Total Patient Care Research Articles

Benefits and limitations of burn wound excision.

This review is intended to provide a balanced view of the role of surgical burn wound excision and closure within the larger context of the total care and rehabilitation of patients with burn injury. The historical background leading to present practice is outlined. The salient technical and logistical problems associated with the performance of wound excision are discussed, with emphasis on the necessity for expeditiously completing these procedures which are associated with major blood loss. A realistic analysis of the results of excisional therapy in patients with burns of varying severity is presented. Benefits attributable to the surgical phase of therapy become progressively more difficult to identify as the size of deep burns increases beyond 20% of total body surface area.

外傷性頚動脈海綿静脈洞ろうを合併した頬骨，下顎骨骨折の１例

A case of traumatic carotid-cavernous sinus fistula (CCF) complicating fractures of the zygoma and mandible is reported. This fistula, characterized by pulsatile bruit, exophthalmons, chemosis, extraocular palsy and diplopia, is a very rare condition that may accompany maxillofacial fractures. Early diagnosis is important, as delay in treatment may cause irreversible neurological and ophthalmological damage.This lesion was treated by embolization of fistula using a detachable balloon catheter with good results.The necessity of total patient care, as well as, the importance of a team approach is emphasized.

The Development of Percutaneous Renal Biopsy in Man

I N 1939, Poul Iversen and Kaj Roholm, in Copenhagen, published their report on aspiration biopsy of the liver. Kaj Roholm had developed a special cutting needle with attached syringe to do this (Fig 1). Soon after the end of World War II, Iversen and Brun began to use Roholm's needle on kidneys (P. Iversen, personal communication). In 1946, I returned to Boston to work once again on the liver, blood, and food. After 6 years in military service, I had to reorient myself to civilian medicine at the Mayo Clinic. I worked for 3 months on Snell's liver service. I hurried back to Boston with Vim-Silverman needles, which Snell's team used on patients' livers. Like others, I aimed at a patient's liver and pulled out kidney tissue. No harm resulted. It was obvious one could deliberately biopsy the kidney to diagnose Bright's disease. This idea excited me. Elsewhere2 there is described how the late Hans Popper arranged for me to visit Poul Iversen and Claus Brun in Copenhagen, who were doing aspiration biopsies of the kidneys; I had serious reservations with its use: the patients were upset and there was a low yield of tissue. In Chicago, I enlisted Robert C. Muehrcke, a medical student, and Murray Franklin to develop the FranklinVim-Silverman needle (Fig 2). Reference 2 described how we developed the technique of percutaneous renal biopsy (PRB) in the prone position. It was an exciting time. In those early years between 1950 and 1960, every renal biopsy taught us something new and remarkable. In 1936, Jean Hamburger, renowned physician and writer, received his PhD from the Sorbonne (Physiology de ['innervation renal, Paris, Mason et cie). In 1959, he was appointed Professor of Medicine at the University of Paris and organized a renal unit in the Hospital Neckar. This was to play an important role in the development of PRB. Hamburger and his colleagues had produced an effective biopsy needle, which was the forerunner of early commercial ones. In addition, his unit became a major center for nephrology, and for the study of immunology in the diagnosis and treatment of renal disorders, especially transplantation. In Boston, a major center for nephrology, John Merrill, David Hume, George Thorn, Gustave Dammin, and their colleagues began to use renal biopsies to study homotransplantation in 1954. Later, biopsies were done on a wide variety of renal disorders. These were performed by the st!,lff, including Donald Oken and many others. In 1951, Conrad Pirani started to grade the various structures seen on biopsy sections from 0 to 4 +. Clinical pathologic correlations were attempted. From his histologic evaluations, one obtained the maximum useful information from renal tissues. This made an enormous difference to the total care of patients. In 1954, Muehrcke et al suggested the use of serial renal biopsies. 3 This illuminated studies on the natural history of diseases and disorders of the kidney, and we began to recognize the effects of treatment, with agents such as corticotropin. Between 1954 and 1957, we published observations on lupus nephritis and other collagen vascular disorders.4 It was apparent that one could make new approaches to pathologic analysis of the dynamic state of a disease and decide if there were florid, moderate, or minimal changes present. Pirani introduced the ideas of local, focal, and diffuse changes, with or without nephron dropout or base-

Organizing and Implementing an Ilizarov Program

The Ilizarov external fixator has made a profound impact on orthopaedic science. With its circular design, it allows correction of three-dimensional deformities including rotation, angulation, translation, shortening, and widening, as well as lengthening and soft tissue defects. Because this device is largely patient centered and patient operated, it has presented a new challenge and career investment for the orthopaedic nurse. A comprehensive Ilizarov program is necessary to address the total patient and his multiple needs in any facility where the Ilizarov method of treatment is adopted. The Ilizarov program is a multidisciplinary team approach that provides a structure for administering and providing total patient care for the Ilizarov patient and his significant other(s).

Sexual ability, activity, attitudes and satisfaction as part of adjustment in spinal cord-injured subjects

Changes in different aspects of sexuality were investigated and related to overall quality of life and physical, psychological and social adjustment in 73 SCI subjects, who were sexually active both before and after injury. Items on sexual interest and satisfaction were treated as one composite variable, the SIS scale, measuring sexual adjustment after injury. Despite severe genital dysfunction, more than half of the subjects (57%) rated their sexual relations after injury as satisfying or at least rather satisfying. The majority continued having intercourse, although many of them more seldom than before, and about half experienced orgasm. Sexual adjustment after injury was closely and positively correlated to frequency of intercourse, willingness to experiment with alternative sexual expressions and young age at injury. Physical and social independence and a high mood level were further positive determinants of sexual adaptation after injury, whereas the neurological level and completeness of injury showed no significant correlation with sexuality. It is suggested that sexual information and counselling should be integrated in the total care of the SCI patient to reduce the negative effects on sexuality, caused by the injury.

Pediatric dentistry: Total patient care

Pediatric dentistry: Total patient care

Dental patient education: Self-care to healthy human development

Credited with a long history of providing preventive care, dentists are challenged by increasing demands from better educated consumers interested in improving their health and caring for themselves. The task of administering patient education services, identifying patients at risk, targeting specific behaviors for change, and managing costs is the subject of this case study. The Self-Care Motivation Model described here, is used to develop a patient education/smoking cessation/lifestyle change program for a patient with numerous dental and general health disturbances. Time and cost saving methods for administering such total patient care are discussed. Suggestions for reframing the context of dental patient education and health behavior change initiatives to include general healthy human development competencies are provided.

Considerations in the Treatment of Acquired Immunodeficiency Syndrome Patients at Home

The rapidly growing acquired immunodeficiency syndrome (AIDS) population faces frequent, expensive hospitalization due to the debilitating sequelae of the disease. Home care offers these patients an opportunity to receive or complete their therapy in comfortable surroundings, allowing them to realize the psychosocial and financial benefits of outpatient care. A myriad of sophisticated drug therapies has been successfully administered in the home setting. Therapy for frequently occurring opportunistic infections often requires treatment with highly toxic drugs such as amphotericin, pentamidine, and ganciclovir. With thorough patient training and diligent monitoring by the home-care pharmacist and nurse, these agents can be safely administered at home. Conventional and investigational chemotherapy and immunomodulator therapy, such as interferon or erythropoeitin, can also be administered at home. Providing total parenteral nutrition to AIDS patients is a controversial treatment modality, but if indicated, it can also be accomplished at home. Outpatient pain management has allowed many patients with terminal or chronic illnesses to minimize time spent in hospitals or extended care facilities, and it can offer the same advantages to patients with AIDS. The psychosocial ramifications of AIDS and its impact on patients and health care professionals must be understood in order to effectively provide total patient care at home. The challenge to the homecare pharmacist is to acquire and maintain a comprehensive knowledge of the treatment options currently available for the management of AIDS.

Pediatric dentistry: Total patient care steven: H. V. WeiPhiladelphia: Lea & Febiger, 1988. 615 pages

Pediatric dentistry: Total patient care steven: H. V. WeiPhiladelphia: Lea & Febiger, 1988. 615 pages

Outcome of Pain Management

Summary The practice of anesthesiology continues to mature as evidenced by the increased involvement of anesthesiologists in the total perioperative care of surgical patients. That care now extends well into the postoperative period with the utilization of new and more powerful techniques for the control of pain. The technique chosen for pain control after operation may have a significant influence on several aspects of recovery. These include postoperative pulmonary function and complications, the neuroendocrine response to surgery and its metabolic consequences, and thromboembolic complications. Other aspects of recovery for which encouraging but less conclusive data are available include postoperative cardiovascular function, gastrointestinal function, and mental status. It seems that the very definition of anesthesia practice is changing. The focus and benefit of our care were previously apparent primarily in the operating room. We now find that directing our efforts towards the period following operation may be of equal, or even greater, benefit to our patients.

Psychological factors and return to work.

Return to work is considered to be a criterion of a good outcome after a myocardial infarction or coronary revascularisation procedure. In general, return to work is not necessarily correlated with cardiac state; a variety of psychological, social and economic factors influence whether or not the individual will return to gainful employment. Psychological variables to be considered include the reactions of patient and family, their understanding of the illness, the personality and behavioural characteristics of the patient, expectations of the results of treatment and attitudes towards disability. These will be influenced by aspects of the job itself or the working environment as perceived by the patient. Physicians' attitudes are strong factors in influencing the final decision on whether or not the patient goes back to work. Employers and fellow employees, by their attitudes to the illness, will also influence the decisions. It follows that assessment and management of psychological problems must be part of total patient care after a coronary event if the optimal number of patients are to return to work, confidence of their ability to cope with its demands. Though the actual way in which assessment is made and appropriate treatment undertaken may vary considerably, a study of available knowledge enables general guidelines on these aspects to be given.

Ambulatory Care Centers

Nurse practitioners continue to struggle to find avenues for professional fulfillment. Urgent care or ambulatory care centers (ACCs) may, because of their need to respond to consumer demands for more comprehensive services, offer nurse practitioners a unique opportunity to establish productive primary care practices based on the concepts of total patient care. A model for such a practice has operated successfully since 1983, establishing that both professional and business success can result from the collaborative efforts of nurse practitioners and physicians in an ACC setting.

Facilitating coping with cancer pain

Pain can be regarded as a complex sociosomato psychic phenomenon. Helping people with cancer pain requires more than skilled drug prescribing. It calls for a holistic approach which takes into account the society and culture of the patient, and necessitates optimal communication with patient and family and knowledge of the psychological processes of coping with stress. Only a multilevel approach is likely to be effective in such total patient care.

Continuous clinical assessment in intensive care nursing: a beginning

The use of continuous assessment methods as a means of evaluating a student's progress has been an integral part of post basic nursing courses for some years now. In practice this has often meant assessment of theoretical work in the form of essays, projects, and objective tests spread throughout the course. In the clinical areas the assessment was usually based on specific skills tests, ward/unit reports and perhaps the one off assessments in total patient care, managerial and teaching skills similar to those undertaken in basic general nurse training. The following article describes how a continuous assessment tool using a competency scoring system has been introduced to assess the student in the clinical area doing a post basic course in intensive care nursing.

Total Patient Care Conference.

Total Patient Care Conference.

The care of SCI patients in the developing nations—Can we stem the rot?

The aims, objectives and results of the Madras Paraplegia Project at the Government General Hospital, Madras is presented. Eight hundred and forty four Spinal Cord Injury (SCI) patients have been treated in 8 years and 4 months. The Madras Model offers an alternative strategy for the total care of SCI patients. The merits and drawbacks are highlighted. The results to date commend replication of the model in areas of the world where the services for SCI Care are meagre or non-existent.

‘Meaningful Communication': can it enhance the Quality of Life?

In treating malignant disease it often seems that the medical profession is primarily concerned with affecting cure or prolonging life, athough it is clear that both the disease, and its treatment, may profoundly affect the patient's normal lifestyle and have a significant effect on the quality of life (QL). Yet the current emphasis on total patient care means that it is no longer enough to be concerned only with the physical aspects of care; the psychosocial effects of disease are becoming increasingly important. Consideration of the patient's QL is a legitimate part of care and interventions can be designed to help the patient to incorporate changes in his physical state into his normal lifestyle. This paper discusses the concept of quality of life and explores the benefits of 'meaningful communication' (education and supportive counselling) in terms of the relief of stress and anxiety. It considers the effects of such communication on the quality of life of affected patients. It is suggested that the l...

Organization and management of an in-patient treatment unit for adolescents

Brookside is a second or third tier treatment unit for disturbed adolescents. Most youngsters admitted have been already "treated" by the usual disciplinary measures, simple behavioural techniques, medication and work of different types with them and their families, which have been found to be ineffective. An outline of the philosophy of treatment developed in the unit is described in the paper--a philosophy aimed at dealing with the source of the disturbance and applicable to any type of adolescent problem. A small minority of referrals from our catchment area, the NETRHA has been found unsuitable for this type of work. This unsuitability is not based on the type of problem, but on our assessment of the potential capacities of the individual. Inevitably, in the in-patient setting, the disturbance of the patients affect the staff, and individual and group patient pathology is reflected in staff stress and staff disturbance. Whilst the philosophy of treatment is aimed at benefiting the patient, it is through the understanding and management of staff difficulties, which became of primary concern in the unit, that the pathology of the patients can be unravelled, understood and dealt with. Paradoxically, attempting to care directly for the patients can lead to impossible difficulties, whilst caring for the philosophy of treatment and the staff leads to a solution of most of the problems, and development of both staff and patients. Total patient care is built into the philosophy and management of the unit. Staying with the problem and working as a team has resulted in successful treatment of youngsters considered to have intractable problems whilst periods of poor staff support and difficulties of working together, have led to failures in treatment. The basis of this philosophy was first introduced to the author during his training years at the Northgate Clinic, London NW9.

A nursing approach to the use of high frequency jet ventilation

As high frequency jet ventilation becomes more popular, there is a great need for the nurse to become more familiar with it and to be aware of the major implications for the total care of the ventilated patient. This article is intended firstly to provide a brief account of the nature of high frequency ventilation, and then a concise explanation of the clinical applications of this particular type of ventilatory support. Secondly, some of the implications for the nurse's assessment of the patient's needs and nursing care during high frequency jet ventilation are indicated. It is hoped this will direct the reader to a more detailed study of high frequency jet ventilation and so promote a greater awareness of the patient's needs in order that they may be met promptly.

Patient Evaluation

This article has focused on the various aspects of patient evaluation that is a vital component in the total care of the dental patient. It must be emphasized that dentists are ultimately responsible for the overall management of the patients that they are treating, and only by careful selection and treatment plan can the practitioner maximize the benefits while minimizing the dangers inherent in outpatient anesthesia.