleep maintenance, as well as on the evidence supporting use of specific treatments.
  • CBT-based treatment packages for chronic insomnia including sleep restriction and stimulus control are effective and therefore should be offered to patients as a first-line treatment (level of evidence, A). Increased availability of this therapy is required.
  • Z-drugs (zaleplon, zolpidem, zopiclone, and eszopiclone) and short-acting benzodiazepines are efficacious for insomnia.
  • Factors that clinicians need to take into account when prescribing medications for insomnia are efficacy, safety, and duration of action of the drug (level of evidence, A). Additional factors are previous efficacy of the drug or adverse effects, and a history of substance abuse or dependence (level of evidence, D).
  • Hypnotic drug treatment encompasses the following guidelines:

    • Hypnotic drugs should be used when clinically indicated.
    • They should be limited to 2 to 4 weeks; however, they are often used for longer periods.
    • Safety (adverse events and carryover effects) are fewer and are less serious with decreasing half-lives (level of evidence, Ib).
    • Studies suggest that dependence (tolerance/withdrawal) is not inevitable with hypnotic therapy for up to 1 year with eszopiclone, zolpidem, and ramelteon. Intermittent dosing may reduce the risk for tolerance and dependence.
    • For discontinuation of hypnotics, intermittent use should be administered at first and then at regular intervals.
    • CBT during taper improves outcome.
  • Prolonged-release melatonin improves sleep-onset latency and quality of life in patients older than 55 years (level of evidence, Ib).
  • Antidepressants for insomnia should be considered when there is a coexistent mood disorder.
  • There is limited evidence for the efficacy of doxepin, trimipramine, trazodone, and paroxetine in insomnia. Clinicians should beware that overdose of tricyclic antidepressants can be toxic even when low-unit doses are prescribed (level of evidence, A).
  • There is no indication for use of antipsychotics as first-line treatment.
  • Antihistamines have a limited role in psychiatric and primary care practice for the management of insomnia.
  • For the treatment of circadian rhythm disorders, melatonin is effective in jet lag disorder (level of evidence, Ia), delayed sleep-phase syndrome (level of evidence, Ib), and free-running disorder (level of evidence, IIa). Light therapy is effective in delayed sleep-phase syndrome (level of evidence, III).
  • For parasomnias, drug treatment should be based on frequency and severity of events. Psychological treatments are effective for nightmares.

Clinical Implications


  • Insomnia is a common sleep disorder that affects up to one third of adults in Western countries, has a higher prevalence in women vs men, and is often associated with a psychiatric disorder.
  • Z-drugs and short-acting benzodiazepines are efficacious for insomnia, and CBT-based treatment packages should be offered to patients as a first-line treatment of chronic insomnia.

http://cme.medscape.com/viewarticle/727938?src=cmemp&uac=100542PN

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