By D. Joey. Keuka College.

Ethical theories identify different sets of beliefs; understanding our own and others’ sets of beliefs (values) helps towards the understanding of differences discount 40 mg protonix overnight delivery. Some examples presented in this chapter include legal and professional perspectives; unlike ethics purchase protonix 20 mg overnight delivery, these expectations can be enforced generic protonix 20 mg with visa, and so nurses should consider their individual professional (and legal) accountability. Ethics are guides to decision-making, and decisions are influenced by sources such as ■ religion ■ law ■ society (and social values) ■ peers ■ individual values If growth from novice to expert entails moving from following rules to initiation (Benner 1984), understanding sources of ‘intuitive’ decisions can substantiate accountable evidence-based practice. The literal translation of both is ‘norm’ (Greek ethos, Latin mores), but they have different connotations. Many staff are uncomfortable with applying economics to healthcare, but while decisions should never be made solely on economic grounds, finance cannot be ignored where resources remain finite. Intensive care nursing relies on technology to support and monitor physiological function. Breathing and heartbeat can be replaced by technology (causing redefinition of death as absence of brainstem function), but intervention may prolong dying rather than prolong life: Rachels (1986) draws a distinction between living and the physical process of being alive. Technology may be used inappropriately; no treatment, intervention or observation should become ‘routine’. This much-used term is value-laden: what one person considers acceptable quality, another may not (e. Values vary between the extremes of preserving life at all costs, and always letting ‘nature’ take its course. Ethical principles Autonomy Beauchamp and Childress (1994) suggest that each ethical principle is part of a continuum. Autonomy, the first principle, is usually interpreted as ‘self-rule’—that is, making an informed free choice. Consent by relatives for mentally competent adults has no legal validity (Brazier 1992; Dimond 1995; Braithwaite 1996). Parents or guardians have the right to consent to treatment for children under 18 (Dimond 1995), but the 1989 Children’s Act and civil law precedent of ‘Gillick competence’ emphasise rights of children to make their own informed decisions provided they have achieved sufficient maturity to fully understand what is proposed (Brazier 1992). So one relatively young child may (legally) make more profound decisions than an older child. If in doubt, nurses should seek help to clarify the rights and duties of all concerned (most hospitals have legal advisors). The law assumes that healthcare staff will act in patients’ best interests (Brazier 1992). Actions in patients’ best interests may be condoned, but nonconsensual touch (including Intensive care nursing 140 any nursing/medical intervention without valid consent) is technically assault. The consent of relatives, while not legally binding, may provide an insight into the patient’s wishes, while building goodwill between relatives and staff. However, the relatives’ values may also differ, and extreme stress and guilt can result from believing they are making ‘life or death’ decisions. Advance directives (‘living wills’) state patients’ wishes for specific (stated) treatments to be withheld (e. Advance directives must necessarily anticipate scenarios where patients cannot express their wishes. However the ability of most people to make informed decisions about hypothetical situations is questionable (Ryan 1996); most consultants oppose withdrawing treatment only on the basis of advance directives (Grubb et al. Patients’ views may have changed since writing the document, especially if it is old (although this would not affect validity of a last will and testament). Nurses finding evidence of an advance directive (possibly through discussions with relatives) should alert unit managers and the multidisciplinary team. Non-maleficence Not doing harm has been fundamental to healthcare since the Hippocratic Oath, and restated in Nightingale’s (1980 [1859]) Notes on Nursing, Roper et al. Benefits of invasive equipment may justify risks from infection; psychological dilemmas are often more complex. Healthcare workers may justify white lies or withholding truth and diagnoses as being in the patients’ and families’ best interests, while others may consider deliberate untruth or withholding information is unjustifiable (unethical). If life is sacrosanct, then death is presumably the greatest possible harm; if death is preferable to continued suffering, then life support can be harmful. Individual assessment of each patient can help nurses to understand what they would consider harmful; once identified, potential and existing harms (e. Euthanasia (‘good death’) presumes life is no longer preferable to death and so treatment becomes harmful, ‘mercy killing’ (active euthanasia) or ‘letting die’ (passive euthanasia) becomes beneficent. But doctors (or, implicitly, other healthcare workers) are not absolutely obliged to maintain life in hopeless cases (Bennett 1995), and so passive euthanasia (withholding treatment) may legally be practised: in such cases, patients die from their existing conditions, not by human actions (Bennett 1995). The acceptance of passive euthanasia may prove to be the ‘slippery slope’ to greater (involuntary) extermination (Randall 1997).

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Fluconazole is well absorbed after oral administration and is widely distributed throughout the body buy 20 mg protonix with visa. Triazole drugs fluconazole mean elimination t is 30 hours in patients with 1/2 work by the same mechanism as imidazoles but have a wider normal renal function order protonix 20 mg on line. However generic 40mg protonix with visa, Aspergillus species nel blockers, ciclosporin, docetaxel and, importantly, war- are resistant and resistant Candida species are problematic in farin. Fluconazole is used clinically will increase during concomitant treatment with fluconazole. It is administered orally or Itraconazole and voriconazole are available as oral and par- intravenously as a once daily dose. Oral bioavailability is good for both Adverse effects agents, but intravenous use is indicated for severe fungal infec- tions. The antifungal spectrum is similar to that of fluconazole Adverse effects include: and is broad. The mean itraconazole t1/2 is 30–40 hours and • hepatitis (rarely, hepatic failure). Induces its own infections metabolism Miconazole Oral Candida (topical therapy for Oral gel, four times daily Nausea and Systemic absorption is ringworm, Candida and pityriasis 2% cream or powder vomiting, rashes. Mechanism of action Key points Echinocandins are non-competitive inhibitors of 1,3-β-D glucan Azole antifungal drugs synthase, an enzyme necessary for synthesis of a glucose poly- mer crucial to the structure and integrity of the cell walls of • Relatively wide spectrum of antifungal activity, fungistatic, but fungicidal with higher concentrations. Fungal cells unable to synthesize this polysaccha- • Impair ergosterol biosynthesis by inhibiting ride cannot maintain their shape and lack adequate rigidity to lanosterol 14-alpha-demethylase (fungal cytochrome resist osmotic pressure, which results in fungal cell lysis. Glucan also appears essential for fungal cell growth and divi- • Available as intravenous, oral and topical formulations. The mechanism of action of echinocandins is unique and • Can be used as therapy for superficial (e. Cryptococcus) fungal drugs of this class are potentially additive or synergistic with infections. It may be Caspofungin and micafungin are not absorbed from the administered orally to treat ringworm (Tinea pedis, T. It is given once Both agents are eliminated by hydrolysis and N-acetylation daily for two to six weeks (longer in infections of the nailbed, as to inactive metabolites. It is elimi- nated by hepatic metabolism with a mean elimination t1/2 of 17 hours. Its major side effects are nausea, abdominal discomfort, Drug interactions anorexia, diarrhoea and rashes (including urticaria). Rifampicin increases terbinafine metabolism, Other agents in this expanding class include anidulafungin. The normal t1/2 is six hours and this is Echinocandin antifungal drugs prolonged in renal failure. Antiviral drug therapy is therefore Griseofulvin is orally active, but its spectrum is limited to der- increasingly important. It is given antibacterial therapy because viruses are intimately incorpo- orally with meals and treatment is recommended for six weeks rated in host cells and the therapeutic targets are often similar for skin infections and up to 12 months for nail infections. To summarize these problems: Mechanism of action • Viral replication is intracellular, so drugs must penetrate Griseofulvin is concentrated in fungi and binds to tubulin, cells in order to be effective. Adverse effects • Although viral replication begins almost immediately after the host cell has been penetrated, the clinical signs These include: and symptoms of infection often appear after peak viral • headaches and mental dullness or inattention; replication is over. Less than which can destroy viruses in this situation remains a 1% of the parent drug is excreted in the urine. Its spectrum is intracellularly; relatively restricted and acquired resistance is a major prob- • viral nucleic acid acts as a template for new strands of lem. It is deaminated to 5-fluorouracil in the components utilizing the host cell’s synthetic mechanisms. Adverse effects include gastro-intestinal upset, leuko- • extracellular release of new viral particles. It is much less effective in secondary than in Aciclovir is relatively contraindicated in pregnancy as it is an primary infection. It does not eliminate vaginal carriage, analogue of guanosine and so potentially teratogenic in the so Caesarean section is indicated to avoid neonatal herpes. Treatment of shingles (herpes zoster) should be started Pharmacokinetics within 72 hours of the onset and is useful for patients with Aciclovir bioavailability is approximately 20% after adminis- severe pain, although it shortens the illness only modestly. The mean elimination t1/2 of aciclovir is three hours meningoencephalitis, aciclovir is given intravenously. Clearance is Mechanism of action largely renal and includes an element of tubular secretion; renal Aciclovir undergoes intracellular metabolic activation to its impairment requires dose/schedule adjustment. Ganciclovir, a guanine analogue, is used to treat sight- or life- • Aciclovir has low oral bioavailability.

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Classically protonix 40mg generic, Negroid crania show wide nasal orifces cheap protonix 40 mg without prescription, round/oval orbits cheap 20mg protonix fast delivery, and alveolar prognathism; Caucasoid crania have narrow nasal orifces, parabolic palates, and rectangular orbits; and Mongoloid crania ofen demonstrate elliptical palates, complex cranial sutures, and square orbits (see Chapter 8). When a cranium is present, facial reconstruction can be performed in addition to anthropologic analysis. Te forensic artist is given the anthro- pologic data of approximate age, sex, ancestry, and physical attributes (e. Te morphologic properties of the cranium are combined with the artist’s presumptive rendition of the sof tissue features, includ- ing eye color and hairstyle, to generate either a sketch or model of how the deceased looked in life (Figure 5. A photo of the resulting face can then be distributed to the media or local community in an attempt to fnd a witness who can identify the individual. Unfortunately, the resulting image does not always accurately approximate the deceased and may end up misdirecting the investigation. Forensic medicine and human identifcation 75 Anthropology and facial reconstruction are rarely used alone to estab- lish identity. Should no materials be present to allow for such a presumptive identifcation, several databases exist for comparison of unidentifed persons to missing per- sons. Te information is then cross-referenced against known missing persons to fnd similar, matching cases. If similar cases are found, the investigating agencies are able to contact each other to obtain the information required to establish a positive identifcation. Unfortunately, not all unidentifed persons or missing persons get placed into the system. Its purpose is to provide a “…role-based access to enter and search records of the unidentifed, while allowing the public access to information that may assist in the identifcation of these individuals. In 2007, the National Institute of Justice began funding the National Missing and Unidentifed Persons System (NamUs). Te database will be searchable by and accessible to medical examiners, forensic scientists, law enforcement, and the general public. Extensive photographs should be taken, including photos of all distinguishing characteristics—eyes, tattoos, scars, etc. In cases of deceased individuals, a full autopsy should be performed, thoroughly docu- menting all disease processes, presence and absence of organs or tissues, organ weights, and detailed and accurate descriptions of all pertinent positive and nega- tive fndings. One unidentifed person can require a great deal of organization and doc- umentation to establish identity; however, in cases of natural or man-made disasters, organization is a necessity. All bodies/body parts, including any and all corresponding property, must be kept separate and uniquely marked. Each body requires the same examination outlined above in an orderly and organized manner, yet it must be conducted as rapidly as possible. In addi- tion, mass disasters may include the need for decontamination of the bodies, a media contact person for the central dispersion of information, as well as a centralized record-keeping system. It is important to remember that identifcation is an extremely important task that allows for the grieving process of loved ones to begin as well as a thorough investigation of the death. Identifcation can only be accomplished through the meticulous examination of the remains. Tough there is always the pressure to rush, one must not sacrifce quality for the rapid answer, as the quick answer is ofen not the correct one. Te science of fngerprint identifcation has evolved over time from the early use of fngerprints to mark business transactions in ancient Babylonia to their use today as core technology in biometric security devices and as scientifc evidence in courts of law throughout the world. To this end, recent increases in homicides, mass disaster incidents, and combat casual- ties from wars in Iraq and Afghanistan highlight the vital role that forensic science plays in human/victim identifcation. While this responsibility is an emerging challenge for many forensic disciplines, fngerprint analysis * disclaimer: names of commercial manufacturers are provided for identifcation only and inclusion does not imply endorsement by the Federal Bureau of investigation. Tis chapter discusses the basics of fngerprint identifcation and how forensic examiners recover friction ridge impressions from remains in order to identify the dead. Te appearance of fnger- prints on clay pots and documents throughout early civilization indicates the possible recognition of the individuality and value of fngerprints as a means of personal identifcation. While this observation is debated by histo- rians, there is no debate that the many instances of fngerprints found in the archaeological record set the stage for the scientifc development of modern fngerprint identifcation in the nineteenth century. Te frst practical application of fngerprints as a form of personal iden- tifcation is credited to Sir William Herschel, a British ofcer based in India, who used fngerprints and handprints as signatures on native contracts to prevent fraud. Henry Faulds, a Scottish physician working in Japan, published a letter in the journal Nature (1880) discussing his scientifc observations on the identifcation potential of fngerprints. Te pioneering research conducted by Faulds was broad in scope, forecasting the forensic use of fngerprints to catch criminals and describing the contemporary method of recording fngerprints using black printer’s ink. His theory regarding the evidentiary value of fngerprints was confrmed when he solved a minor crime involving the pilfering of purifed alcohol from his hospital laboratory. Faulds was able to compare greasy fngerprints found on a piece of glassware with inked impressions he had collected from his staf, identifying one of his medical students as the ofender and making what is considered to be the frst fngerprint identifcation in history. Te studies performed by Galton detailed the individuality and persistency of Fingerprints and human identifcation 81 friction ridge skin, providing empirical support to the underlying scientifc principles of fngerprint identifcation.

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