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By J. Tizgar. Western Oregon University.

Plug formation discount detrol 4mg fast delivery, in essence detrol 2mg sale, buys the body time while more sophisticated and durable repairs are being made. In a similar manner, even modern naval warships still carry an assortment of wooden plugs to temporarily repair small breaches in their hulls until permanent repairs can be made. Coagulation Those more sophisticated and more durable repairs are collectively called coagulation, the formation of a blood clot. The process is sometimes characterized as a cascade, because one event prompts the next as in a multi-level waterfall. The result is the production of a gelatinous but robust clot made up of a mesh of fibrin—an insoluble filamentous protein derived from fibrinogen, the plasma protein introduced earlier—in which platelets and blood cells are trapped. The process is complex, but is initiated along two basic pathways: • The extrinsic pathway, which normally is triggered by trauma. All three pathways are 2+ dependent upon the 12 known clotting factors, including Ca and vitamin K (Table 18. Vitamin K (along with biotin and folate) is somewhat unusual among vitamins in that it is not only consumed in the diet but is also synthesized by bacteria residing in the large intestine. Some recent evidence indicates that activation of various clotting factors occurs on specific receptor sites on the surfaces of platelets. Extrinsic Pathway The quicker responding and more direct extrinsic pathway (also known as the tissue factor pathway) begins when damage occurs to the surrounding tissues, such as in a traumatic injury. This enzyme complex leads to activation of factor X (Stuart–Prower factor), which activates the common pathway discussed below. Intrinsic Pathway The intrinsic pathway (also known as the contact activation pathway) is longer and more complex. Common Pathway Both the intrinsic and extrinsic pathways lead to the common pathway, in which fibrin is produced to seal off the vessel. As these proteins contract, they pull on the fibrin threads, bringing the edges of the clot more tightly together, somewhat as we do when tightening loose shoelaces (see Figure 18. This process also wrings out of the clot a small amount of fluid called serum, which is blood plasma without its clotting factors. During this process, the inactive protein plasminogen is converted into the active plasmin, which gradually breaks down the fibrin of the clot. Additionally, bradykinin, a vasodilator, is released, reversing the effects of the serotonin and prostaglandins from the platelets. This allows the smooth muscle in the walls of the vessels to relax and helps to restore the circulation. Several circulating plasma anticoagulants play a role in limiting the coagulation process to the region of injury and restoring a normal, clot-free condition of blood. For instance, a cluster of proteins collectively referred to as the protein C system inactivates clotting factors involved in the intrinsic pathway. And as noted earlier, basophils release heparin, a short-acting anticoagulant that also opposes prothrombin. A pharmaceutical form of heparin is often administered therapeutically, for example, in surgical patients at risk for blood clots. The coagulation cascade restores hemostasis by activating coagulation factors in the presence of an injury. How does the endothelium of the blood vessel walls prevent the blood from coagulating as it flows through the blood vessels? Disorders of Clotting Either an insufficient or an excessive production of platelets can lead to severe disease or death. As discussed earlier, an insufficient number of platelets, called thrombocytopenia, typically results in the inability of blood to form clots. Another reason for failure of the blood to clot is the inadequate production of functional amounts of one or more clotting factors. This is the case in the genetic disorder hemophilia, which is actually a group of related disorders, the most common of which is hemophilia A, accounting for approximately 80 percent of cases.

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Menstrual Cycle This means the cycle of changes that regularly take place in the lining of the uterus (endometrium) under the influence of hormones with the outward sign of menstruation or monthly period of females purchase detrol 4 mg mastercard. When no fertilised ovum arrives in the uterus generic detrol 2 mg fast delivery, the endometrium breaks down and results in the menstrual flow. After menstruation, there is a period of repair for the endometrium, followed by a resting period and slow growth. During the middle of this resting period a new ovum is discharged from the ovary (ovulation) The menstrual cycle contains the following phases. Menstruation 5 days Period of repair 6 days Resting period with ovulation 10 days Total 28 days Ovulation usually takes place midway between the beginning of two menstrual periods. Hormones and the reproductive system Hormones are most important in the working of the reproductive organs. At puberty, hormones from the anterior pituitary gland stimulates the sex glands (ovary in the female, testes in the male) to produce their sex hormones. In the female, oestrogen, promotes development of the female sex organs and tissue growth for the development of feminine features. The knowledge of basic principles of psychology is significant in taking care of nurse herself and also in her interaction with the patient. The nurses should understand that the fulfillment of basic needs as given below is imperative in achieving one’s own self actualization. Our attitude & emotional expressions are also learned behavior Learning is defined as the mental activity by means of which knowledge, skill, attitude, apprecia­ tions and ideas are acquired, resulting in modifications of behaviors Factors influencing learning: ­ It is depends upon the following factors 1) Nature of the learner 2) Nature of the learning material 3) Nature of the learning situations Nature of the learner:­ Perception ­ Sense organs are the gateways to acquire knowledge. Process of perception should be perfect Organic defects ­ Visual defects, hearing impairment and infections Fatigue ­ Strain, loneliness, lack of fresh air, sunlight and compulsive learning causes fatigue. It depends only with learner’s will power Age & learning ­ The capacity of learning improves up to 23 years & declines after 40 years Nature of learning:­ Meaningful learning easier than learning with out knowing the meaning of the learning method 74 1) Definite goal: ­ With a clear goal in mind the student works towards a definite purpose. Regular and frequent review of the amount of progress being made towards the goal promotes effective leaning 3) Distribution of practice board: ­ Shorter practice period are more effective than longer periods this will reduces the mental fatigue 4) Whole versus part method: ­ Whole method should be adopted with easy unit and difficult material can be learned in small units 5) Logical learning: ­ Logical learning calls for an arrangement and also assimilation with ideas in minds. Students should try to grasp the meaning of text 6) Rest:­ Take rest in between studies prevents mental fatigue 7) Levels of anxiety: ­ Avoids undue worry, anxiety & nervousness to promote better learning. Otherwise it will have an inhibiting and interfering effect 8) Over learning/repetitions at regular intervals helps to retain the material over a longer period of time Theories of learning 1) Trail and error 2) Theory of conditioned reflexes A) Classical conditioning B) Operant conditioning 3) Cognitive learning A) Insight learning B) Sign learning Trial and error: ­ Edward Lee Thorndike American Psychologist considered as the father of educa­ tional, psychology conducted series of experiments on trial and error method of learning by animals and found out that all learning is trial & error and he has developed certain laws of learning. They are · Law of effect:­ The response followed by a reward will be strengthened · Law of Exercise:­ There is a direct relationship between repetition and the strength of the stimulus response. Any task that is repeated shows a tendency for the strengthening of the bond Eg: Reading, writing, typing, singing, dancing, drawing learned by constant practice · Law of readiness: Learning takes place best when a person is ready to learn Theory of conditioned reflexes Classical conditioning:­ Ivan Pavlov a Russian physiologist, a researcher experimented on a dog. Later Pavlov observed that the dog salivated at the mere sound of the bell without giving meat powder. Principles of classical conditioning used in the following areas for learning 75 1) Developing good habits 2) Breaking of bad habits and elimination of fear 3) Training of animals 4) Use in psychotherapy 5) Useful in developing favorable attitude Operant conditioning:­ Skinner experimented on a rat which was placed inside a glass box containing a lever and food tray. Pressing the lever was the response to be learned (the operant response) and the food was the stimulus consequences (reinforcement). Thus the rate of presses increased with rewarding of the rat with food Cognitive learning Learning by insight: ­Gestalt psychologist concluded that the individual learns by his ability known as insight & not by trial & error method. Mean while one end of one stick got incidentally fastened in to the ring fixed on the end of the other stick, with the result that both the sticks were joined together. It takes place by cognition which includes concepts like knowledge, thinking, planning, inference and purpose. Learning consists in the recognition of signs and their meanings in relation to goals in sign learning, a comparison was made between two group of hungry rats in a maze. In one group, each subject received food each time it ran the maze and steady improvement was noticed. In the other, each subject was given access to the maze without finding a food reward and little improvement occurred in time or error scores. However, when food was introduced at the tenth trial, performance soon approximated that of the group which had been rewarded continually.

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Erythromycin is the only antibiotic ointment recommended Recommended Regimen for Children Who Weigh >45 kg and for use in neonates buy cheap detrol 1 mg on-line. Obtaining a medical history alone has been shown to be Te presence of objective signs of vulvar infammation in the insufcient for accurate diagnosis of vaginitis and can lead to absence of vaginal pathogens after laboratory testing detrol 1 mg with mastercard, along the inappropriate administration of medication. Terefore, with a minimal amount of discharge, suggests the possibil- a careful history, examination, and laboratory testing to ity of mechanical, chemical, allergic, or other noninfectious determine the etiology of vaginal complaints are warranted. Information on sexual behaviors and practices, gender of sex partners, menses, vaginal hygiene practices (such as douch- Bacterial Vaginosis ing), and other medications should be elicited. Cervicitis also can sometimes cause a vaginal microbial changes, whereas others experience them vaginal discharge. Clinical labora- partners, a new sex partner, douching, lack of condom use, tory testing can identify the cause of vaginitis in most women and lack of vaginal lactobacilli; women who have never been and is discussed in detail in the sections of this report dedi- sexually active can also be afected. Douching might increase the risk for three of the following symptoms or signs: relapse, and no data support the use of douching for treatment • homogeneous, thin, white discharge that smoothly coats or relief of symptoms. Additional for the detection of elevated pH and trimethylamine, it has low regimens include metronidazole (750-mg extended release sensitivity and specifcity and therefore is not recommended. However, efcacy of using intravaginal lactobacillus formulations to treat additional evaluations are needed to confrm these associations. Monthly oral metronidazole administered with fuconazole has also been Providers should consider patient preference, possible evaluated as suppressive therapy (337). Intravaginal clindamycin cream is preferred in case of allergy Similarly, data are inconsistent regarding whether the or intolerance to metronidazole or tinidazole. Several Treatment is recommended for all pregnant women with additional trials have shown that intravaginal clindamycin symptoms. Some women have symptoms between metronidazole use during pregnancy and teratogenic characterized by a difuse, malodorous, yellow-green vaginal or mutagenic efects in newborns (342,343). However, many women have the antimicrobial agent used to treat pregnant women, oral minimal or no symptoms. Because of the high prevalence therapy is preferred because of the possibility of subclinical of trichomoniasis in clinical and nonclinical settings upper-genital–tract infection. Each of these tests, which are performed on vaginal secretions, Alternative Regimen have a sensitivity of >83% and a specifcity of >97%. Both Metronidazole 500 mg orally twice a day for 7 days* tests are considered point-of-care diagnostics. Although these tests tend to be more sensitive than those requiring vaginal wet preparation, false positives might occur, especially in populations with a Te nitroimidazoles comprise the only class of drugs use- low prevalence of disease. Of Culture is another sensitive and highly specifc commer- these drugs, metronidazole and tinidazole are available in the cially available method of diagnosis. While the metronidazole regimens have resulted in cure rates of approxi- sensitivity of a Pap test for T. Because of the high rate of reinfection among patients in In men, wet preparation is not a sensitive test, and no whom trichomoniasis was diagnosed (17% were reinfected approved point-of-care tests are available. Although some trials suggest the possibility of been identifed in 2%–5% of cases of vaginal trichomoniasis increased prematurity or low birth weight after metronidazole (362,363), but high-level resistance only rarely occurs. For not only be considered for treatment regardless of pregnancy patients failing this regimen, treatment with tinidazole or stage, but be provided careful counseling regarding condom metronidazole at 2 g orally for 5 days should be considered. In lactating women who are administered metronidazole, Management of Sex Partners withholding breastfeeding during treatment and for 12–24 Sex partners of patients with T. Treatment with azoles results in relief of symptoms and negative cultures in 80%–90% of patients who complete therapy. For women with negative wet mounts who are symptomatic, vaginal cultures for Candida should be considered. If the wet mount is negative and Candida cultures Te creams and suppositories in this regimen are oil-based cannot be done, empiric treatment can be considered for and might weaken latex condoms and diaphragms. However, to maintain clinical and mycologic control, some vulvovaginitis etiologies, which can result in adverse clinical specialists recommend a longer duration of initial therapy outcomes. Oral agents occasionally edema, excoriation, and fssure formation) is associated with cause nausea, abdominal pain, and headache.

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It is • Monitoring equipment Transducers and a moni- now accepted that all patients recovering from tor capable of displaying two or three pressure anaesthesia should be nursed in an area with ap- waveforms buy cheap detrol 2mg on-line, end-tidal carbon dioxide monitor and propriate facilities to deal with any of the problems thermometer cheap 2 mg detrol with mastercard. Patients who have undergone pro- longed surgery, or where a prolonged stay is The anaesthetist’s responsibility to the patient expected, may be recovered on their beds to does not end with termination of the anaesthetic. Each patient Although care is handed over to the recovery staff should be cared for in a dedicated area equipped (nurse or equivalent), the ultimate responsibility with: remains with the anaesthetist until discharge from • oxygen supply plus appropriate circuits for the recovery area. If there are inadequate numbers administration; of recovery staff to care for a newly admitted pa- • suction; tient, the anaesthetist should adopt this role. In addition the following must be available imme- diately: • Airway equipment Oral and nasal airways, a The length of time any patient spends in recovery range of endotracheal tubes, laryngoscopes, a will depend upon a variety of factors, including bronchoscope and the instruments to perform length and type of surgery, anaesthetic technique a cricothyroidotomy and tracheostomy. Most • Breathing and ventilation equipment Self-inflating units have a policy determining the minimum bag-valve-masks, a mechanical ventilator and a length of stay, which is usually around 30mins, chest drain set. Hypoventilation is always • Adequate breathing accompanied by hypercapnia, as there is an in- • Stable cardiovascular system, with minimal bleeding verse relationship between arterial carbon dioxide from the surgical site (PacO2) and alveolar ventilation. Common causes • Adequate pain relief of hypoventilation include: •W arm • Obstruction of the airway Most often due to the tongue. Partial obstruction causes noisy breathing; in complete obstruction there is Complications and their little noise despite vigorous efforts. It is pre- vented by recovering patients in the lateral posi- Hypoxaemia tion, particularly those recovering from surgery This is the most important respiratory complica- where there is a risk of bleeding into the airway tion after anaesthesia and surgery. An oropharyngeal or nasopharyn- advent of pulse oximetry has had a major impact geal airway may be required to help maintain the on the prevention of hypoxaemia and should be airway (see page 18). If hypoxaemia is se- vere, persistent or when there is any doubt, arterial blood gas analysis should be performed. Hypox- No patient should be handed to the care of the recovery aemia can be caused by a number of factors, either nurse with noisy respiration of unknown cause. If severe, the Alveolar hypoventilation administration of the specific antagonist naloxone This is the commonest cause of hypoxaemia and may be required (see page 39). Eventually a point is reached where there is commonly, a deeply unconscious patient unable only ventilation of ‘dead space’, that is, the volume to maintain a patent airway. Provide adequate analgesia (con- lungs will be dependent on the relative propor- sider central neural block). The patient should be oxygen content more than increasing the oxygen con- given oxygen, reassured, sat upright to improve centration in areas of V/Q > 1 increases content. Eventually, areas of atelectasis develop, and the recovery period, this process is disturbed mainly in dependent areas of the lung that are (ventilation/perfusion (V/Q) mismatch). Only a small circumstances: additional volume of oxygen is taken up as the • smokers; haemoglobin is already almost fully saturated • obesity; (98%). The net result is: corrected by increasing the inspired oxygen con- • Blood perfusing alveoli ventilated with air has an centration. However, because of the dispropor- oxygen content of approximately 20mL/100mL of tionate effect of areas V/Q < 1, once more than 30% blood. The oxygen content of the Management of hypoxaemia pulmonary blood flow through areas ventilated with 100% oxygen will only increase by 1mL/100 All patients should be given oxygen in the imme- mL of blood (21mL/100mL of blood, Table 3. As it is very insoluble Patients who continue to hypoventilate, have per- in blood, it rapidly diffuses down a concentration sistent V/Q mismatch, are obese, anaemic or have gradient into the alveoli, where it reduces the par- ischaemic heart disease, will require additional tial pressure of oxygen in the alveoli, making the oxygen for an extended period of time. This can be treated by giving determined either by arterial blood gas analysis or oxygen via a facemask to increase the inspired oxy- by using a pulse oximeter. Devices used for delivery of oxygen Pulmonary diffusion defects Any chronic condition causing thickening of the Variable-performance devices: masks or alveolar membrane, for example fibrosing alveoli- nasal cannulae tis, impairs transfer of oxygen into the blood. In the recovery period it may occur secondary to the These are adequate for the majority of patients re- development of pulmonary oedema following covering from anaesthesia and surgery. The precise fluid overload or impaired left ventricular func- concentration of oxygen inspired by the patient is tion. It should be treated by first administering unknown as it is dependent upon the patient’s oxygen to increase the partial pressure of oxygen in respiratory pattern and the flow of oxygen used the alveoli and then by management of any under- (usually 2–12L/min). There • air entrained during peak inspiratory flow from are no circumstances where it is appropriate to ad- the holes in the side of the mask and from leaks minister less than 21% oxygen. As a guide, they increase the in- precise concentration of oxygen, unaffected by the spired oxygen concentration to 25–60% with oxy- patient’s ventilatory pattern. Oxygen is fed into a Venturi that en- nose breathe may find either a single foam-tipped trains a much greater but constant flow of air. Lower flows of oxygen are used, 2–4L/min meets the patient’s peak inspiratory flow, reducing increasing the inspired oxygen concentration to entrainment of air, and flushes expiratory gas, re- 25–40%.

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Accurate assessment of the true incidence of shaken baby syndrome presents an exceedingly difficult challenge order 1 mg detrol with amex. Some infants may not be brought to medical attention at the time of injury but later manifest unexplained developmental delays detrol 4 mg, neurological impairments, and learning difficulties (American Academy of Pediatrics, 2001; Duhaime et al. Consequently, experts suspect that documented cases of shaken baby syndrome represent a mere fraction of the total number of shaken infants per year. It is estimated that one of every 2,600 infants will be violently shaken before reaching one year of age (Lithco, 2004). In a prospective, population-based study of the incidence of shaken baby syndrome, Barlow found a rate of 24. Thirteen to 30% of shaken infants succumb to fatal injuries (American Academy of Ophthalmology, 2002; American 10 11 Academy of Pediatrics, 2001; Dias et al. Half of the remaining infants experience blindness and various global neurological impairments, including seizures, spasticity, paralysis, and developmental delays (A. Shaken baby syndrome is an ominous form of child abuse with devastatingly high rates of morbidity and mortality. Any physician suspecting an infant has been abused is legally obligated to report the case to state or province-specific child welfare agencies. Efforts to educate health care providers about the characteristic features of shaken baby syndrome will serve to increase the detection and reporting of new cases, and hopefully increase the conviction rate of identified perpetrators. Caffey first described the combination of subdural hemorrhages, retinal hemorrhages and long bone fractures in infants without external signs of injury; he named the phenomenon ‘whiplash shaken baby syndrome’ (Caffey, 1972). In his landmark article in 1972, he called for the implementation of a nation-wide prevention campaign. Unfortunately, clinical 11 12 and research efforts remained focused on intervention rather than prevention for several reasons. First, the perceived importance of educating the public about shaken baby syndrome differed among professionals. Some felt it was common knowledge that shaking an infant was dangerous, while others routinely gave advice to shake apneic infants. Second, it was believed that the impulsive act of infant shaking was not amenable to primary prevention through public education. Third, the risk factors associated with shaken baby syndrome were unclear, eliminating the possibility of targeted secondary prevention initiatives (Barron, 2003). Prevention-based research finally began in the United States in the mid 1980’s and has been steadily gaining momentum world-wide. After a 1989 survey by Showers demonstrated that 25 to 50% of adults and adolescents were unaware of the dangers of violent infant shaking, prevention efforts in the form of media campaigns, public education initiatives, male-targeted parenting classes, baby-sitting training courses, and hospital-based programs began to appear. Unfortunately, the impact these programs had on the incidence of shaken baby syndrome remained unknown because the programs were sporadic, fragmented, and unevaluated. In the long term, the total cost of comprehensive medical 12 13 care for a single shaken infant can exceed $1 million (Showers, 1998). These figures do not even begin to capture the hidden costs of shaken baby syndrome, when one considers each victim’s loss of societal productivity and occupational revenue, the cost of prosecuting and incarcerating perpetrators, the cost of foster care and child welfare agency involvement, and the on-going mental, physical, and educational therapy that each victim requires (Dias & Barthauer, 2001, August). Financial costs aside, shaken baby syndrome has devastating effects on the personal lives and emotional health of victims and affected families. Clearly, the hidden costs of treating victims of shaken baby syndrome far exceed the costs of implementing a prevention program. Health professionals, administrators, law enforcement officers, politicians, and affected families have taken a proactive stance in disseminating information about shaken baby syndrome. The conferences provide a unique opportunity for professionals from fields including medicine, 13 14 nursing, law, policing, social work, and psychology to share new research findings, discuss prevention strategies, and educate each other about shaken baby syndrome. On a local level, many shaken baby syndrome prevention initiatives are in operation across North America. The program has been implemented in multiple prisons in the United States, Canada, and Australia; however, its quantifiable effectiveness in reducing the incidence of shaken baby syndrome has never been examined (Dutson, Dulfano, & Nink, 2003). In Wisconsin, the Shaken Baby Association began educating Milwaukee police officers about shaken baby syndrome in 2001.

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