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A doctor must have complete clinical independence in deciding on the care of a person for whom he or she is medically responsible quality 40 mg pantoprazole. The doctor’s fundamental role is to alleviate the distress of his or her fellow men pantoprazole 40mg otc, and no motive discount 40mg pantoprazole otc, whether personal purchase pantoprazole 20mg with mastercard, collective buy 40mg pantoprazole mastercard, or political, shall prevail against this higher purpose. Where a prisoner refuses nourishment and is considered by the doctor as capable of forming an unimpaired and rational judgment concerning the con- sequences of such voluntary refusal of nourishment, he or she shall not be fed artificially. The decision regarding the capacity of the prisoner to form such a judgment should be confirmed by at least one other independent doctor. The consequences of the refusal of nourishment shall be explained by the doctor to the prisoner. The World Medical Association will support and should encourage the international community the national medical associations and fellow doctors to support the doctor and his or her family in the face of threats or reprisals resulting from a refusal to condone the use of torture or other forms of cruel, inhuman, or degrading treatment. Principle 1 Health personnel, particularly physicians, charged with the medical care of prisoners and detainees have a duty to provide them with protection of their physical and mental health and treatment of disease of the same quality and standard as is afforded to those who are not imprisoned or detained. Principle 2 It is a gross contravention of medical ethics, as well as an offense under applicable international instruments, for health personnel, particularly physi- cians, to engage, actively, or passively, in acts that constitute participation in, complicity in, incitement to or attempts to commit torture or other cruel, inhu- man or degrading treatment or punishment. Principle 3 It is a contravention of medical ethics for health personnel, particularly physicians, to be involved in any professional relationship with prisoners or detainees the purpose of which is not solely to evaluate, protect or improve their physical and mental health. Principle 4 It is a contravention of medical ethics for health personnel, particularly physicians: a. To apply their knowledge and skills in order to assist in the interrogation of pris- oners and detainees in a manner that may adversely affect the physical or mental health or condition of such prisoners or detainees and which is not in accordance with the relevant international instruments; b. To certify or to participate in the certification of the fitness of prisoners or detainees for any form of treatment or punishment that may adversely affect their physical or mental health and which is not in accordance with the relevant international instruments or to participate in any way in the infliction of any such treatment or punishment that is not in accordance with the relevant inter- national instruments. Principle 6 There may be no derogation from the foregoing principles on any ground whatsoever, including public emergency. At the meeting of the Council of National Representatives of the Interna- tional Council of Nurses in Singapore in August 1975, a statement on the role of the nurse in the care of detainees and prisoners was adopted. The fundamental responsibility of the nurse is fourfold: to promote health, to prevent illness, to restore health, and to alleviate suffering. The nurse, when acting in a professional capacity, should at all times maintain standards of personal conduct that reflect credit on the profession. The nurse takes appropriate action to safeguard the individual when his or her care is endangered by a coworker or any other person. Members of the armed forces, prisoners and persons taking no active part in the hostilities a. The following acts are and shall remain prohibited at any time and in any place whatsoever with respect to the above-mentioned persons: a. Everyone is entitled to all the rights and freedoms, set forth in this Declara- tion, without distinction of any kind, such as race, color, sex, language, reli- gion, political or other opinion, national or social origin, property, birth or other status (Article 2), b. No one shall be subjected to torture or to cruel, inhuman, or degrading treat- ment or punishment (Article 5). In relation to detainees and prisoners of conscience, interrogation proce- dures are increasingly being employed resulting in ill effects, often perma- nent, on the person’s mental and physical health. Nurses having knowledge of physical or mental ill-treatment of detain- ees and prisoners must take appropriate action, including reporting the matter to appropriate national and/or international bodies. Nurses participate in clinical research carried out on prisoners only if the freely given consent of the patient has been secured after a complete explana- tion and understanding by the patient of the nature and risk of the research. The nurse’s first responsibility is to the patients, notwithstanding con- siderations of national security and interest. It will come into effect at some future date (unknown at the time of writing), and the Act will give effect to rights and freedoms guaranteed under the European Convention on Human Rights. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law. Deprivation of life shall not be regarded as inflicted in contravention of this article when it results from the use of force that is no more than absolutely necessary: a. Ethical Documents 401 Article 3 No one shall be subjected to torture or to inhuman or degrading treat- ment or punishment. No one shall be deprived of his liberty save in the following cases and in accordance with a procedure prescribed by law: a. Everyone who is arrested shall be informed promptly, in a language that he under- stands, of the reasons for his arrest and of any charge against him. Everyone arrested or detained in accordance with the provisions of paragraph 1(c) of this article shall be brought promptly before a judge or other officer autho- rized by law to exercise judicial power and shall be entitled to trial within a reasonable time or to release pending trial. Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speed- ily by a court and his release ordered if the detention is not lawful. Everyone who has been the victim of arrest or detention in contravention of the provisions of this article shall have an enforceable right to compensation.

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It seems likely that abrupt discontinuation of either drug in a chronic user could result in driving impairment pantoprazole 20 mg with visa, but that situation has never been tested (70) pantoprazole 40 mg visa. Large doses can result in toxic psychosis with symptoms indistinguishable from paranoid schizophrenia cheap 40mg pantoprazole visa, a condition that is extremely unlikely to improve driving per- formance order 20 mg pantoprazole free shipping. Sedative Hypnotics Benzodiazepines impair psychomotor performance in nontolerant indi- viduals order pantoprazole 40mg mastercard, generally in a dose-dependent manner. Most of the widely prescribed benzodiazepines increase lateral lane movement and slow response time to a lead car’s change in speed. Several of the benzodiazepines (50 mg of oxazepam, 30 mg of flurazepam, and 2 mg of lormetazepam) predictably impair driving the morning after. Diazepam (15 mg) impaired performance on a clinical test for drunkenness, which comprised 13 tests assessing motor, vestibular, men- tal, and behavioral functioning (78,79). A recent study (80) showed a clear relationship between dose of benzodiazepines and risk of impairment, which the authors believed probably supported a limit for benzodiazepines and driv- ing as low as within the therapeutic range. Acute doses of many benzodiazepines slow response time in simple or choice visual reaction time tests and impair attentional performance and cause deficits that do not result from sedation. In fact, the impairment of sustained attention and vigilance in benzodiazepine users is the direct result of some as yet uncharacterized direct action on perceptual sensitivity (70). Multiple Drug Use Polydrug use is common and can result in complex interactions, with the drugs having additive, antagonistic, or overlapping effects. In a study on alcohol and can- nabis (81), it has been shown that when they are administered together, the result was one of additive impairment. However, in the laboratory setting, simultaneous administra- tion of alcohol and cocaine seems to minimize alcohol-related deficits (75). Over-the-Counter Preparations An increasing number of drugs can now be bought over the counter from pharmacies. The newer nonsedating antihistamines, such as terfenadine and astemizole, generally do not impair driving. However, one study that measured driving performance across differing doses of terfenadine found that performance was impaired at very high doses (240 mg), stressing the need to establish the behavioral effects of drugs over a range of doses (85). The second-generation group of antihistamines is less lipophilic than the pre- vious generation and thus cross the blood–brain barrier less readily, which accounts for the lower levels of sedation observed with the newer drugs. Thus, although the second-generation antihistamines generally produce less seda- tion than first-generation compounds, if therapeutic doses are exceeded, the so-called nonsedating antihistamines become sedating and can impair driving. Assessment in the Field by Police In the United Kingdom, if a police officer stops a driver, for whatever reason, and believes the driver is unfit to drive, it is highly likely that a road- side breath test will be conducted. That is not the case in the United States, where field breath testing is only permitted in some states, and then only for drivers under the age of 21 years (22). Stopping a vehicle is a seizure, but it may be reasonable if the police officer has a justifiable suspicion that an offense is being committed. This then gives them the probable cause to carry out subsequent tests similar to the Sec- tion 4 procedure to prove impairment. Until recently in the United Kingdom, police traf- fic officers received little or no training in the recognition of signs and symp- toms of drug effects. Police officers were trained to observe and document known indicators of drug use and impairment. Instead of breath testing, a series of standardized field sobriety tests, which include psychomotor and divided attention tests, is conducted. If alco- hol is suspected, the following tests are carried out: walk and turn test, one-leg stand, and the horizontal gaze nystagmus test. In addition, if drugs are sus- pected, a Romberg balance test is also carried out. Unlike chemical tests (with refusal to submit possibly resulting in immediate license suspension), drivers in the United States are not legally required to take any field sobriety tests; however, if the driver submits, the results can be introduced as additional evi- dence of impairment. These tests are all divided attention tests, which assess the individual’s balance and coordination, as well as the ability to follow simple instructions (i. They are as follows: • Horizontal gaze nystagmus: nystagmus may be caused by any number of condi- tions, but its presence could indicate drugs or alcohol. Eight impairment indicators are measured; if two of the eight are present, impairment would be indicated. Some drugs alter the body’s inter- nal clock and make the person act faster or slower than normal. Interview with the arresting officer: the purpose is to ascertain baseline informa- tion, including the circumstances of the arrest, whether an accident occurred, whether drugs were found, and if so, what they looked like. Preliminary examination: the purpose of the preliminary examination is to deter- mine whether if there is sufficient reason to suspect a drug offense and to try to exclude any underlying medical problems. General observations and details of any current medical problems are ascertained, and the first measurement of the pulse is taken. If no signs of drug influence are found, the procedure is termi- nated; if any medical problems are found, a medical assessment is obtained, and if drugs are still suspected, a full assessment is carried out. If at any time during the assessment a serious medical condition is suspected, a medical opinion will be obtained. Eye examination: the driver is assessed for horizontal gaze nystagmus, vertical gaze nystagmus, and convergence.

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No aspect of airway management should be considered routine; as with all other aspects of care discount pantoprazole 20mg on-line, frequent assessment enables the individualisation of care in order to meet the patient’s needs generic pantoprazole 40mg. Overviews are usually best obtained from books discount 40mg pantoprazole with visa, but many articles usefully pursue aspects in detail 40mg pantoprazole otc. Wood (1998) provides an extensive literature review on dilemmas of endotracheal suction discount pantoprazole 40 mg line. Reviewing literature for developing departmental guidelines, McKelvie (1998) gives a reliable overview. Identify those effects that you have observed in your own clinical practice and those from the literature. Lighter sedation ■ enables patients to remain semiconscious, thus reducing psychoses while promoting autonomy ■ reduces hypotensive and cardioinhibitory effects caused by most sedatives Light sedation is a narrow margin between over- and under-sedation. The focus is therefore a nursing one rather than pharmacological, although some widely used sedatives are described. Neuromuscular blockade, once a common adjunct of sedation therapy, is also mentioned. Shelly (1998) stresses that comfort (in its widest sense) can be achieved through sedation. Sedation is now usually only necessary for ventilation if patients have: ■ tachypnoea, which will cause exhaustion ■ discomfort from artificial ventilation (usually from oral endotracheal tubes; also for brief procedures such as cardioversion and bronchoscopy). There are some specific pathologies, such as intracranial hypertension, where sedation is therapeutic. Some authors suggest that potential line displacement justifies sedation (Shelly 1994). Amnesia prevents recall of often horrific procedures, but inability to recall experiences, however horrific, may cause greater psychological trauma (Perrins et al. Prolonged benzodiazepine use causes receptor growth and down-regulation (tolerance), necessitating higher doses (Eddleston et al. Endorphins (endogenous opiates) contribute to sedative effects of critical illness. Midazolam is largely hepatically metabolised and renally excreted, so failure of these organs may cause accumulation of active metabolites (especially with older people, who usually have reduced renal clearance); causing unpredictable increases in half-life with critical illness (Bion & Oh 1997). Being relatively cheap, midazolam is still used by many units for prolonged sedation. Flumazenil’s effect is far shorter than benzodiazepines (half-life under one hour (Armstrong et al. Opiates Most opiates have sedative effects; as analgesia is usually necessary, this ‘side effect’ can be beneficial, provided it is remembered when assessing sedation. Opiates may become Sedation 51 the most important part of sedative regimes (Bion & Oh 1997). Morphine remains one of the most powerful opiates, but newer drugs, such as fentanyl, achieve rapid sedation with strong respiratory depression (which facilitates ventilation). Propofol Propofol’s lipid emulsion facilitates transfer across the blood-brain barrier, achieving rapid sedation. Inactivity of metabolites (Sherry 1997) and rapid redistribution into fatty tissue (Eddleston et al. Widely used for short- term sedation, Propofol is relatively expensive and so some units restrict use to circumstances where sedation is planned to last less than one day. Propofol depresses cerebral metabolism, thus reducing both cerebral oxygen consumption and intracranial pressure (Viney 1996). A number of disadvantages have been reported with propofol: ■ bradycardia from resetting of carotid receptors (Sherry 1997) ■ hypotension from resetting of baroreceptors, sympathetic inhibition and increased venous capacitance (Robinson et al. Use of any drug or equipment beyond a manufacturer’s licence places the onus of legal liability on the users (see Chapter 45). Since propofol does not have any analgesic effect, concurrent analgesia should be given. Intensive care nursing 52 Bolus sedation The introduction of shorter-acting sedatives together with the improvement of infusion pump technology has largely replaced the use of bolus sedation with continuous infusions. Like analgesia, bolus sedation can cause fluctuations between under- and over- sedation (Shelly 1998). Where sedative effects are prolonged, constant infusion can result in over-sedation (Shelly 1998). The lighter levels of sedation now preferred create relatively narrow margins between over-sedation and under-sedation. Over-sedation is arguably inhumane, depriving patients of life awareness, but it also causes respiratory and cardiovascular depression (compromising tissue perfusion) and so it potentially prolongs recovery. Drugs also increase the costs of patient care, placing further burdens on (usually) stretched unit budgets. Thus unnecessary drugs are psychologically, physiologically and financially undesirable. Increased protein (muscle) breakdown from stress-induced hypermetabolism (see Chapter 3) prolongs ventilatory weaning and (eventual) ambulation, thus increasing the risk of later complications such as pneumonia and thromboses. However, sedation is difficult to measure, both because the needs of patients vary (Shelly 1998) and because of the discrepancies between different assessors (Westcott 1995).

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She looks very ill cheap 40 mg pantoprazole free shipping, acid is reabsorbed by an active transport system which is with a temperature of 39 cheap pantoprazole 20 mg free shipping. Lithium also undergoes active tubular reab- raised at 15000/μL cheap pantoprazole 40 mg with visa, and there are numerous white cells and sorption (hitching a ride on the proximal sodium ion transport rod-shaped organisms in the urine buy pantoprazole 20mg with visa. Despite the normal creatinine level discount pantoprazole 20 mg visa, he is concerned that the dose may need to be adjusted and calls the resident medical officer for advice. The patient is hypotensive • The kidney cannot excrete non-polar substances and will be perfusing her kidneys poorly. Serum creatinine efficiently, since these diffuse back into blood as the may be normal in rapid onset acute renal failure. Consequently, the kidney tant to obtain an adequate peak concentration to combat excretes polar drugs and/or the polar metabolites of her presumed Gram-negative septicaemia. This will achieve the usual peak concentra- depend on glomerular filtration, so the dose of drugs, tion (since the volume of distribution will be similar to such as digoxin, must be reduced, or the dose interval that in a healthy person). Competition for these carriers can cause drug interactions, although less commonly than induction or inhibition of cytochrome P450. Oxford: Oxford University Press, 2005: • The urine may be deliberately alkalinized by infusing 2599–618. Polyspecific organic cation transporters: their functions tubule by the same system that normally reabsorbs and interactions with drugs. Trends in Pharmacological Sciences sodium, so salt depletion (which causes increased 2004; 25: 375–81. Gastro-intestinal, cardiac, renal, liver and thyroid infarction, acute abdomen) Coeliac disease disorders all influence drug pharmacokinetics, and individu- Diabetic neuropathy Drugs, e. This can cause therapeutic failure, so alternative routes of administration (Chapter 4) are sometimes needed. Significant reductions in the absorption logical factors alter gastric emptying (Table 7. However, of cefalexin occur in cystic fibrosis, necessitating increased there is little detailed information about the effect of disease doses in such patients. Patients with small bowel resection on drug absorption, in contrast to effects of drugs that slow may absorb lipophilic drugs poorly. Cardiac failure affects pharmacokinetics in several ways and these are discussed below. Absorption of several antibiotics actually increases in cardiac failure as an adaptive response redistributing blood to Crohn’s disease. Usual doses 10 can therefore result in elevated plasma concentrations, pro- Heart ducing toxicity. Drugs such as lidocaine with a high hepatic extraction ratio of 70% show perfusion-limited clearance, and steady- 0 60 120 180 240 state levels are inversely related to cardiac output (Figure 7. Nephrotic syndrome is associated with resistance permission of the American Heart Association Inc. Phenytoin some degree of chronic renal impairment for drugs with a low is an exception, because therapy is guided by plasma concen- therapeutic index that are eliminated mainly by renal excre- tration and routine analytical methods detect total (bound tion. In renal impairment, phenytoin protein bind- there is 50% elimination by renal excretion. The British ing is reduced by competition with accumulated molecules National Formulary tabulates drugs to be avoided or used normally cleared by the kidney and which bind to the same with caution in patients with renal failure. The therapeutic range therefore has to be adjusted to lower values in patients with Clearance renal impairment, as otherwise doses will be selected that (ml/min) Weight cause toxicity. A reduced loading dose of 100 100 Serum digoxin is therefore appropriate in such patients, although the 90 90 creatinine effect of reduced glomerular filtration on digoxin clearance is 80 80 R (mg/100 ml) even more important, necessitating a reduced maintenance 70 70 5. Keep ruler at crossing point on R, then move the right-hand side of the Glomerular filtration and tubular secretion of drugs usually ruler to the appropriate serum creatinine value and read off fall in step with one another in patients with renal impair- clearance from the left-hand scale. Drug excretion is directly related to glomerular filtra- mol/L to mg/100mL, as is used on this scale, simply divide by 88. Low molecular weight heparin Metformin Creatinine would rise gradually over the next few days as it con- tinued to be produced in his body but was not cleared. The high albumin treatment under way but, although precise, such recommenda- concentration in tubular fluid contributes to the resistance to tions are inevitably based only on the effects of reduced renal diuretics that accompanies nephrotic syndrome. Therapy with these drugs is appropriately monitored by measuring ‘peak’ concentrations 1. Monitor therapeutic and adverse effects and, where the interval between doses is extended. The same is true of patients with heart failure, nephrotic These are useful approximations to get treatment under way, syndrome, cirrhosis or ascites. Such patients develop acute but their mathematical precision is illusory, and must not lull reversible renal impairment, often accompanied by salt and the inexperienced into a false sense of security – they do not water retention and hypertension if treated with non-steroidal permit a full ‘course’ of treatment to be prescribed safely. The British National Formulary has a vasodilator prostaglandins, notably prostaglandin I2 (prosta- useful appendix which is concise, simple and accessible.