Hair toe tourniquets: a review of two case studies

Digit hair tourniquets are relatively uncommon. There are reports in the literature of hair tourniquets involving other appendages, such as the penis and uvula, however the phenomenon is not widely recognised and is often overlooked by healthcare professionals. This article discusses two case studies in which hair was responsible for creating a tourniquet around a digit. The article explores possible causes and management options for patients, with reference to the case studies. Midwives and health visitors are central to minimising the risk of injury to children as they can educate expectant mothers about this potential problem.

Cardiac Monitoring in the Emergency Department

Patients present to the emergency department (ED) with a wide range of complaints and ED clinicians are responsible for identifying which conditions are life threatening. Cardiac monitoring strategies in the ED include, but are not limited to, 12-lead electrocardiography and bedside cardiac monitoring for arrhythmia and ischemia detection as well as QT-interval monitoring. ED nurses are in a unique position to incorporate cardiac monitoring into the early triage and risk stratification of patients with cardiovascular emergencies to optimize patient management and outcomes.

[Negative pressure therapy in traumatology]

The treatment of complex wounds in traumatology is a source of concern for nurses. Negative pressure therapy constitutes a solution for difficult-to-treat situations in the framework of open fractures and loss of limb tissue.

[Setting up situated learning in vascular rehabilitation]

A pedagogical tool as well as a concept, situated learning describes the skills used in a situation in a given context, structuring the reflection, analysis and choice of nursing procedures, based on theoretical knowledge, know-how and interpersonal skills. A vascular rehabilitation team has chosen to formalise two situations from among the most common care procedures carried out in the department: the changing of complex dressings and ensuring the personal hygiene and comfort of a dependent patient with skin wounds.

Intra-aortic balloon counterpulsation complicated by limb ischaemia: a reflective commentary

Intra-aortic balloon counterpulsation (IABC) is widely used to support the failing myocardium, particularly in patients with a background of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). CS is primarily due to left ventricular failure and is the most serious complication of AMI. Using Driscoll's 'What?' reflective model to guide critical thinking, an incident involving a patient who required IABC following AMI is explored. There are various complications associated with IABC, limb ischaemia being very common. Risk factors, which predispose patients to the development of limb ischaemia following intra-aortic balloon pump insertion, are discussed as are the issues surrounding their care. Nurses are in an ideal position to detect any complications that may occur. They should be familiar with the patient's medical history, including any risk factors, which could predispose them to the development of limb ischaemia. Consideration of these factors and the adjunctive treatment the patient may require can be used to plan care accordingly. Anecdotal evidence suggests that more patients are requiring haemodynamic support from IABC. Nurses and health care professionals who have the responsibility of caring for these patients need to be adequately trained in order to maintain a high standard of care. However, there appears to be a lack of evidence-based guidelines determining the optimum frequency of limb observations to assess for limb ischaemia. Further evidence as to the timing of limb observations is required in order that protocols can be written to guide the practice.

New targets for pharmacological intervention in the glutamatergic synapse

Excitotoxicity is thought to be a major mechanism in many human disease states such as ischemia, trauma, epilepsy and chronic neurodegenerative disorders. Briefly, synaptic overactivity leads to the excessive release of glutamate that activates postsynaptic cell membrane receptors, which upon activation open their associated ion channel pore to produce ion influx. To date, although molecular basis of glutamate toxicity remain uncertain, there is general agreement that N-methyl-d-aspartate (NMDA) subtype of ionotropic glutamate receptors plays a key role in mediating at least some aspects of glutamate neurotoxicity. On this view, research has focused in the discovery of new compounds able to either reduce glutamate release or activation of postsynaptic NMDA receptors. Although NMDA receptor antagonists prevent excitotoxicity in cellular and animal models, these drugs have limited usefulness clinically. Side effects such as psychosis, nausea, vomiting, memory impairment, and neuronal cell death accompany complete NMDA receptor blockade, dramatizing the crucial role of the NMDA receptor in normal neuronal processes. Recently, however, well-tolerated compounds such as memantine has been shown to be able to block excitotoxic cell death in a clinically tolerated manner. Understanding the biochemical properties of the multitude of NMDA receptor subtypes offers the possibility of developing more effective and clinically useful drugs. The increasing knowledge of the structure and function of this postsynaptic NMDA complex may improve the identification of specific molecular targets whose pharmacological or genetic manipulation might lead to innovative therapies for brain disorders.

Health-related quality of life after revascularization for peripheral arterial occlusive disease: long-term follow-up

AIM

This paper reports a study to measure quality of life, before and after revascularization, in patients with intermittent claudication and critical limb ischaemia from a long-term perspective.

BACKGROUND

Patients with peripheral arterial occlusive disease have a number of problems which affect their quality of life and a successful revascularization results in immediate improvements in quality of life. However, knowledge of the durability of the improvements is sparse. Therefore, research on the outcomes of treatment and nursing care should investigate the long-term effects on quality of life and daily activities.

METHODS

A quasi-experimental longitudinal follow-up study was conducted with 80 patients with intermittent claudication and 62 with critical ischaemia. Assessment with the Nottingham Health Profile was made before revascularization and 6 months, 12 months and up to 4 years afterwards. The data were collected between 1995 and 2000.

RESULTS

Quality of life was improved 6 and 12 months after revascularization in patients with intermittent claudication in energy, pain, emotional reactions and physical mobility, while those with critical limb ischaemia also had improvements in pain and sleep. The improvement in pain was particularly evident for both groups and remained significantly improved up to 4 years after revascularization. Patients with critical limb ischaemia, however, deteriorated significantly with regard to physical mobility between 12 months and 4 years. Being a woman and belonging to the critical ischaemia group was significantly associated with high total Nottingham Health Profile score. Thus, patients with intermittent claudication had more durable benefits from revascularization than those with critical limb ischaemia. However, both groups had less pain than at baseline after 4 years.

CONCLUSION

The degree to which quality of life was durable over time seems to depend on the severity of the disease and gender. Patients with critical limb ischaemia were older, had more other diseases and a lower quality of life than patients with intermittent claudication, which confirmed that patients with critical limb ischaemia need more ongoing nursing support to maintain independence in daily life a long time after revascularization.

Diabetes and its effect on wound healing and patient care

Diabetes is a multisystem disorder that affects the wound healing process. Physiological changes in tissues and cells may delay healing and complications of diabetes also have an impact. Given these factors, it is important for health care teams working across the acute community interface to manage diabetic wounds effectively.

Appraisal and coping with vaso-occlusive crisis in adolescents with sickle cell disease

PURPOSE

To explore the relationships among appraisals of vaso-occlusive events, coping behavior during the event, and adjustment in adolescents with sickle cell disease.

METHOD

A descriptive, correlation design used a purposive sample of 68 adolescents with sickle cell disease. Three questionnaires were used to collect the data: Pain Beliefs and Perceptions Inventory (PBPI), Coping Strategies Questionnaire (CQS), and a demographic questionnaire. Correlation and multiple regression were used to analyze the data.

FINDINGS

Appraisal factors positively correlated with coping strategies and adjustment. Multiple regression found that appraisal of the event as catastrophic predicted the reinterpretation of pain sensations (p < .001).

CONCLUSIONS

Adolescents with more negative thoughts during vaso-occlusion crisis used ineffective coping strategies and reported poorer adjustment.

Extraanatomic bypass surgery

The term "extraanatomic bypass" applies to grafts that pass through a different anatomic pathway than do the natural blood vessels they replace. These grafts are devised to circumvent complex problems when conventional vascular procedures are not possible or are too hazardous to perform. There are various indications, advantages, and disadvantages to each of these grafts. Extraanatomic bypass grafts are an accepted technique with known patency rates. Quality nursing care plays a significant role in successful patient outcome.

Chronic critical limb ischemia: what is the benefit of radiological intervention? Indications and results

Indications of interventional radiological procedures in patients with chronic critical limb ischemia are not clearly defined. PTA of limb arteries is used only in 3 of 4% of patients, although 20 to 40% might be candidates for a proximal intervention in the iliac arteries. Following PTA of intrapopliteal arteries, limb salvage varies from 56 to 82% and arterial patency rate from 34 to 100% after 1 to 2 years follow-up in non controlled case series studies. Arterial local thrombolysis shows better results than surgery in subgroups of patients in a few studies. Pulse spray technique does not show better clinical results than conventional infusion of the plasminogen activator. Overall, radiological interventions give similar results compared with surgery, concerning limb salvage rate, length of hospital stay, morbidity and mortality, but significantly more patients are discharged home versus a nursing institution after radiological treatment than after surgery. Radiological techniques seem to be cost effective compared to surgery. Amputation should be carried out only after all revascularization possibilities have been ruled out at a multidisciplinary vascular center.

Comparison of cost affecting parameters and costs of the "closed" and "open" in situ bypass technique

OBJECTIVES

The "closed" in situ bypass results in a reduction of wound complications compared to the "open" technique. This advantage is partly diminished by extra costs for the "closed" procedure and a larger percentage of residual arteriovenous (AV)-fistulae. This aim of this study was to analyse costs related to "closed" and "open" procedures.

METHODS

The cost affecting parameters: (1) duration of operation; (2) length of hospital stay; and (3) number of treated residual AV-fistulae, were analysed in a randomised group of 73 patients (35 "closed" and 38 "open") in two centres. In addition, costs of the operation, nursing care and treatment of AV-fistulae were analysed.

RESULTS

The "closed" and "open" group showed a median duration of operation of 210 min (range 105-570) and 154 min (range 90-355) (p < 0.05), length of hospital stay of 16 days (range 5-51) and 25 days (range 12-65) (p < 0.01), and a percentage of patients treated for residual AV-fistulae of 40% and 5%, respectively (p < 0.01). The median "closed" operation was US$798 more expensive than the "open". Median postoperative care was US$2664 less for the "closed" group. Mean estimated costs for treatment of AV-fistulae was US$9 in the "open" and US$167 in the "closed" group.

CONCLUSION

The "closed" in situ vein bypass technique is cost-effective in comparison with the "open" technique.

The costs of managing lower limb-threatening ischaemia

One hundred and fifty consecutive patients presenting with limb-threatening ischaemia were studied prospectively to determine treatment and rehabilitation costs in the first year. Limb salvage was attempted in 104 (69%) patients but failed in 13%. Mortality at 1 year was 27%. The cost of treatment, inpatient stay, occupational therapy, physiotherapy, convalescence, disablement services, home adaptations, home care, district nursing, transportation and outpatient visits were determined for each patient. The patients were classified according to their presentation and initial treatment into five groups (number of patients) whose median management costs (interquartile range) for 12 months were: Gp 1 (23 - Revascularisation for acute ischaemia = 3970 pounds (2984-5511) Gp 2 (29) - Angioplasty for critical ischaemia = 6611 pounds (3630-10,200) Gp 3 (52) - Reconstruction for critical ischaemia = 6766 pounds (4337-9677) Gp 4 (34) - Primary amputation = 10,162 pounds (7894-13,026) Gp 5 (12) - Primary bilateral amputations = 13,848 pounds (11,440-18,056) At 1 year, there was no significant difference in the cost of managing a patient with a critically ischaemic limb by angioplasty or surgical reconstruction. The cost of revascularisation for acute ischaemia was comparatively low because these patients required minimal rehabilitation. The median cost of managing a patient following amputation was almost twice that of successful limb salvage justifying an aggressive revascularisation policy. However, justification of such a policy on economic grounds requires salvage failure episode to be minimised as they increase costs considerably.

[Use of drugs in patients with critical leg ischemia]

A survey on drugs prescriptions for chronic critical limb ischaemia (CLI) patients was conducted by the nurses involved in the i.c.a.i.-nursing study, a companion study of a randomized clinical trial. The aim of the survey was to describe the epidemiology of drugs prescriptions for CLI patients. The 360 CLI patients admitted to 31 vascular medical or surgical wards, from 1 to 30 november 1994 were recruited for the study. Nurses collected data on risk factors, drugs anamnesis and registered on an ad hoc form CLI specific drugs prescribed during hospital stay and on discharge. Information on the aims and expectations for drugs prescription was also collected. Two noteworthy results: the large variation of drugs associations among wards and the scarce prescription of analgesic drugs (11.8% before admission; 25.8% during hospital stay and 8.0% at discharge). This study represents one of the few pharmacoepidemiology studies available in the literature, conducted by nurses.

Anterior ischemic optic neuropathy

Anterior ischemic optic neuropathy (AION) occurs when there is compromised blood supply to the optic nerve and can result in visual loss. Ophthalmic nurses are key health professionals to recognize this entity and triage the patient accordingly. A case study of a patient with non-arteritic AION is presented.

Epidural sympathetic blockade to relieve vascular insufficiency in an infant with purpura fulminans

The patient in septic shock who develops vascular insufficiency secondary to purpura fulminans is a challenge to the healthcare team. Initial management is directed toward reversing the disease process by administering antibiotics immediately and initiating life-support measures. Emergency measures include optimizing oxygenation and ventilation, reestablishing and/or maintaining circulation and end-organ perfusion and correcting electrolyte imbalances and coagulopathies. After the emergent life-saving needs of the patient have been addressed, attention may be directed toward saving extremities. Epidural sympathetic blockade proved to be successful as an essential adjunctive intervention in preserving the lower extremities of our patient. We encourage other healthcare providers to consider this treatment to help decrease the morbidity of vascular insufficiency secondary to meningococcal purpura fulminans.

Assessment brings its own relief. Nursing care of individuals suffering from ischaemic leg pain

Although pain has been the focus for much recent nursing research, little attention has been paid to relief of ischaemic leg pain. A structured and thorough assessment, which clearly identifies the pain experienced, and the use of analgesia and complementary methods of pain control can help reduce the chronic pain associated with this condition.

Acute mesenteric ischemia

Acute mesenteric ischemia is a potentially life-threatening vascular disorder affecting the gastrointestinal tract. The prognosis depends on early recognition, accurate diagnosis, and timely intervention to prevent extensive tissue necrosis and the onset of sepsis and multi-organ complications. Identifying the patient at risk, evaluating physical findings and laboratory data, maintaining adequate cardiac output and perfusion pressure, and implementing medical interventions are nursing care measures essential to patient survival. Future directions for the management of acute mesenteric ischemia are focused on identifying early markers of ischemia and mucosal injury to diagnose the condition accurately and reliably before the onset of systemic consequences.

Acute lower limb ischemia: a case study

Acute ischemia of the lower extremity is a limb and life-threatening situation that demands prompt recognition and immediate treatment. The leading cause of acute limb ischemia is typically an arterial embolus of cardiac origin. Other significant causes are thrombosis of an atherosclerotic vessel and arterial injury/trauma. This case study examines complexities of diagnosis and treatment of acute ischemia while focusing on nursing care of a patient with an acute embolic occlusion.