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Student Survival Skills

Acute Care
for Nurses
Claire Boyd

WlLEY Blackwell
ACUTE CARE
FOR NURSES
Student
Survival Skills
Series
Survive your nursing course with these essential guides for all student nurses:

Medicine Management Skills for Nurses, 2nd Edition

Claire Boyd
9781119807926

Clinical Skills for Nurses, 2nd Edition

Claire Boyd
9781119871545

Study Skills for Nurses

Claire Boyd
9781118657430

Care Skills for Nurses

Claire Boyd
9781118657386

Communication Skills for Nurses

Claire Boyd and Janet Dare
9781118767528

Calculation Skills for Nurses, 2nd Edition

Claire Boyd
9781119808121

Wellbeing Strategies for Nurses

Claire Boyd
9781119893554

Reflective Practice for Nurses

Claire Boyd
9781119882480
ACUTE CARE
FOR NURSES

Claire Boyd
RGN, Cert Ed
Practice Development Trainer
Bristol, UK
This edition first published 2023
© 2023 John Wiley & Sons Ltd
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Contents

PREFACE vii
INTRODUCTION ix
ACKNOWLEDGEMENTS xi

PART 1 NURSING IN THE ACUTE CARE SETTING 1

1 DIAGNOSTIC TESTS AND ADVANCED FORMULAE 3
2 RECOGNISING SEPSIS 25
3 CONFLICT RESOLUTION 43
4 PATIENT ASSESSMENT 63
5 SITUATION, BACKGROUND, ASSESSMENT, AND RESPONSE (SBAR) 89

PART 2 RECOGNISING AND RESPONDING TO MEDICAL EMERGENCIES 103

6 AIRWAY 105
7 BREATHING 117
8 CIRCULATION 135
9 DISABILITY 149
10 EXPOSURE 173

PART 3 ACUTE CARE SKILLS 185

11 EMERGENCY FLUID MANAGEMENT 187
12 TREATING PAEDIATRIC DEHYDRATION 207
13 HYPODERMOCLYSIS 217
14 CENTRAL LINES 231
15 INVASIVE AND NON-­INVASIVE VENTILATION 243
 Contents

PART 4 CRITICAL CARE SIMULATION 265

16 CRITICAL CARE SIMULATION 267
17 MEDICAL ABBREVIATIONS 281

18 ANSWERS TO ACTIVITIES, QUESTIONS, AND TEST

YOUR KNOWLEDGE 293

APPENDIX 1: NATIONAL EARLY WARNING SCORE 2 OBSERVATION CHART 315

APPENDIX 2: SEPSIS TOOL CHART 317
APPENDIX 3: FLUID PRESCRIPTION CHART 319
INDEX 321

vi
Preface

This book has been developed to assist the healthcare worker in the field of
acute care.

It is designed as a resource for nursing students, including nursing associates,

Registered Nurses, and midwives requiring a bit of revision, assistant practitioners
and senior health care assistants, perhaps working toward their vocational skills
certification (qualification and credit framework level two), return to practice nurses,
overseas nurses, and basically anyone requiring these more acute clinical skills and
rapid assessment of the acutely ill patient. This knowledge has never been so
important, especially during times of pandemic and winter pressures.
Introduction

Hello, my name is Claire, and those of you who have read the other books in this
series will know that I have been in health care for more than 40 years, beginning my
nursing career as a Nursing Auxiliary (Healthcare Assistant). After completing my
training to become a Registered General Nurse and later obtaining a Certificate in
Education to become a Teacher/Lecturer in health care, I began teaching medics,
nurses, students, among others, in clinical skills.

As with other books in the series, this book has been divided into four sections. Part
1 begins by looking at some medication management formulas as revision before
going on to look at some more advanced formulas you may see in the clinical setting.
As these books are what you want, it was requested, by readers just like you, that
sepsis and conflict resolution chapters were added.

• Sepsis was included because of the fact that healthcare systems worldwide,
including our beloved NHS (National Health System), have pledged to reduce
the number of infections and deaths by early recognition and treatment.
• Conflict resolution was added because of the assaults on healthcare staff. We’ve
all seen angry patients and their families upset that visitors have been banned
because of the coronavirus disease 2019 pandemic; others were furious that
they were asked to wear masks in the hospital setting or because of cancelled
clinics as a result of staff needed to cover for their sick colleagues in the ward
areas. In truth, assaults by those we are trying to care for is nothing new.

Part 2 looks at assessment techniques and the individual components of the ABCDE
assessment, moving on from the vital signs clinical observation at a superficial level
and looking at the individual components more in depth, as well as the clinical
actions performed by the more experienced nurse.

Part 3 focuses on some of the higher skills, such as caring for the ventilated patient, fluid
resuscitation in adults and children, and subcutaneous fluid hydration in those unable to
tolerate the intravenous route. Without adequate hydration, patients will die very quickly.

Throughout the book we will look at real-­life scenarios, with questions at the end of
chapters to consolidate our understanding.
 Introduction

You will find a soupçon (that’s a posh word for ‘sprinkling’) of humour, as goodness
knows nursing is a stressful profession at the best of times, never mind adding
pandemics and winter pressures to the mix!

A man speaks frantically on the phone: ‘My wife is pregnant and her contractions
are only two minutes apart’!!
Midwife: ‘Is this her first child’?
Father: ‘No, you fool’, he shouts. ‘This is her husband’!!

Everything has been designed as a quick overview read, cutting out the waffle (and
perhaps ‘the nice to know’) and relaying only the important, vital information. See the
information box below as an example as to what I mean:

VITAL VERSUS NICE TO KNOW

Source: tommoh29 / Adobe Stock.

HOW TO SWITCH ON A LIGHT SWITCH

VITAL:
1 Go to light switch.
2 Using index finger of dominant hand, press down switch to turn on.

NICE TO KNOW:
You did not need to know how electricity is generated, how it is supplied to
dwelling, how the fuse box is wired, how the light switch is wired, etc., as
asked only to switch on the light switch!

Thank you to the students, and others, for writing and verbalising what you wanted
covered in this book, thereby getting it right for you, the healthcare professional.

x
Acknowledgements

As always my thanks go to the many healthcare nurses and students I have had
the pleasure of working with in the acute care setting (Southmead Hospital) and the
community setting (South Gloucestershire care homes, Brain Injury Rehabilitation
Centre, etc.). We have had so many laughs along the way, in often difficult times.

Acknowledgements also go to North Bristol NHS Trust and to all my friends and
colleagues in the Staff Development Department.

Thank you to Tom Marriott, Ann Hunt, Selvakumar Gunakundru, and Sheila Higgins,
copy editor, and all those at Wiley-­Blackwell, and to Magenta Styles, who first
approached me to begin this series of books.

This book is dedicated to my family – husband Rob, children Simon and Louise,
my lovely son-­in-­law David, and my two little treasures, Owen and Rhys, who kept us
all laughing in our COVID bubble!
Part 1
...................
NURSING IN THE
ACUTE CARE
SETTING
Chapter 1
...................
DIAGNOSTIC TESTS
AND ADVANCED
FORMULAE

Acute Care for Nurses, First Edition. Claire Boyd.

© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
 Chapter 1

LEARNING OUTCOMES
By the end of this chapter you will have an understanding of how
to calculate mean arterial pressure (MAP), drug administration
calculations, percentage strength of drugs, solution strength
of drugs (e.g., mg/ml), infant feeding regimens, infant growth
­expectations, body surface area (BSA), and body mass index
(BMI); how to measure cardiac output (CO); how to assess lung
function and renal clearance; and how to determine energy
­requirements of the body.

Working in health care, we all need to have a good grasp of

mathematics to perform our professional duties, such as
keeping accurate fluid balance records (see Appendix 3),
totting up the vital signs on the National Early Warning Score
2 observation chart (see Appendix 1), and administering
medications, to name just three. As our careers progress, we
may be involved in more complex mathematics. This may
involve having an understanding of body organ and systems
calculations. Even if you are not expected to undertake these
calculations, it is still good to have the knowledge of how
these readings are obtained and what they mean to the
patient’s health.

MEAN ARTERIAL PRESSURE

For instance, in Chapter 2 we will look at mean arterial
pressure (MAP) of blood pressures (BPs) in relation to
sepsis. This reading often pops up on automatic BP
machines (electronic sphygmomanometers), but what
exactly is it and how do we obtain this reading if using a
manual sphygmomanometer (aneroid), as shown in
Figure 1.1, with a stethoscope?

4
Diagnostic Tests and Advanced Formulae

Figure 1.1 Aneroid sphygmomanometer.

Mean arterial pressure (MAP)

MAP is the average blood pressure of an individual
during a single cardiac cycle and informs us whether the
blood flow is adequately perfusing the tissues/organs.
This is a vital calculation for patients in critical care and
in cases of septic shock.

Working out the MAP from a BP recording is actually very

simple:

Step 1: Take BP recording.

Step 2: Multiply the diastolic BP (DBP) by 2.
Step 3: Add this value to the systolic BP (SBP) and divide by 3.

Example: BP: 120/80 mmHg

DBP: 80 × 2 = 160
160 + 120 (SBP) = 280
Divide by 3 = 93.3
 Chapter 1

Activity 1.1  

1 Work out the MAP of BP 135/85 mmHg.

2 Work out the MAP of BP 120/70 mmHg.

DID YOU KNOW?

The normal MAP range is between 70 and 100 mmHg. The body
needs at least 60 mmHg to provide enough blood to the ­coronary
arteries, kidneys, and brain.

HEALTHCARE CALCULATIONS
Before we look at some more advanced body organ and
systems calculations, we will first revise our more everyday
or ‘bread and butter’ drug administration calculations.

Drug Dosages for Tablets/Capsules

What you want WYW

Formula:
What you ve got WYG

A patient has been administered 0.25 mg of digoxin orally.

Stock: 250-­microgram (μg) tablets. How many tablets do
you administer?

First, change 250 μg to milligrams (mg):

250 μg/1000 = 0.25 mg.

WYW: 0.25 mg
WYG: 0.25 mg = 1 tablet

6
Diagnostic Tests and Advanced Formulae

Question 1.1
Prescription: 8 mg morphine
Stock: 10 mg/2 ml
How much do you administer?

Drug Dosages for Injections, Syrups, Elixirs,

Among Others

What you want WYW

Formula: Volume
What you ve got WYG

A patient requires a subcutaneous injection of 22 units.

10 ml stock ampoules contain 100 units to every 1 ml. What
volume do you draw up?

WYW 22 units
Volume : 1 ml 0.22 ml
WYG 100 units

Question 1.2 A patient is prescribed 400

μg of Granisetron syrup orally. Stock ­solution
= 1 mg/5 ml. How much do you draw up?

Infusion Pump Rates (in millilitres per

hour)
Volume
Formula: Rate
Time
A patient is to receive 4 l of 0.9% sodium chloride over eight
hours. What is the infusion rate in millilitres per hour?
4 l 4000 ml
Volume 4000
500 ml / h
Time 8
 Chapter 1

Question 1.3 350 ml of blood is to given to a

patient over four hours. What is the infusion
rate in millilitres per hour?

Drip Rates (in Drops per Minute)

Volume ml Drops per ml

Formula:
Time h 60 minutes per hour

The patient has been prescribed 1 l of 5% glucose to run

over eight hours. What is the infusion rate in drops per
minute, using a standard administration set delivering
20 drops/ml?

Change 1 litre into ml 1000 ml

Volume Drops per ml 1000 20

41.6 42 drops / min
Time 60 8 60

Question 1.4 Patient has been prescribed

0.5 l of fluid to run over five hours. What is the
infusion rate in drops per minute, using a blood
administration set delivering 15 drops/ml?

Duration of Infusions

Volume Drops per ml

Formula:
Rate 60 minutes per hour
600 ml of fluid is dripping at 20 drops/min. The intravenous
(IV) set delivers 15 drops/ml. How long will the infusion take?

Volume Drops per ml 600 15

7 hours 30 minutes
Rate 60 20 60

8
 Diagnostic Tests and Advanced Formulae

Question 1.5 An IV set delivers 15 drops/ml.

A patient is to receive 1 l of Intralipid at 30
drops/min. How long will the infusion take?

TOP TIP
0.33 does not mean 0.33 minute. This is a decimal value and
needs to be changed to minutes by doing the following
­conversion:

33
60 minutes per hour 19.8 ~ 20 minutes
100

Drugs According to Body Weight

Formula : Total dose per day Weight kg Dose

A patient with diabetic ketoacidosis needs to commence a

fixed rate insulin infusion at 0.1 unit/kg/h as per trust policy.
How much insulin should be prescribed to an 85 kg patient?
Weight Dose 85 0.1 8.5 units / h

Question 1.6 A patient has a deep vein

thrombosis and has been prescribed ­enoxaparin
(low-­molecular-­weight heparin). The patient
weighs 74 kg. The dose of enoxaparin is
1.5 mg/kg. How much do you administer?

DID YOU KNOW?

I think my calculator is broken. The only numbers that seem to
work are 1, 3, 5, 7, and 9. It’s very odd.
 Chapter 1

Calculating How Many Minutes Drug to

Run Over
Dose prescribed
Formula:
Rate
Furosemide should not exceed 4 mg of the run over one
minute because of speed shock. A patient has been pre-
scribed 20 mg. Over what time should this be administered?

Dose prescribed 20
5 minutes
Rate 4

Speed shock
A systemic reaction caused by the rapid injection of a
medication into the circulation, resulting in toxic levels
of medication in the plasma. Symptoms can include
cardiac arrest, flushed face, headache, irregular pulse,
shock fainting, and tightness in the chest.

Question 1.7 A patient has been prescribed

15 mg. Over what time should this be
administered?

Percentage Strength of Drug

A patient is given 2 l of 0.45% sodium chloride. How many
grams of sodium will the patient receive?

Change 2 l into millilitres 2000 ml.

2000
0.45 9g
100

Question 1.8 How many grams of ­medication

do you have in 20 g of 12% w/w ointment?

10
Diagnostic Tests and Advanced Formulae

Solution Strength of Drug (mg/ml)

500 mg of amoxicillin powder has been reconstituted in
25 ml of water for injection. What is the concentration in
milligrams per millilitre (mg/ml)?
500
20mg / ml
25

Question 1.9 1 g of a drug has been recon-

stituted in 20 ml of water for injection. What
is the strength in mg/ml.

Extra Questions
And now a couple of questions for you to do on your
own – just for your own enjoyment!

Question 1.10 A patient is given 0.9%

sodium chloride at a rate of 400 ml/h for five
hours. How many litres will the patient receive?

Question 1.11 An infusion of dextrose 5%

started at 10:00 and finished at 22:00. How
many litres will the patient have received if
the infusion is running at a rate of 100 ml/h?

Question 1.12 A patient has been pre-

scribed ibuprofen 5 mg/kg/d in three divided
doses. The patient weighs 60 kg. Calculate
the daily dose and single dose.
 Chapter 1

DID YOU KNOW?

OD = Once daily
BD = Twice daily, or 12 hourly
TDS = Three times daily, or 8 hourly
QDS = Four times daily, or 6 hourly

Question 1.13 Stock ampoules of IV

­hydrocortisone = 100 mg in 2 ml. Patient requires
135 mg IV. How much would you administer?

Question 1.14 A patient is to have 2 l of

clear fluid in 24 hours. He has received
1500 ml in 6 hours. How many drops per
minute are required to correct the infusion?

TOP TIP
If you struggled with any of these calculations, perhaps you may
wish to read the calculations book in this student survival series
set of books.

Now let’s look at some advanced body, organ, and systems

calculations starting with infant feeding regimens.

CALCULATING INFANT FEEDING

REGIMENS
Obviously, correctly preparing feeds for bottle-­fed babies is
important. A hungry baby usually cries between feeds, and
an overfed baby can experience diarrhoea and vomiting.

12
 Diagnostic Tests and Advanced Formulae

Infants need to receive 150–200 ml per kilogram body

weight per 24 hours. Here is the formula for calculating feed:

Volume of feed Amount of milk ml /

Number of feeds in 24 hours
Weight of baby kg

Activity 1.2  

Calculate the volume of feed for a baby weighing 4.9 kg. He is fed six times
every 24 hours. Remember that you need to calculate for the least (150 ml)
and the most (200 ml) amounts.

WORKING OUT INFANT GROWTH

EXPECTATIONS
A newborn baby is expected to regain birth weight after two
weeks and then gain the following:

200 g per week until three months of age

150 g per week for a further three months
100 g per week until nine months of age

Three months is assumed to equal 13 weeks.

Imagine that you are required to calculate the expected

weight of an infant aged 12 weeks whose birth weight was
3.2 kg. After two weeks, this infant weighs 3.2 kg again.
The answer is:

12 − 2 = 10 weeks
At 200 g/week = 10 × 200 g = 2000 g = 2 kg

Therefore, the expected weight = 3.2 kg + 2 kg = 5.2 kg at

12 weeks old.
 Chapter 1

Activity 1.3  

You are required to calculate the expected weight of an infant aged 12 weeks
whose birth weight was 2.2 kg. After two weeks, this infant weighs 2.2 kg again.

BODY SURFACE AREA

ESTIMATIONS
For neonates and children, body surface area (BSA)
estimates are more accurate than body weight when
calculating drug dosages.

As people grow in height and weight, their skin surface area

increases – this BSA is measured in square metres (m2).

The most commonly used simplified formula to determine

BSA is the Mosteller formula, which is expressed as:

Body surface area: the square root of product of the weight in

kilograms multiplied by the height in centimetres divided by
3600. The result is in square metres.

Or how I express this:

height cm weight kg
BSA m2
3600

Then, to calculate BSA using this formula, I get my calcula-

tor: I put in the height (or length) of the child in centimetres
and multiply it by the weight of the child in kilograms. I then
divide the result by 3600 (do not worry about where the
3600 comes from, just go with it). When I have an answer, I
press the square root button on my calculator to get the BSA
in square metres (m2).

Here is an example that walks you through the steps.

14
 Diagnostic Tests and Advanced Formulae

Your first patient of the day is a woman 1.70 m tall and

weighing 65 kg – you need to calculate her BSA:

1 Convert metres into centimetres.

1 metre 100 centimetres, and so
1.70 100 170 centimetres
2 Multiple height by weight.
170 65 11, 050
3 Divide the result in step 2 (11 050) by 3600.
3.0694
4 Find the square root using a calculator.
1.75 m2

Activity 1.4  

You need to find the BSA of a small child weighing 16.4 kg whose height is 100 cm.

However, many people use a scale called a nomogram to

estimate BSA, although it is considered to be much less
accurate that the Mosteller formula. There are separate
nomograms for infants, children, and adults. Figure 1.2
shows the nomogram for infants for working out the BSA.

Let me show you how to use the nomogram. First, get a ruler
or something with a straight edge. If you want to find the BSA
of an infant with a length of 70 cm and a weight of 32 kg,
place the straight edge on the height scale at 70 cm and
across to the weight scale at 32 kg. The straight edge crosses
the surface area scale at approximately 0.78. This means that
the BSA is 0.78 m2. Try this out for yourself on the nomogram.

Now, put the same details into the Mosteller formula:

Height weight 70 cm 32 kg
3600 3600
 Chapter 1

BMI (kg/m2) = Weight (kg) / [Height (m)]2

2.6
2.5
2.4
2.3
2.2
2.1 90
2.0
1.9 80

1.8
70
1.7
1.6
60
1.5
140
1.4
50
Height (cm)

130 1.3
45

Weight (kg)
1.2
40
110 1.1
35
1.0
30
100 0.9

90 25
0.8

80 20
0.7
19
18
17
70 0.6
16
15
14
0.5 13
12

Figure 1.2 Nomogram for infants.

16
 Diagnostic Tests and Advanced Formulae

Using your calculator, input:

70 32 2240 / 3600 0.62

Then find the square root, or press the square root button on
your calculator, and you get 0.79 m2.

The formula method and the nomogram method often give

variable answers!

Table 1.1 shows some useful parameters of average values

when administering medications to children, which should
be used only if you are unable to find specific doses. NOTE:
You will always need to check this first with the prescriber.

Table 1.1 Useful approximate values.

Percentage of
Age Weight (kg) Height (cm) Surface area (m2) adult dose
Newborn 3.4 50 0.23 12.5
1 month 4.2 55 0.26 14.5
2 months 4.4 51 0.28 15
3 months 5.6 59 0.32 18
4 months 6.5 62 0.36 20
6 months 7.7 67 0.40 22
8 months 8.5 72 0.44 25
1 year 10 76 0.47 28
18 months 11 90 0.53 30
3 years 14 94 0.62 33
5 years 18 108 0.73 40
7 years 23 120 0.88 50
10 years 30 142 1.09 60
12 years 37 145 1.25 75
14 years 45 150 1.38 80
16 years 58 168 1.65 90
Adult (male) 68 173 1.80
Adult (female) 56 163 1.60
 Chapter 1

BODY MASS INDEX

The body mass index (BMI) is the most commonly used
measurement of obesity, but it is also used to check that
individuals are within a healthy range. A high BMI is
associated with an increased risk for ill health, such as
cardiovascular disease.

The following is the formula for working out someone’s BMI:

BMI kg / m2 Weight kg / Height m 2.

The World Health Organisation classifies weight into BMI

ranges (see Table 1.2).

Table 1.2 World Health Organisation weight classifications.

Description Body mass index range (mmHg)

Normal 18.5–24.9
Overweight 25.0–29.9
Obesity Class I (moderate) 30.0–34.9
Obesity Class II (severe) 35.0–39.9
Obesity Class III (very severe) >40.0

Activity 1.5  

Robert Simons is a student nurse. His height is 1.72 m and he weighs 66 kg.
Work out his BMI using the formula and his weight classification according to
the World Health Organisation.

18
Diagnostic Tests and Advanced Formulae

MAKING ORGAN AND SYSTEMS

CALCULATIONS
Some of the calculations you need to perform in the
healthcare setting are in relation to the bodily organs and
systems, such as cardiac output (CO) measurements, lung
function, and renal clearance measurements, to establish
how healthy, or poorly, your patients are. This section looks
at the calculations and formulae used to gather this
information.

MEASURING CARDIAC OUTPUT

CO is the amount of blood pumped by the heart’s left
ventricle (in millilitres) in one minute (expressed as ml/min).
It is dependent on the amount of blood pumped out with
each ventricle contraction – known as the stroke volume
(SV) – and the heart rate (also known as the pulse rate [P]).
The SV at rest in the standing position averages between
60 and 80 ml of blood in most adults.

Here are some of the factors that increase CO:

• Anaemia
• Cirrhosis of the liver
• Pregnancy
• Severe infection
• Thiamine deficiency (beriberi)

To work out the CO, you can use the following formula:

CO SV beats per minutes P

This formula is often expressed as CO = SV × P = ml/min.

Given the SV and Ps shown in the following list, the resulting

COs are as follows:

SV = 70 ml, P = 70 beats/min: CO = 70 × 70 = 4900 ml/min

SV = 69 ml, P = 65 beats/min: CO = 69 × 65 = 4485 ml/min
SV = 70 ml, P = 60 beats/min: CO = 70 × 60 = 4200 ml/min
SV = 65 ml, P = 62 beats/min: CO = 65 × 62 = 4030 ml/min
 Chapter 1

ASSESSING LUNG FUNCTION

Pulmonary function tests are important tests used in the
evaluation of respiratory health. They are conducted for the
following reasons:

• To screen for the presence of obstructive and/or

restrictive lung diseases
• To evaluate the ability of a patient to be weaned off a
ventilator
• To assess the progression of lung disease and the
effectiveness of treatment
• To collect baseline readings before surgery to determine
the risk for respiratory complications after surgery

In the respiratory world, you need to know the following terms:

Vital capacity: the amount of air that can be forcibly exhaled

from the lungs after a full inhalation.

Forced vital capacity (FVC): the amount of air forcibly exhaled

from the lungs after taking the deepest breath possible.

Forced expiratory volume in one second (FEV1): the amount of

air that can be forcibly exhaled from the lungs in the first
second of a forced exhalation.

To assess the lung function, you use the following formula,

which expresses it as a percentage:

The expired volume ratio

FEV1 100% / FVC

Here’s the process for calculating a person’s total FVC when

their FEV1 is 4.5 l and their FEV1% is 90%:

FEV1% FEV1 100% / FVC

100%/ 100 /
90% 4.5 l 90 4.5 l FVC
10 /
9 4.5 l FVC

FVC 9 451/ FVC

45 /
FVC 9 5

20
Diagnostic Tests and Advanced Formulae

Therefore, this person has a FVC of 5.0 l.

Now, you need to calculate the FEV1% for an individual with

a FEV1 of 4.2 l and a FVC of 5.0 l:

FEV1% 4.2 100% / FVC1 4.2 / 5.0 100% / 1

84%FEV1

RENAL CLEARANCE
Renal clearance refers to the ability of the kidneys to remove
a given substance from the blood in a given time. Here’s the
formula for calculating the renal clearance:

Renal clearance Urine Volume / Plasma

You can express this as U × V/P.

Note that U = the concentration of the substance in the

urine (mg/ml); P = the concentration of the substance in the
plasma (mg/ml); and V = the volume of urine excreted
(ml/min).

John Smith has the following recordings (in addition to all

The Beatles albums!): U = 80 mg/ml, V = 120 ml/min, and
P = 55 mg/ml. Here’s how you calculate John’s renal
clearance of creatinine:

80 120 / 55 174.5 ml / min

WORKING OUT THE ENERGY

REQUIREMENTS OF THE BODY
Energy calculations are generally performed by physicians
and dieticians, but nurses can be asked to participate in the
calculations when completing nutrition charts for patients.

Energy is measured in kilojoules (kJ). A calorie is a unit that

indicates a food’s energy value: 1 cal is equal to 1000 kcal
(kcal) and 1 kcal = 4.2 kJ.

The average person should derive their energy sources from

the following:
 Chapter 1

• 15% from protein

• 35% from fat
• 50% from carbohydrate

If a 35-­year-­old postal worker requires 3000 kcal/day, how

many of these 3000 kcal should come from fat?

3000 35% 3000 35 / 100 1050 kcal

To convert this amount into kilojoules: 1050 × 4.2 = 4410 kJ

A keen jogger has an energy requirement of 250 kJ/kg of

body weight per day. If they weigh 50 kg, how many
kilocalories do they require in one day?

250 50 12 500 kJ / day

Converted in kilocalories = 12 500 kJ ÷ 4.2 = 2976 kcal per day

Here’s another little puzzle to keep your grey cells ticking over.

A patient is on a strict low-­sodium diet totaling 2400 cal/day.

The dietician asks you what his estimated caloric intake is
for the day.

Find the answer as follows:

• Look at the nutrition chart: You see that they ate only
50% of their breakfast, lunch, and tea.
• Work out the answer by multiplying the desired intake of
2400 cal by the percentage the patient consumed:
2400 kcal × 50%.

Or more clearly: 2400 kcal × 0.5 = 1200 kcal (the number of

calories the patient has consumed today).

TEST YOUR KNOWLEDGE

1 A patient is prescribed 27 mg of Adenocor. Stock
ampoules contain 30 mg in 10 ml. What volume of the
drug do you need to administer?
2 What is the BSA for a small child weighing 18.2 kg and
with a height of 110 cm?
3 What is the BMI for a woman with a height of 1.55 m
and a weight of 120 kg?

22
 Diagnostic Tests and Advanced Formulae

4 Find the CO from the following readings: SV = 75 ml.

5 Solumedrol 2.5 mg/kg is prescribed for a child weighing
15 kg. Stock ampoules contain 125 mg/3 ml. How many
millilitres do you administer?
6 Work out the renal clearance of a patient with the
following readings:
Urine: 50 mg/ml
Volume: 20 ml/min
Plasma: 40 mg/ml

KEY POINTS
• MAP
• Revision of drug administrations
• Percentage strength of drug
• Solution strength of drug (mg/ml)
• Infant feeding regimens
• Infant growth expectations
• BSA
• BMI
• Measuring CO
• Assessing lung function
• Renal clearance
• Working out energy requirements of the body

WEB RESOURCES
BMI: https://www.nhs.uk/common-­health-­questions/lifestyle/
what-­is-­the-­body-­mass-­index-­bmi/
Nutrition: https://www.nutrition.org.uk/
World Health Organisation BMI: https://www.who.int/toolkits/
child-­growth-­standards/standards/
body-­mass-­index-­for-­age-­bmi-­for-­age
Maths: http://bbc.co.uk/schools/gcsebitesize/maths/number
Healthcare math: https://www.mathcentre.ac.uk/students.
php/health/arthmetric/rules/resources/
Maths: https://testandcalc.com/
Healthcare math: www.snap.nhs.uk
Chapter 2
...................
RECOGNISING
SEPSIS

Acute Care for Nurses, First Edition. Claire Boyd.

© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
 Chapter 2

LEARNING OUTCOMES
By the end of this chapter you will have an understanding of
­sepsis, including the incidence, physiology, how to recognise
it, risk factors, and treatment. You will also have knowledge of
the sepsis six and an understanding of blood results used in
­conjunction with diagnosing sepsis.

To begin this chapter, look at the following medical terms

and think for a moment about what they actually mean:

• Bacteraemia
• Sepsis syndrome
• Severe sepsis
• Septicaemia
• Systemic inflammatory response syndrome

Did you know that all these terms mean the same thing and
have now been deemed obsolete and replaced by one
term – sepsis.

Within the healthcare environment (World Health Assembly,

National Health Service [NHS], National Institute for Health
and Care Excellence [NICE]) there has been a big push to
improve the identification, diagnosis, and management of
sepsis to improve patient safety outcomes.

Question 2.1 So, what exactly is sepsis?

Isn’t it just blood poisoning?

Well done – you’ve just found another term for sepsis! Sepsis
is a very serious reaction to an infection. Normally the body’s
immune system kicks in to fight off the infection, but in the

26
 Recognising Sepsis

case of sepsis the immune system response becomes

overactive and starts to cause damage to the body itself.
NICE has defined sepsis as ‘a life-­threatening condition that
arises when the body’s response to an infection injures its
own tissues and organs’ (NICE, 2016, https://www.nice.org.
uk/guidance/ng51).

We can see where sepsis fits into the infection spectrum in

Figure 2.1.

Infection
Sepsis
With no
An infection with
physiological
abnormal physiology
deterioration

Septic Shock
Infection with
abnormal
physiology
indicative of multi-
organ failure

Figure 2.1 Infection criteria.

We can see from Figure 2.1 that sepsis is the worst kind of
infection, which can lead to septic shock. To understand
why we are so concerned about sepsis, first we need to see
some facts and figures.
 Chapter 2

SEPSIS FACTS AND FIGURES

DID YOU KNOW?

• Sepsis claims 8 million lives each year worldwide – many of
whom are children.
• There are approximately 250 000 cases of sepsis in the United
Kingdom every year.
• There are approximately 46 000–52 000 deaths in the United
Kingdom every year from sepsis.
• Sepsis claims more lives than breast, bowel, and prostate can-
cers put together and more lives than lung cancer.
• Sepsis costs the NHS approximately £1.5–£2 billion every year.
• Sepsis costs the wider economy approximately £11–£15.6
every year.
• Forty percent of all sepsis survivors suffer permanent life-­
changing effects.

WHAT HAPPENS TO THE BODY

DURING SEPSIS?
The functional changes that occur during sepsis are as
follows:

• The body senses that injury has occurred (the infection)

and attempts to repair itself by releasing white blood
cells (WBCs), platelets, and fibrin. In sepsis this process
happens globally across the body.
• Vasodilation occurs as a means to move WBCs, fibrin,
and platelets to where they are needed in the damaged
tissues.
• The patient will now present as hot and initially warm
around the peripheries.
• Capillary leakage occurs and the WBCs, fibrin, and
platelets need to get inside the blood vessels and
interstitial tissues where the pathogens are.

28
 Recognising Sepsis

• The patient becomes oedematous.

• Inflammatory mediator molecules are released, causing
vasodilation, pain at the site of infection, and clot
formation.

RECOGNISING SEPSIS
More than 70% of cases of sepsis arise in the community,
and yet a large proportion of the public do not recognise the
symptoms that can lead to a delay in treatment.

One of the problems of sepsis is that individuals may feel

unwell but may not have a high temperature so sepsis may
be difficult to diagnose, leading to delayed treatment and
eventually to septic shock – organ failure and death.

Sepsis is a clinical emergency. For each hour’s delay in

administering antibiotics in septic shock, mortality
increases by 7.6%; therefore, identifying sepsis in the first
instance is vital in saving lives. This is more difficult in
those who are unable to communicate just how unwell they
are feeling, for example, babies and adults with learning
difficulties. This is where our observation skills come to the
fore, and we need to ask, ‘Are they acting differently from
normal?’ This is due to the fact that there is no one sign to
diagnose sepsis. Also, symptoms present differently in
adults and children.

Table 2.1 shows how to spot symptoms in adults; if they

develop any of the symptoms, it may be sepsis.

Table 2.1 How to spot sepsis in adults.

S = Slurred speech or confusion

E = Extreme shivering or muscle pain
P = Passing no urine (in 24 hours)
S = Severe breathlessness
I = It feels like you are going to die
S = Skin mottled or discoloured
Source: Adapted from Sepsis Trust.
 Chapter 2

Table 2.2 shows how to spot symptoms in children. If they

develop any of the symptoms, it may be sepsis, but if ever in
doubt, act fast and dial 999 or go straight to accident and
emergency department.

Table 2.2 How to spot sepsis in children.

1. Is the child breathing very fast? Y/N

2. Has the child had a ‘fit’ or convulsion? Y/N
3. Does the child look mottled, bluish, or pale? Y/N
4. Does the child have a rash that does not fade when pressed? Y/N
5. Is the child very lethargic or difficult to wake? Y/N
6. Does the child feel abnormally cold to the touch? Y/N
A child under five years old might have sepsis if they:
Are not feeding Y/N
Are vomiting repeatedly Y/N
Have not passed urine for 12 hours Y/N

RISK FACTORS TO SEPSIS

Anyone can get sepsis if they have an infection, but some
people have a higher risk than others, for example, the
immunosuppressed. Those at higher risk for sepsis than
others include:

• Babies, younger than one year old

• People older than 75 years
• People who are ‘frail’
• People with diabetes
• People with weak immune systems
• People who are undergoing chemotherapy and/or
radiotherapy treatment
• Women who have just given birth or recently been pregnant
(including those who have had a miscarriage or abortion)
• People who have recently had a serious illness

Babies are also at greater risk if they were born prematurely

or their mother had an infection whilst pregnant, including a
mild infection.

30
 Recognising Sepsis

OBSERVATION CHARTS
One of the first assessments we can perform when suspect-
ing sepsis is to perform a set of observations and plot the
results on the National Early Warning Score 2 (NEWS2)
observation chart. This chart enables us to assess our
patients and care for them before their condition becomes
critical or, at the very least, any worse. It is important we
understand how to use the NEWS2 chart as gathering the
vital signs recordings as part of this assessment, so here’s a
quick overview.

The NEWS2 observation chart can be seen in Appendix 1

and records six vital signs (or physiological measurements)
in the order of A, B, C, D, and E on the chart:

A and B Relates to the respiration rate (RR)

A and B Also relates to the patient’s oxygen
saturations (SpO2)
C Relates to the systolic blood pressure
C Also relates to the pulse rate (also referred
to as the heart rate)
D Relates to the patient’s consciousness or
any new confusion
E Relates to the patient’s temperature

This observation chart (NEWS2) can be used on:

• All adult in-­patients (and care home residents)

• Occasionally children in adult wards
• Pregnant mothers up to 20 weeks

There are also adapted NEWS2 charts for patients requiring

neurological observations (with the Glasgow Coma Scale
incorporated into the chart). There are also adapted charts
for use in maternity (for pregnant mothers >20 weeks’
gestation, children, babies, and neonates) and for patients
requiring-­end-­of-­life care.
 Chapter 2

The NEWS2 chart is brightly coloured, whereby each vital

sign generates a score of 0–3, depending on which colour
zone the recording is plotted:
White Scores 0
Yellow Scores 1
Orange Scores 2
Red Scores 3

Once all the vital sign scores have been collected and
plotted on the chart and totted up to give a score, we are
directed as to what to do with this information, such as:

• Score of 0–4: Ward-­based response

• Score of 3 in any individual parameter: Urgent ward-­
based response
• Score of 5–6: Urgent response
• Score ≥7: Emergency response

Patients with sepsis often present with a NEWS2 score >5,

which is made up due to a persisting hypotension requiring
vasopressors to maintain a MAP >65 mmHg. After serum
lactate levels have been obtained (via venepuncture or

Vasopressors
A drug or other agent that causes the constriction of
blood vessels.

arterially) with sepsis, these levels are >2 mmol/l (despite

adequate volume resuscitation). We will look at lactate in
detail later in this chapter.
Before we continue with this chapter, we first need to have
an understanding of some of the abbreviations we may use
in relation to sepsis:

32
 Recognising Sepsis

Activity 2.1  

What do these healthcare abbreviations and/or terminology mean?

1 FBC
2 U’s & E’s
3 LFT
4 INR
5 APTT
6 MSU
7 CSU
8 Hb
9 WBC
10 CRP
11 Vasodilation
12 Vasoconstriction
13 AKI
14 CXR

SEPSIS SIX
The sepsis six consists of six recommendations to be
delivered within one hour of the initial diagnoses of sepsis.

TOP TIP
The sepsis six is often remembered by stating ‘three things in and
three things out.’

IN: Administer oxygen.

Administer IV antibiotics.
Administer IV fluids.
 Chapter 2

OUT: Take blood cultures.

Take serum lactate levels and blood tests.
Measure urine output and start fluid balance chart.

Table 2.3 breaks down the whys and wherefores for each of
the sepsis six recommendations.

Table 2.3 The sepsis six recommendations breakdown.

Sepsis six Recommendations

IN: Oxygen Give 100% oxygen (15 l/min via face mask with reservoir bag
unless oxygen restriction necessary (e.g. in chronic CO2
retention – aim for an oxygen saturation of 88%–92%)
IN: IV Use as per own healthcare provider protocol. Prescribed first
antibiotics dose on the front of the prescription chart. Delay in
administration increases mortality.
IN: IV fluids Give a 500–1000 ml bolus of Hartmann’s solution. Larger bolus
may be required, e.g. if systolic blood pressure is <90 mmHg or
lactate >4, consider 1500–2000 ml.
OUT: Blood Take as per Trust guidelines. Culture other sites as clinically
cultures indicated, e.g. sputum, wound swabs, cerebrospinal fluid.
Consider chest X-­ray.
OUT: Lactate Lactate on atrial or venous sample. Also request full blood
and bloods count, ureas and electrolytes, C-­reactive protein, liver function
test, clotting (International Normalised Ratio and activated
partial thromboplastin) and glucose. Consider blood transfusion
if haemoglobin is <7 (or above this with comorbidities).
OUT: Urine Monitor urine output hourly. Consider catheter. Perform
output urinalysis and send off midstream urine/catheter sample of
urine.

DID YOU KNOW?

LACTATE: Normal blood lactate concentration = 0.5–1.3 mmol/l.
Patients with critical illness can be considered to have normal
lactate concentrations <2 mmol/l.

34
 Recognising Sepsis

The next sections will look at lactate and WBCs and their
relation to sepsis. But first we can see from the sepsis six
that a recommendation for ‘bloods’ is to consider a blood
transfusion if haemoglobin (Hb) is >7 by some NHS Trusts.
The next section looks at full blood count (FBC) normal
values.

FULL BLOOD COUNT NORMAL

VALUES
Red blood cells (RBCs) contain a substance called Hb,
which transports oxygen around the body. The amount of
oxygen that is delivered to the body tissues depends on the
number of RBCs we have and how well they work. An RBC
count is usually carried out as part of an FBC count blood
test. The blood is obtained via venepuncture in an EDTA
(ethylene diamine tetra acetic acid) additive tube, with a
sample of blood consisting of approximately 2–4 ml. A
normal RBC count is as follows, with women generally
having a lower RBC than men:

Male adult: 4.7–6.1 million cells per microlitre (cells/μl)

Female adult: 4.2–5.4 million cells per microlitre (cells/μl)

An FBC comprises the following tests:

• Hb
• WBC count
• Platelet count (Plt)
• RBC count
• Haematocrit (HCT)
• Mean cell volume – red cell (MCV)
• Mean cell haemoglobin (MCH)
• WBC count:
• Neutrophils
• Lymphocytes
• Monocytes
• Eosinophils
• Basophils
Another random document with
no related content on Scribd:
 CHAPTER XII.

ORGANS OF REPRODUCTION.

All fishes are dioecious, or of distinct sex. Instances of so-called

hermaphroditism are, with the exception of Serranus, abnormal
individual peculiarities, and have been observed in the Cod-fish,
some Pleuronectidæ, and in the Herring. Either the generative organ
of one side was found to be male, that of the other female; or the
organ of one or both sides was observed to have been developed
partly into an ovary partly into a testicle. In the European species of
Serranus a testicle-like body is attached to the lower part of the
ovary; but many specimens of this genus are undoubtedly males,
having normally developed testicles only.
The majority of fishes are oviparous, comparatively few
viviparous; the embryos being developed either in the ovarium or in
some dilated portion of the oviduct. In viviparous fishes actual
copulation takes place, and the males of most of them are provided
with copulatory or intromittent organs. In oviparous fishes the
generative products are, during sexual excitement, discharged into
the water, a very small quantity of semen being sufficient for effectual
impregnation of a number of ova dispersed in a considerable
quantity of water; circumstances which render artificial impregnation
more practicable than in any other class of animals.
In Branchiostoma the generative organs occupy the ventral side
of the abdominal cavity, into which they discharge their contents. No
ducts are developed in either sex.
In the Cyclostomes the generative organ is single, and fixed to or
suspended from the median line of the back of the visceral cavity by
a duplicature of the peritoneum (mesoarium); the testicle and ovary
being distinguishable by their contents only. These escape by
dehiscence of the cells or capsules and rupture of the peritoneal
covering into the abdominal cavity, and are expelled by reciprocal
pressure of the intertwined sexes through the porus genitalis, which
is sunk between two labia of the skin in Myxine, and produced into a
long papilla in Petromyzon.
 69.—Ovum of Myxine
glutinosa, enlarged.
The ova of the Lampreys are small, globular, like those of
Teleosteans. Those of Myxine have a very peculiar shape when
mature; they are of an oval form, about 15 millimetres long and 8
millimetres broad, enveloped in a horny case, which at each end is
provided with a bundle of short threads, each thread ending in a
triple hook. Whilst in the mesoarial fold the eggs are attached to one
another by means of these hooks, and after being expelled they
probably fix themselves by the same means to other objects. As in
all fishes producing ova of large size, the number of ova matured in
one season is but small.
In Teleosteans the generative organs are comparatively large. In
some families the ovaries are without closed covering and without
oviducts, as in Salmonidæ, Galaxiidæ, Notopteridæ, Murænidæ, and
others. The surface of such an open ovary—as, for instance, that of
the Salmon—is transversely plaited, the ova being developed in
capsules in the stroma of the laminæ; after rupture of the capsules
the mature ova drop into the abdominal cavity, and are expelled by
the porus genitalis. The ovaries of the other Teleosteans are closed
sacs, continued into oviducts. Frequently such ovaries coalesce into
a single body, or one in which the division is effected internally only
by a more or less complete septum. Fixed by a mesoarium, the
ovaries occupy generally a position outwards of the intestine or air-
bladder; their form varies as well as the thickness and firmness of
their covering, which frequently is an extremely thin transparent
membrane. The inner surface of the ovarian sac is transversely or
longitudinally plaited or covered with fringes, on which the ova are
developed, as in the open ovaries. In the viviparous Teleosteans the
embryons are likewise developed within the ovary, notably in the
Embiotocidæ, many Blenniidæ, and Cyprinodontidæ, Sebastes
viviparus, etc. Among the Cyprinodonts the end of the oviduct is
attached to the anterior anal rays, which are modified into supports
of its termination. In Rhodeus the oviduct is periodically prolonged
into a long oviferous tube, by means of which the female deposits
her ova into the shells of living Bivalves.

Fig. 70.—Ditrema argenteum, with fully developed young, ready for expulsion
by the genital orifice, o; a, folds of the ovarian sac; v, vent.

The ova of Teleosteous Fishes are extremely variable in size,

quite independently of the size of the parent species. The ova of
large and small individuals of the same species, of course, do not
differ in size; but, on the whole larger individuals produce a greater
number of ova than smaller ones of the same species. The larger the
size of the ova is in a species, the smaller is the number produced
during one season. The ova of the Eel are almost microscopic. The
small sized roe in the Herring, Lump-fish, Halibut, and Cod-fish, have
been estimated at respectively 25,000, 155,000, 3,500,000, and
9,344,000. Larger in size and fewer in number are those of
Antennarius, Salmo, Aspredo, Lophobranchs, etc. Comparatively
largest are those of Gastrosteus; and the Siluroid genus Arius, the
males of which take care of their progeny, produces ova from 5 to 10
millimeters in diameter. The ova of all Teleosteans are perfectly
globular and soft-shelled. Teleosteans without oviduct, deposit them
separated from one another; whilst in many Teleosteans with an
oviduct the ova are enveloped in a glutinous substance, secreted by
its glands, swelling in the water and forming lumps or cords, in which
the ova are aggregated.

Fig. 71. Ovum of Arius

boakii (Ceylon), showing
embryo. Nat. size.
 Fig. 72.—Abdomen of
Aspredo batrachus, with the ova
attached; at a, the ova are
removed, to show the spongy
structure of the skin, and the
processes filling the interspaces
between the ova. (Natural size.)
Instances of the female taking care of her progeny are extremely
scarce in fishes. At present only two examples are known, that of the
Siluroid genus Aspredo, and of Solenostoma. In the former, during
the time of propagation, the integuments of the lower side of the flat
trunk of the female assume a soft and spongy texture. After having
deposited the eggs, the female attaches them to, and presses them
into, the spongy integument, by merely lying over them. She carries
them on her belly, as the Surinam Toad (Pipa) carries her ova on the
back. When the eggs are hatched the excrescence on the skin
disappears, and the abdomen becomes as smooth as before. In
Solenostoma the inner side of the long and broad ventral fins
coalesces with the integuments of the body, a large pouch being
formed for the reception of the eggs. There is a peculiar provision for
the retention of the eggs in the sac, and probably for the attachment
of the embryo. The inner walls of the sac are lined with long
filaments, arranged in series along the ventral rays, and more
numerous and longer at the base of the rays than in the middle of
their length, behind which they disappear entirely. They are also
more developed in examples in which eggs are deposited in the sac
than in those which have the sac empty. The filaments most
developed have a length of half an inch, and are beset with
mamilliform appendages. A slightly undulated canal runs along the
interior of the filament.

Fig. 73.—Solenostoma cyanopterum ♂ (Indian Ocean).

 Fig. 74.—Pouch with ova, formed by
the ventral fins of Solenostoma. Lower
aspect; the edges of the fins have been
pushed aside to allow of a view of the
inside of the pouch. (Natural size.)
The Testicles of the Teleosteans are always paired, and occupy
the same position as the ovaries. Their size varies extraordinarily at
the different seasons of the year. Vasa deferentia are constant. In
the males of viviparous Teleosteans the urogenital papilla is
frequently enlarged, and clearly serves as an intromittent organ. In
Clinus despicillatus the vas deferens widens within the abdomen into
a cavity occupied by a complex network of loose fasciculi, rising from
the mucous membrane. The cavity can be compressed by a special
powerful muscle, the accumulated semen being thus expelled with
considerable force through the narrow aperture of the penis. In many
Cyprinodonts the vas deferens runs along the anterior anal rays,
which may be thickened, and prolonged into a long slender organ.
Many Teleostei take care of their progeny, but with the exception
of Aspredo and Solenostoma, mentioned above (p. 160), it is the
male on which this duty devolves. In some, as in Cottus,
Gastrosteus, Cyclopterus, Antennarius, Ophiocephalus, Callichthys,
the male constructs with more or less skill a nest, and jealously
guards the ova deposited in it by the female. The male of some
species of Arius carries the ova (Fig. 71) about with him in his
capacious pharynx. The species of Chromis, inhabiting the sea of
Galilee, are said to take care of their ova in the same manner. And,
finally, in the Lophobranchs, nature has aided this instinct by the
development of a pouch on the abdomen or lower side of the tail. In
the Syngnathidæ this pouch is formed by a fold of the skin
developed from each side of the trunk and tail, the free margins of
the fold being firmly united in the median line, whilst the eggs are
being hatched in the inside of the pouch. In Hippocampus the pouch
is completely closed, with a narrow anterior opening.

Fig. 75.—Syngnathus acus ♂, with sub-caudal pouch.

 Fig. 76.—Sub-caudal pouch of
Syngnathus acus, with the young, ready
to leave the pouch. One side of the
membrane of the pouch is pushed aside
to admit of a view of its interior. (Natural
size.)
The genital organs of Ganoids show similar diversity of structure
as those of Teleosteans, but on the whole they approach the
Batrachian type. The ovaries are not closed, except in Lepidosiren;
all Ganoids possess oviducts. In the Sturgeons the oviduct as well
as the vas deferens is represented by a funnel-shaped prolongation
of the peritoneum, which communicates with the wide ureter. The
inner aperture of the funnel is on a level of the middle of the testicle
or ovary, the outer within the ureter; and it is a noteworthy fact that
only at certain periods of the life of the fish this outer aperture is
found to be open,—at other times the peritoneal funnel appears as a
closed blind sac within the ureter. The mode of passage of the
semen into the funnel is not known.
In Polypterus and Amia, proper oviducts, with abdominal
apertures in about the middle of the abdominal cavity, are
developed; they coalesce with the ureters close to the common
urogenital aperture.
In Ceratodus (Fig. 77), a long convoluted oviduct extends to the
foremost limit of the abdominal cavity, where it opens by a slit at a
considerable distance from the front end of the long ovary; this
aperture is closed in sexually immature specimens. The oviducts
unite close to their common opening in the cloaca. During their
passage through the oviduct the ova receive a gelatinous covering
secreted by its mucous membrane. This is probably also the case in
Lepidosiren, which possesses a convoluted oviduct with secretory
glands in the middle of its length. The oviduct begins with a funnel-
shaped dilatation, and terminates in a wide pouch, which posteriorly
communicates with that of the other side, both opening by a common
aperture behind the urinary bladder.
The ova of Ganoids, as far as they are known at present, are
small, but enveloped in a gelatinous substance. In the Sturgeon
have been counted as many as 7,635,200. Those of Lepidosteus
seem to be the largest, measuring 5 millimetres in diameter with their
envelope, and 3 millimetres without it. They are deposited singly, like
those of Newts.
 Fig. 77.—Ovaries of Ceratodus.
a, Right ovary shown from the inner
surface, which is covered by the
peritoneum; a’, Left ovary, showing
its outer surface; l, Portion of liver;
o, Oviduct; p, the lower part of the
oviduct is opened to show the folds
of its inner membrane; q, Opening
of the left oviduct into the right; r,
Abdominal orifice of the oviduct.
 In Chondropterygians (and Holocephali) the organs of
reproduction assume a more compact form, and are more free from
a lengthened attachment to the back of the abdominal cavity. The
ovaries of the majority are paired, single in the Carchariidæ and
Scylliidæ, one remaining undeveloped. But the oviducts are always
paired, beginning immediately behind the diaphragma with a
common aperture. They consist of two divisions, separated by a
circular valve; the upper is narrow, and provided within its coats with
a gland which secretes the leathery envelope in which most of the
Chondropterygian ova are enclosed; the lower forms the uterine
dilatation, in which the embryoes of the viviparous species are
developed. Generally the vitelline sac of the embryoes is free, and
without connection with the uterus, which in these cases has merely
the function of a protecting pouch; but in Carcharias and Mustelus
lævis a placenta uterina is formed, the vascular walls of the vitelline
sac forming plaits fitting into those of the membrane of the uterus.
The ends of the uteri open by a common aperture behind the ureter
into the cloaca.
 Fig. 78.—Ventral fins and claspers of Chiloscyllium trispeculare.
The testicles are always paired, rounded, and situated in the
anterior part of the abdominal cavity, covered by the liver. Vasa
efferentia pass the semen into a much-convoluted epididymis, which
is continued into the vas deferens; this, at the commencement of its
course, is spirally wound, but becomes straight behind, and has its
end dilated into a seminal reservoir. It opens with the urethra in a
papilla within the cloaca.
The so-called claspers of Chondropterygians (Fig. 78) are
characteristic of all male individuals. They are semi-ossified
appendages of the pubic, with which they are movably joined, and
special muscles serve to regulate their movements. Sometimes they
are armed with hook-like osseous excrescences (Selache). They are
irregularly longitudinally convoluted, and, when closely ad-pressed to
each other, form a canal open at their extremity. A gland, abundantly
discharging a secretion during the season of propagation, is situated
at, and opens into, the base of the canal. It is still doubtful whether
the generally-adopted opinion that their function consists in holding
the female during copulation is correct, or whether they are not
rather an intromittent organ, the canal of which not only conducts the
secretion of their proper gland but also the impregnating fluid.

Fig. 79.—Egg of a Scyllium

from Magelhan’s Straits (? Sc.
chilense). Natural size.
 Fig. 80.—Egg-shell of Cestracion
philippi, half natural size, linear.
I. External view. II. Vertical section.
a, One spiral ridge; b, The other
spiral ridge; c, Cavity for the ovum.

The ova of the oviparous Chondropterygians are large and few in

number; they are successively impregnated, and the impregnation
must take place before they are invested with a tough leathery
envelope which would be impenetrable to the semen, that is, before
they enter the uterus; therefore, copulation must take place in all
these fishes. The form of the egg-shell differs in the various genera;
generally (Fig. 79) they are flattened, quadrangular, with each of the
four corners produced, and frequently prolonged into long filaments
which serve for the attachment of the ova to other fixed objects. In
Notidanus the surfaces are crossed by numerous ridges. In
Cestracion (Fig. 80) the egg is pyriform, with two broad ridges or
plates, wound edgewise round it, the two ridges forming five spires.
The eggs of Callorhynchus (Fig. 81) have received a protective
resemblance to a broad-leaved fucus, forming a long depressed
ellipse, with a plicated and fringed margin.
 Fig. 81.—Egg of
Callorhynchus antarcticus. a,
Cavity for the embryo.
 CHAPTER XIII.

GROWTH AND VARIATION OF FISHES.

Changes of form normally accompanying growth (after absorption

of the vitelline sac) are observed in all fishes; but in the majority they
affect only the proportional size of the various parts of the body. In
young fishes the eyes are constantly larger than in adult relatively to
the size of the head; and again, the head is larger relatively to that of
the body. Changes amounting to metamorphosis have been hitherto
observed in Petromyzon only. In the larval condition (Ammocætes)
the head is very small, and the toothless buccal cavity is surrounded
by a semicircular upper lip. The eyes are extremely small, hidden in
a shallow groove; and the vertical fins form a continuous fringe. In
the course of three or four years the teeth are developed, and the
mouth changes into a perfect suctorial organ; the eyes grow; and the
dorsal fin is divided into two divisions. In Malacopterygians and
Anacanths the embryonal fringe from which the vertical fins are
developed, is much longer persistent than in Acanthopterygians. A
metamorphosis relating to the respiratory organs, as in Batrachians,
is indicated in the class of Fishes by the external gills with which
fœtal Plagiostomes (Fig. 58, p. 136) and the young of some
Ganoids, viz. the Protopterus and Polypterus, are provided.
 Fig. 82.—Mouth of Larva of Petromyzon
branchialis.

Fig. 83.—Mouth of Petromyzon fluviatilis.

mx, Maxillary tooth; md, Mandibulary tooth; l,
Lingual tooth; s, Suctorial teeth.
Fig. 84.—Armature of præoperculum of young Caranx
ferdau. (Magnified.)
I. Of an individual, 1¼ inch long. II. Of an individual, 2
inches long.

Fig. 85.—Tholichthys osseus. Six times the

natural size.