By S. Nemrok. William Mitchell College of Law.

The volume of amniotic fluid steadily increases throughout pregnancy until about 36 weeks purchase lopid 300 mg visa, after which it slowly decreases generic 300mg lopid with visa. Hormones and waste produced by the foetus are also present as these are excreted in the urine of the foetus purchase 300mg lopid mastercard. It is attached to the edges of the placenta and otherwise is pushed against, but not attached to, the inside of the uterus. The procedure is usually performed through the vagina and cervix with a pair of toothed forceps that are used to grasp and tear the membrane. Antenatal care involves regular visits to a doctor or nurse from the third month of pregnancy onwards. During these visits appropriate blood and ultrasound tests will be ordered when necessary, and the mother’s urine will be tested. Other checks on the mother and baby’s health will also be performed depending on the stage of pregnancy, and may include weight, blood pressure, checking for swollen ankles and feet, checking the size of the uterus, listening for the baby’s heart beat, checking the baby’s position and feeling the baby’s movements. The score is derived by giving a value of 0, 1 or 2 to each of five variables - heart rate, breathing, muscle tone, reflexes and colour. By the age of 18 months a girl is usually half her adult height, and a boy is by the age of two years. Many children grow quickly and then stop early so that they are short, whereas others seem to grow at a slower pace but continue until they outstrip everyone else. The most significant factor in determining height is heredity - the children of tall parents will usually also be tall. Nutrition is also significant, and a child who is poorly nourished is likely to be shorter than one who is well nourished. Advances in nutrition are the main reason for an overall increase in the height of populations of the developed world. At about four months, the baby will usually be able to sit up with support, and at the age of seven months should be able to sit alone. They can probably put one leg after the other if they are led at about 11 months, and pull themselves up on the furniture by one year. At about 14 months a baby can usually stand alone, and the major milestone of walking will probably occur around 15 months. Physical development does not equate with mental development, and parents should not be concerned if their child takes its time about reaching the various stages - Einstein was so slow in learning to talk that his parents feared he was retarded. Most newborn babies sleep most of the time - although there are wide variations and some babies seem to stay awake most of the day and night, to the distress of their parents. Gradually solids become an integral part of the diet, and by six months the amount of milk can usually be reduced in proportion to solids in each meal. If the baby is not breast fed, infant formula is recommended for most of the first year, although many babies cope with ordinary cow’s milk from six months. By the time a baby is a toddler, they should be eating much the same meals as the rest of the family, assuming these are nutritious and well balanced. Some parents become excessively anxious because their child seems to be a fussy eater, and they worry that the child will not receive adequate nutrition. This is usually because meals have become a battleground with a parent insisting on every last scrap being consumed. If you allow your child some individual choice in what and how much they eat, it is unlikely that problems will arise. If a child goes off a particular food for a period, respect their wish - it will usually be short- lived. No-one would suggest that children ought to be thin and that a little extra fat does not provide the necessary fuel for a growing and energetic youngster, but increasingly it is being realised that fat children grow into overweight adults. They are often fitted with comfortable beds, pleasant surroundings, music and facilities for the father and other supporters. Ideally they should be attached to, or close to, a more sophisticated maternity hospital so that if necessary appropriate assistance is rapidly available for both mother and child. A specially designed chair is used for the purpose with a U shaped seat open to the front, supportive arms, and a back that slopes backwards. The actual structure, degree of padding and comfort depends on the individual design and expectations of the mother and midwife. The range of weights for the average Caucasian baby in developed nations is shown on the following graph. The blastocyst travels down the Fallopian tube to the uterus where it implants in the wall, seven days after fertilisation. If the mixture is made stronger than the manufacturer recommends, the baby will get too much fat, protein, minerals and salt, and not enough water. Milk, especially when at room temperature, is an ideal breeding ground for bacteria, and it is therefore essential that formula is prepared in a sterile environment. If these precautions are not followed, the baby may develop gastroenteritis and require hospitalisation. Carers will generally be advised by the hospital or baby health clinic how much to offer the baby (calculated according to weight), but just as breastfed babies have different needs that can vary from feed to feed, so too do bottle-fed babies. But within reason, babies can generally be relied upon to assess their own needs quite satisfactorily. Just as with breastfed babies, it is generally considered best to feed a baby as and when they are hungry. Frequent breaks from the bottle during a feed in order to let a burp come up and the milk go down can also smooth the progress of the feed and avoid stomach discomfort afterwards. The woman feels a tightening of the uterus that may last from a few seconds to a couple of minutes, but there is usually no pain associated with the phenomenon, although the more intense Braxton Hicks contractions may be difficult to differentiate from the onset of labour late in pregnancy. Some women have breasts that are higher or lower on the chest, but when kneeling on all fours so the breast is hanging down, the nipple is usually over the fourth to sixth rib on each side. The size, shape and position of the breast is determined genetically, so women are likely to have a similar shaped and sized breasts to that of their mother and both maternal and paternal grandmothers. The primary function of breasts is to produce milk to feed babies, but they also have a very important role to play as secondary sexual characteristics and thereby to attract a suitable male partner.

Besides cheap 300mg lopid otc, the medical and surgical treatment various factors like regular exercise buy lopid 300mg low price, staying happy purchase lopid 300 mg on-line, meeting groups, yoga etc. Early diagnosis, appropriate treatment under the guidance of an expert physician or a neurophysician, group therapy, exercise, yoga and if necessary surgery can control this disease to a large extent. In the cities like Ahmedabad and Mumbai, there are associations of patients suffering from Parkinsonism, which give relevant information regarding the disease, teach exercises and yoga in groups and provide other services to the patients. Actually in dementia a patient’s memory, thinking ability, communication skills (to understand language and make others understand) and behavior are affected. In addition to that, Lewy bodies disease, Creutzfeldt Jakob disease, Huntington’s disease, Sub cortical Leucoencephalopathy, A. Amongst the other causes of dementia are diseases of thyroid, parathyroid, diabetes, effect of toxic chemicals, and heavy metals etc. Symptoms of Alzheimer’s Dementia : In the initial stage of the disease the following symptoms are seen. Medically this disease can be divided into three stages and in the final stage the patient becomes completely dependent. It is a well known fact that many famous people like former American President Ronald Reagan, Rita Heyworth, Sugar Ray Robinson, E B White and others have suffered from this disease. However, extensive research is being carried out to design drugs to decrease the intensity of the symptoms. The patient and his relatives should have proper information and education regarding the disease in order to cope with day-to-day problems and difficulties. Diagnosis : l Along with the earlier mentioned symptoms, various cognitive tests for testing the patient’s memory, understanding, linguistic co-ordination can confirm the diagnosis of dementia. Mini mental status examination, word list memory test, work recall test and various neuropsychological measures are used to diagnose the disease and its intensity. For example if the patient has E-4 Apolipoprotein gene on the 19th chromosome, there are high chances of his offsprings suffering from Alzheimer’s disease. The formation of neurofibrillary tangles in the neurons of the brain and accumulation of plaques of a protein called Beta- amyloides outside the cells, causing damage and edema in the fragile brain cells, is the pathological hallmark of Alzheimer’s disease. Amongst newer medicines there are Rivastigmin (Exelon) and Galantamine (Reminyl) with even better results. In our country, cost is a problem and therefore Piracetam (Normabrain; Nootropil) or Ergot group of medicines are more popular to these costly newer drugs. Multi-infarct Dementia : When a decrease in the supply of blood to various small portions of the brain damages the ce;;s in those areas then Multi-infarct Dementia results. A rise in the blood pressure damages small capillaries and small clots are formed in these capillaries, which results in lowering of the blood supply in certain parts of the brain. The lipid profile, Doppler of the blood vessels of the neck, 2D Echo of the heart etc are the tests which are specially helpful in the detection of the disease. Along with the drugs for thinning of the blood, regulating blood pressure and diabetes strictly, maintaining discipline in eating habits and regular exercise are very essential to prevent this disease. It is a matter of debate whether healthy close relatives (daughter, son, sister, brother) of people suffering from Alzheimer’s dementia or others (which are hereditary) should get themselves examined as a precautionary measure. In some countries such facilities are available where genetic investigations can accurately predict the possibility of a person suffering from this disease in future. In many such cases, Alzheimer’s disease is wrongly diagnosed, for example, Hypothyroidism, vitamin deficiency, and many collagen diseases like S. Prevention of Dementia and Improving Brain Power : It is believed that as the age progresses the cells in the brain degenerate, gradually resulting in loss of memory as well as mind power. Recent research has shown that if the right kind of environment is provided there can be development of the new nerve fibres in the brain of older or aging people. This will result in more supply of blood and oxygen to the brain, which will keep the nervous system alert. After every one to one and half-hours of work, it is advisable to take a break for some minutes and move around for some time. Diverting the mind to a different subject after continuous working on a particular subject can make the brain more alert. After meals one feels drowsy because the blood supply to the brain decreases, so only limited food should be eaten in the afternoon. Try remembering telephone numbers or birthdays of friends and relatives or at least try to remember the birthdays of close relatives and family members. One should end the day with positive thoughts without any worries, which is not a very difficult task. Few tips for students to improve memory : l While you settle down to study, keep your textbooks, notebooks, pen etc. If you find the subject difficult, resort to deep-breathing for 2 minutes so as to increase your concentration. Note down the important points Discuss what you have read with your friends and then open the book and confirm what you have retained. Ribosomal Memory : As per the principles of Ribosomal memory following suggestions for retaining whatever is read are extremely useful. Similarly to read the next one and after reading for a while, to keep the book aside and try to remember everything. To write all important points, or discuss with the colleagues and then review if any points are left out. As mentioned early, there is no definite, effective or quick way to improve memory; however the method given above is time tested method to improve memory performance for students as well as other people. If there is an infection in the nose and the ears with pus discharge, throat infection, infectious boils on the face, pus in the other body parts like the chest or septicemia, then there is a possibility of infection in the brain. It is not possible to describe all these diseases here, but some important diseases will be discussed. Tuberculosis of the Brain : Usually, tuberculosis infection of the brain comes from other parts of the body like lungs or stomach. Headache, low-grade fever, vomiting, loss of appetite, excessive weakness or anxiety are the initial symptoms of this disease. Gradually, seizures, paralysis of one or more limbs can occur and in advanced stage, coma due to the edema of the brain and even death may occur.

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This arises from the lateral epicondyle of the humerus and then blends into the lateral side of the annular ligament order lopid 300mg free shipping. This ligament supports the head of the radius as it articulates with the radial notch of the ulna at the proximal radioulnar joint purchase 300mg lopid otc. This is a pivot joint that allows for rotation of the radius during supination and pronation of the forearm generic 300mg lopid mastercard. Hip Joint The hip joint is a multiaxial ball-and-socket joint between the head of the femur and the acetabulum of the hip bone (Figure 9. The hip carries the weight of the body and thus requires strength and stability during standing and walking. This space is deep and has a large articulation area for the femoral head, thus giving stability and weight bearing ability to the joint. The acetabulum is further deepened by the acetabular labrum, a fibrocartilage lip attached to the outer margin of the acetabulum. The surrounding articular capsule is strong, with several thickened areas forming intrinsic ligaments. These ligaments arise from the hip bone, at the margins of the acetabulum, and attach to the femur at the base of the neck. The ligaments are the iliofemoral ligament, pubofemoral ligament, and ischiofemoral ligament, all of which spiral around the head and neck of the femur. The ligaments are tightened by extension at the hip, thus pulling the head of the femur tightly into the acetabulum when in the upright, standing position. These ligaments thus stabilize the hip joint and allow you to maintain an upright standing position with only minimal muscle contraction. Inside of the articular capsule, the ligament of the head of the femur (ligamentum teres) spans between the acetabulum and femoral head. This intracapsular ligament is normally slack and does not provide any significant joint support, but it does provide a pathway for an important artery that supplies the head of the femur. The hip is prone to osteoarthritis, and thus was the first joint for which a replacement prosthesis was developed. A common injury in elderly individuals, particularly those with weakened bones due to osteoporosis, is a “broken hip,” which is actually a fracture of the femoral neck. This can happen as one lower limb is taking a step and all of the body weight is placed on the other limb, causing the femoral neck to break and producing a fall. Any accompanying disruption of the blood supply to the femoral neck or head can lead to necrosis of these areas, resulting in bone and cartilage death. Femoral fractures usually require surgical treatment, after which the patient will need mobility assistance for a prolonged period, either from family members or in a long-term care facility. In addition, hip fractures are associated with increased rates of morbidity (incidences of disease) and mortality (death). Surgery for a hip fracture followed by prolonged bed rest may lead to life-threatening complications, including pneumonia, infection of pressure ulcers (bedsores), and thrombophlebitis (deep vein thrombosis; blood clot formation) that can result in a pulmonary embolism (blood clot within the lung). What is a possible consequence following a fracture of the femoral neck within the capsule of the hip joint? The medial tibiofemoral joint and lateral tibiofemoral joint are located between the medial and lateral condyles of the femur and the medial and lateral condyles of the tibia. The knee is well constructed for weight bearing in its extended position, but is vulnerable to injuries associated with hyperextension, twisting, or blows to the medial or lateral side of the joint, particularly while weight bearing. The patella is a sesamoid bone incorporated into the tendon of the quadriceps femoris muscle, the large muscle of the anterior thigh. Acting via the patella and patellar ligament, the quadriceps femoris is a powerful muscle that acts to extend the leg at the knee. It also serves as a “dynamic ligament” to provide very important support and stabilization for the knee joint. The medial and lateral tibiofemoral joints are the articulations between the rounded condyles of the femur and the relatively flat condyles of the tibia. During flexion and extension motions, the condyles of the femur both roll and glide over the surfaces of the tibia. The rolling action produces flexion or extension, while the gliding action serves to maintain the femoral condyles centered over the tibial condyles, thus ensuring maximal bony, weight-bearing support for the femur in all knee positions. As the knee comes into full extension, the femur undergoes a slight medial rotation in relation to tibia. The rotation results because the lateral condyle of the femur is slightly smaller than the medial condyle. The resulting small medial rotation of the femur serves to “lock” the knee into its fully extended and most stable position. Flexion of the knee is initiated by a slight lateral rotation of the femur on the tibia, which “unlocks” the knee. This lateral rotation motion is produced by the popliteus muscle of the This OpenStax book is available for free at http://cnx. Located between the articulating surfaces of the femur and tibia are two articular discs, the medial meniscus and lateral meniscus (see Figure 9. Each is a C-shaped fibrocartilage structure that is thin along its inside margin and thick along the outer margin. While both menisci are free to move during knee motions, the medial meniscus shows less movement because it is anchored at its outer margin to the articular capsule and tibial collateral ligament. The menisci provide padding between the bones and help to fill the gap between the round femoral condyles and flattened tibial condyles. Some areas of each meniscus lack an arterial blood supply and thus these areas heal poorly if damaged. The knee joint has multiple ligaments that provide support, particularly in the extended position (see Figure 9. The fibular collateral ligament (lateral collateral ligament) is on the lateral side and spans from the lateral epicondyle of the femur to the head of the fibula. The tibial collateral ligament (medial collateral ligament) of the medial knee runs from the medial epicondyle of the femur to the medial tibia. As it crosses the knee, the tibial collateral ligament is firmly attached on its deep side to the articular capsule and to the medial meniscus, an important factor when considering knee injuries. In the fully extended knee position, both collateral ligaments are taut (tight), thus serving to stabilize and support the extended knee and preventing side-to-side or rotational motions between the femur and tibia. The articular capsule of the posterior knee is thickened by intrinsic ligaments that help to resist knee hyperextension. Inside the knee are two intracapsular ligaments, the anterior cruciate ligament and posterior cruciate ligament.

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It then opens into the posterior wall • Jugular foramen (already described) of the foramen lacerum before turning upwards again to enter the • Foramen lacerum (the internal carotid through its internal opening) cranial cavity through the internal opening of the foramen purchase lopid 300 mg on-line. Each • Mental (Mental nerve) ramus divides into a coronoid process and the head discount lopid 300 mg on line, for articulation • Greater and lesser palatine foramina (Greater and lesser palatine with the mandibular fossa purchase lopid 300mg amex. Parasympathetic fibres are shown in orange Superior orbital Superior fissure Cavernous Trochlear oblique sinus nerve Abducent nerve Lateral Internal rectus carotid Petrous artery temporal Fig. Maxillary V The trochlear nerve arises from the dorsal surface of the brain Mandibular V Auriculotemporal Supraorbital Greater occipital Infraorbital Lesser occipital Greater auricular Mental Supraclavicular Transverse Sternomastoid cutaneous Clavicle Fig. Its anterior ramus joins the outgrowth of the embryonic brain and the nerve is therefore enveloped hypoglossal nerve but leaves it later to form the descendens hypoglossi. The cell bodies are in the retina and the axons pass back in • C2: The posterior ramus forms the greater occipital nerve which is the optic nerve to the optic chiasma where the axons from the nasal sensory to the scalp. They also front of the pons, traverses the cavernous sinus and enters the orbit supply sensory branches: the greater auricular, lesser occipital, an- through the superior orbital fissure. The superioris, superior, inferior and medial rectus muscles and the inferior greater auricular supplies the skin in the parotid region, the only sens- oblique. It also carries parasympathetic fibres to the ciliary ganglion ory supply to the face which is not derived from the trigeminal. The where the fibres synapse and then pass in the short ciliary nerves to the others supply the skin of the neck and the upper part of the thorax. The olfactory nerve: the cell bodies of the olfactory nerve are in superior orbital fissure and supplies the superior oblique. Parasympathetic fibres are shown in orange Deep temporal (to temporalis) Auriculotemporal Foramen ovale Otic ganglion Muscular branches Buccal Parotid gland Chorda tympani Lingual Inferior alveolar Submandibular ganglion Mylohyoid nerve Submandibular gland Fig. The pos- the trigeminal ganglion which consists of the cell bodies of the sensory terior superior dental nerve enters the back of the maxilla and supplies axons and lies in a depression on the petrous temporal bone. The maxillary nerve leaves the sphenopalatine fossa via the divides into ophthalmic, maxillary and mandibular divisions. The inferior orbital fissure, travels in the floor of the orbit where it gives the motor root forms part of the mandibular division. This traverses the cavernous sinus and enters the orbit via the superior orbital fissure where it divides into frontal, lacrimal and nasociliary (c) The mandibular division (Fig. The frontal nerve lies just under the roof of the orbit and This leaves the cranial cavity through the foramen ovale and immedi- divides into supraorbital and supratrochlear nerves which emerge ately breaks up into branches. The lacrimal nerve lies alveolar nerve, which enters the mandibular foramen to supply the laterally and supplies the skin of the eyelids and face. This nerve parasympathetic secretomotor fibres from the sphenopalatine ganglion does have one motor branch, the mylohyoid nerve, which supplies the to the lacrimal gland. The lingual nerve lies runs along the medial wall of the orbit to emerge onto the face as the close to the mandible just behind the third molar and then passes for- infratrochlear nerve. It is joined by the chorda tympani which sinuses and the long ciliary nerves to the eye which carry sensory fibres carries taste fibres from the anterior two-thirds of the tongue and from the cornea and sympathetic fibres to the dilator pupillae. All parasympathetic secretomotor fibres to the submandibular and sublin- branches of the ophthalmic division are sensory. It also carries parasympath- This leaves the cranial cavity through the foramen rotundum and enters etic secretomotor fibres, which have synapsed in the otic ganglion, to the pterygopalatine fossa. The mandibular nerve are the greater and lesser palatine nerves to the hard and soft division thus contains both motor and sensory branches. The nerve passes through the middle ear and the parotid gland Vagus Spinal accessory Cranial accessory Foramen magnum Internal carotid Cardiac branch External carotid To sternomastoid Pharyngeal and trapezius Superior laryngeal Internal jugular vein Internal laryngeal External laryngeal Cricothyroid Cardiac branch Subclavian artery Recurrent laryngeal (left) Fig. In terior border of the pons and has a long intracranial course (so is often the neck the vagus (and cranial root of the accessory) gives the follow- the first nerve to be affected in raised intracranial pressure) to the cav- ing branches: ernous sinus, where it is closely applied to the internal carotid artery, • The pharyngeal branch which runs below and parallel to the glos- and thence to the orbit via the superior orbital fissure. The former enters the larynx by piercing the the parotid gland, in which it divides into five branches (temporal, thyrohyoid membrane and is sensory to the larynx above the level of zygomatic, buccal, marginal mandibular and cervical) which are the vocal cords, and the latter is motor to the cricothyroid muscle. In the middle ear it gives off the greater subclavian artery before ascending to the larynx behind the com- petrosal branch which carries parasympathetic fibres to the mon carotid artery. On the left side it arises from the vagus just sphenopalatine ganglion and thence to the lacrimal gland. In the middle below the arch of the aorta and ascends to the larynx in the groove ear it also gives off the chorda tympani which joins the lingual nerve between the trachea and oesophagus. Sensory fibres in the chorda tympani have nerves supply all the muscles of the larynx except for cricopharyn- their cell bodies in the geniculate ganglion which lies on the facial geus and are sensory to the larynx below the vocal cords. The vestibulocochlear (auditory) nerve: this leaves the brain side of the medulla with the vagus and is distributed with it. It root arises from the side of the upper five segments of the spinal cord, divides into vestibular and cochlear nerves. It leaves the vagus below the jugular foramen and passes back- the side of the medulla and passes through the jugular foramen. It then crosses the pos- curves forwards between the internal and external carotid arteries to terior triangle to supply trapezius (see Fig. It nerve but the spinal root of the accessory leaves it again almost imme- gives off the descendens hypoglossi but this is actually composed of diately. The intracranial parts of the two vertebral arteries are also shown diagrammatically although they are in a different plane 132 Head and neck The common carotid artery • The middle meningeal arteryaruns upwards to pass through the Arises from the brachiocephalic artery on the right and from the arch of foramen spinosum. Each common carotid passes up the ascends on the squamous temporal bone in a deep groove, which it neck in the carotid sheath (Fig. At the level of the upper border of the thyroid upwards and backwards towards the vertex and the posterior branch cartilage it divides into internal and external carotid arteries. After head injuries it may bleed to produce a subdural haemorrhage, the symptoms of which may be delayed for some time The external carotid artery (Fig. Ascends in the neck a little in front of the internal carotid to divide into • Branches which accompany the branches of the maxillary nerve in its two terminal branches, the maxillary and superficial temporal arter- the pterygopalatine fossa and have the same names. Associated with this is the border of the gland towards the isthmus and the lower passes down the carotid body, a chemoreceptor supplied by the same nerve. Within the skull it passes forwards in the cavernous the hyoid and loops upwards for a short distance before running for- sinus and then turns backwards behind the anterior clinoid process to ward deep to hyoglossus to enter and supply the tongue. Other tuous course at the side of the mouth and lateral to the nose to reach the branches are described on p. It gives off a tonsillar branch in the neck, superior and callosum and supplies the front and medial surfaces of the cerebral inferior labial branches and nasal branches. It is dis- • The posterior communicating artery: a small artery which passes tributed to the side of the scalp and the forehead. It ends by entering the pterygopala- These arteries and the communications between them form the tine fossa through the pterygomaxillary fissure.

If mercury is above desired level purchase lopid 300mg on-line, grasp tip of thermometer securely 300mg lopid mastercard, stand away from soiled objects and sharply flick wrist downward purchase lopid 300 mg without a prescription. Ask the client to deep breath slowly and relax 9) Gently insert thermometer into anus in the direction of umbilicus 3. Don’t force the thermometer 10) If resistance is felt during inserting, withdraw the thermometer immediately. Never force the thermometer 11) Hold thermometer in place for 2 seconds or according to agency policy 12) Carefully remove thermometer, discard plastic sleeve cover in appropriate container, and wipe off any remaining secretions with clean tissue. Gently rotate until scale appears 14) Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue. It is believed that when the patient is flat in bed, respiration often is more free and turning is easier, advantages that are important in the prevention of respiratory complications. Prone Position: In the prone position, the client lies on the abdomen with the head turned to one side. Both children and adults often sleep in this position, sometimes with one or both arms flexed over their heads (Figure 34­16). When used periodically, the prone position helps to prevent flexion contractures of the hips and knees, thereby counteract­ing a problem caused by all other bed positions. The prone position also promotes drainage from the mouth and is especially useful for unconscious clients or those clients recovering from surgery of the mouth or throat. Fowler’s Position: Off all the positions prescribed for a patient, perhaps the most common, as well as the most difficult to maintain is the Fowler’s position. The patient’s with abdominal drainage usually are put in Fowler’s position as soon as they have recovered conciousness, but great caution must be observed in raising the bed. Hand washing is a vigorous, brief rubbing together of all surfaces of hands lathered in soap, followed by rinsing under a stream of water. The purpose is to remove soil and transient organisms from the hands to reduce to microbial counts over time. Situation for hand washing: Garnerand Favero recommend that nurses wash hands in the following situations. Medical Hand Washing Equipments: 1) Easy to reach sink with warm running water 2) Antimicrobial soap / Regular soap. Use circular movements to wash palms, back of hands, wrists, forearms and interdigital spaces for 20­25 Seconds. Ask the assisting nurse to bring the gown over shoulders 3) The assisting nurse fastens the ties at the neck. Assess the patients for following: § Muscle strength § Joint mobility and contracture formation(arthritis) § Paralysis or paresis § Orthostatic hypotension(risk of fainting) § Activity tolerance § Level of comfort(pain) § Vital signs 2. Assess the patients sensory status § Adequacy of central and peripheral vision § Adequacy of hearing § Loss of peripheral sensation § Cognitive status 3. Assess for any contra indications to lift or transfer § Check for the doctors order § Assess patients level of motivation § Patients eagerness § Whether patient avoids activity § Assess previous mode of transfer § Assess patients specific risk for falling when transferred § Assess special equipments needed to transfer § Assess for safety hazards § Perform hand hygiene § Explain procedure to patient § Transfer the patient After care: § Following each transfer assess the patients body alignment, tolerance, fatigue, comfort § If the patient is transferred to bed after transfer, side rails are raised 41 § If the patient is transferred to wheel chair the brakes are released before moving the patient § Record the procedure accurately. The patients performance is also recorded § Any difficulty of disruption occurred during the transfer is also recorded with date and time § The patients comfort, vital signs are all recorded Procedure: § Transferring a patient from a bed to stretcher § An immobilized patient who must be transferred from a bed to a stretcher requires a three person carry or two person carry § Another method is using a sheet to lift Transferring a patient from a bed to stretcher: § Three of you should stand side by side facing of patients bed § Each person assumes responsibility for one of three areas a) Head and Shoulders b) Hips and thighs c) Ankles § Perform three­person carry from bed to stretcher(Bed at Stretcher level) § Three persons stand side by side facing side of patients bed 1. Each person assumes responsibility for one of three areas: head and shoulders, hips and thighs, and ankles 2. Each person assumes wide base of support with foot closer to stretcher in front and knees slightly flexed 3. Arms of lifters are placed under clients head and shoulders, hips and thighs, and ankles with fingers securely around other side of clients body(see illustration) 4. Have the wheel chair(lock the brakes at its 45° angle to bed § Apply transfer belt(if present) § Ensure that the patient has stable non skid shoes. For a man who has not been able to reach the toilet facilities he may stand at the bedside and void into a plastic of metal receptacle for urine. If he is unconscious or unable to stand at bedside the assistant needs to assist him to use the urinal. Purpose: § Provide a container for collection of urine § To measure the urine output § For observation of color and consistency of urine Indications: For patient with impair mobility due to surgery, fracture, injury Elderly man (aging impairs micturation) may require urinal more frequently to avoid urinary incontinence For mobile person who is able to go to bathroom, does not require urinal. The pan is approximately 5cm deep Fracture pan Designed for patients with body or leg casts, the shallow upper end approximately 1­3cm deep that slips easily under the patient Offering bedpan A bedpan for patients confined to bed provides a means to collect stool Female bedpan to pass urine and feces, For male bedpans only for defecation Sitting on a bedpan can be extremely uncomfortable. Purposes The nursing assistance paces and removes the bedpan to bed to bed ridden patients For bowel elimination when the patient is not permitted to go out of bed Obtain a stool specimen During bowel training, it facilitates bowel incontinence Indication: For the patients restricted to bed must use bedpan for defecation. To make a ‘reef knot’ take the ends of the bandage one in each hand cross the end in the right hand under and then over the end in the left hand thus making a turn. Then cross the end now in the right hand over and then under the end in the left hand thus making a second turn. Preparation of the Patient § Explain the sequence of the procedure to the patient and explain how the patient can assist you. Rules For Application Of Roller Bandage § Face the patient § When bandaging left limb, hold the head of the bandage in the right hand and vice versa. The usual practice of tearing the final end into two long tails and tying them up is quite satisfactory. With the back of the patient’s hand towards you, take a fixing turn round the wrist and carry the next turn upwards at an angle of 45°, turn the bandage over to cross itself at a right angle, and bring it round the limb ready for the next turn. It can be used to apply pressure over an extended joint or to bandage a leg, foot, hand or arm if movement is allowed. To use it on the leg, take a fixing turn, then carry the bandage upwards across the front of the limb at 45° round behind it at the same level and downwards over the front to cross the first turn at a right angle. Succeeding turns pass alternately above and below these turns, forming a pattern at each side of the joint. Elbow bandage Roller bandages can be used at these joints to hold dressings in place, or to support soft tissue injuries such as strains (or) sprains. Spread the bandage over the chest, with one end going over the shoulder on the uninjured side, and the other hanging over the abdomen; the point should be beneath the elbow. Place the fore arm slightly raised over the middle of the sling; bring the lower end up and tie on the injured shoulder to the other end with a reef knot. Fold a narrow then at the base, place it just above the eye brows, then take the two ends backwards, cross them below the occiput with the point underneath, then back to the fore head where they are tied. The other two are called the ends Cuff and Collar Sling A Clove hitch This supports the wrist only, with the casualty’s fore arm flexed and fingers touching the opposite shoulder, a clove hitch, made from a narrow bandage, is placed round his wrist.

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Doxycycline cheap 300 mg lopid fast delivery, in contrast to other tetracyclines lopid 300 mg sale, is eliminated by nonrenal mechanisms purchase lopid 300mg without prescription. Clinical uses: A tetracycline is the drug of choice in infections with Mycoplasma pneumoniae, chlamydiae, rickettsiae, and some spirochetes. They are used in combination regimens to treat gastric and duodenal ulcer disease caused by Helicobacter pylori. They may be employed in various gram-positive and gram-negative bacterial infections, including Vibrio infections. A tetracycline in combination with an aminoglycoside is indicated for plague, tularemia, and brucellosis. Adverse reactions Gastrointestinal adverse effects: Nausea, vomiting, and diarrhea are the most common and these effects are attributable to direct local irritation of the intestinal tract. Tetracyclines suppress susceptible coliform organisms and causes overgrowth of Pseudomonas, Proteus, staphylococci, resistant coliforms, clostridia, and Candida. This can result in intestinal functional disturbances, anal pruritus, vaginal or oral candidiasis, or enterocolitis (associated with Clostridium difficile) with shock and death. It causes discoloration, and enamel dysplasia; they can also be deposited in bone, where it may cause deformity or growth inhibition. If the drug is given to children under 8 years of age for long periods, similar changes can result. They are hepato and nephrotoxic drug, the also induce sensitivity to sunlight (demeclocycine) and vestibular reactions (doxycycline, and minocycline). Erythromycin Erythromycin is poorly soluble in water but dissolves readily in organic solvents. Antimicrobial Activity: Erythromycin is effective against gram-positive organisms, especially pneumococci, streptococci, staphylococci, and corynebacteria. Mycoplasma, Legionella, Chlamydia trachomatis, Helicobacter, Listeria, Mycobacterium kansasii, and Mycobacterium scrofulaceum are also susceptible. Gram-negative organisms such as Neisseria species, Bordetella pertussis, Treponema pallidum, and Campylobacter species are susceptible. Pharmacokinetics: Erythromycin base is destroyed by stomach acid and must be administered with enteric coating. Clinical Uses: Erythromycin is the drug of choice in corynebacterial infections (diphtheria, corynebacterial sepsis, erythrasma); in respiratory, neonatal, ocular, or genital chlamydial infections; and in treatment of community-acquired pneumonia because its spectrum of activity includes the pneumococcus, Mycoplasma, and Legionella. Erythromycin is also useful as a penicillin substitute in penicillin-allergic individuals with infections caused by staphylococci, streptococci, or pneumococci. Adverse Reactions Gastrointestinal Effects: Anorexia, nausea, vomiting, and diarrhea. Liver Toxicity: Erythromycins, particularly the estolate, can produce acute cholestatic hepatitis (reversibile). It increases serum concentrations of oral digoxin by increasing its bioavailability. Clarithromycin and erythromycin are virtually identical with respect to antibacterial activity except that clarithromycin has high activity against H. Clarithromycin penetrates most tissues, with concentrations equal to or exceeding serum concentrations. The advantages of clarithromycin compared with erythromycin are lower frequency of gastrointestinal intolerance and less frequent dosing. Azithromycin The spectrum of activity and clinical uses of azithromycin is identical to those of clarithromycin. Clindamycin Clindamycin is active against streptococci, staphylococci, bacteroides species and other anaerobes, both grampositive and gram-negative. Clinical uses: Clindamycin is used for the treatment of severe anaerobic infection caused by Bacteroides. It is used for prophylaxis of endocarditis in patients with valvular heart disease who are undergoing certain dental procedures. Clindamycin plus primaquine is an effective for moderate to moderately severe Pneumocystis carinii pneumonia. Adverse effects: Diarrheas, nausea, and skin rashes, impaired liver functions are common. Severe diarrhea and enterocolitis is caused by toxigenic C difficile (infrequently part of the normal fecal flora but is selected out during administration of oral antibiotics). Pharmacokinetics: Aminoglycosides are absorbed very poorly from the intact gastrointestinal tract. The kidney clears aminoglycosides, and excretion is directly proportionate to creatinine clearance. Ototoxicity can manifest itself either as auditory damage, resulting in tinnitus and high-frequency hearing loss initially; or as vestibular damage, evident by vertigo, ataxia, and loss of balance. Nephrotoxicity results in rising serum creatinine levels or reduced creatinine clearance. Streptomycin Streptomycin is mainly used as a first-line agent for treatment of tuberculosis. Adverse Reactions: Disturbance of vestibular function (vertigo, loss of balance) is common. The frequency and severity of this disturbance are proportionate to the age of the patient, the blood levels of the drug, and the duration of administration. Vestibular dysfunction may follow a few weeks of unusually high blood levels or months of relatively low blood levels. Gentamicin Gentamicin inhibits many strains of staphylococci and coliforms and other gram-negative bacteria. It is a synergistic companion with beta-lactam antibiotics, against Pseudomonas, Proteus, Enterobacter, Klebsiella, Serratia, Stenotrophomonas, and other gram-negative rods that may be resistant to multiple other antibiotics. Gentamicin is also used concurrently with penicillin G for bactericidal activity in endocarditis due to viridans streptococci. Creams, ointments, or solutions gentamicin sulfate are for the treatment of infected burns, wounds, or skin lesions. It is resistant to many enzymes that inactivate gentamicin and tobramycin, and it therefore can be employed against some microorganisms resistant to the latter drugs. Strains of multidrug- resistant Mycobacterium tuberculosis, including streptomycin-resistant strains, are usually susceptible to amikacin. Kanamycin, Neomycin, Paromomycin These drugs are closely related is also a member of this group.

If patient continues to be agitated after 20 minutes cheap 300 mg lopid fast delivery, increase the previous dose by 5 mg every 20 minutes until agitation subsides lopid 300 mg line. If starting with 2 mg and patient uncontrolled at 20 minutes generic lopid 300 mg with mastercard, increase to 5 mg and follow guidelines above. Once patient responds to haloperidol, 25% of the loading dose required should be given every 6 hours on a scheduled basis. If patient is still not effectively sedated with maximum daily doses of haloperidol, consider using a different drug for sedation or the addition of a second drug with haloperidol (e. Extrapyramidal symptoms, parkinsonian symptoms, akathisias, dystonic reactions, and tardive dyskinesia (long-term use) b. To be used for complete or partial reversal of narcotics in suspected overdose or for diagnostic/therapeutic purposes. No clear benefit from treatment (Pollycarpou et al Anticonvulsants for alcohol withdrawal Cochrane Rev 2005). Alcoholic hallucinosis – Hallucinations that develop within 12-24 hours and resolve within 24-48 hours. Approximate 90% of individuals who drink etoh for >40+ consecutive days develop major withdrawal symptoms. In contrast, in individuals with sustained intake <30 days most develop only minor symptoms upon cessation of alcohol (Isbell et al Q J Stud Alcohol 1955). Controversy over use of anti-psychotics relates to the potential for these agents to lower seizure threshold. For all definitions below, pneumonia equals a new infiltrate, signs/symptoms of infection (fever, leukocytosis), purulent sputum, and/or worsening oxygenation. Anaerobes are rarely pathogens alone; only need to treat in chronic aspiration with pleuropulmonary involvement. Bacteriologic strategies using quantitative culture thresholds result in less antibiotic use; however suffer from methodologic difficulty (lab expertise, bronchoscopy). Severe Obructive Lung Disease : Asthma Acute severe asthma with impending respiratory failure Issue in Presentation and Severity 1. Acute Asphyxia Asthma Slowly progressive over days or weeks Rapid Onset Inflammation / Eos and Mucus Little inflammation / mucus- probably smooth muscle contraction Unlikely to improve rapidly – May rapidly improve with bronchodilators ++++ Initial Risk of high Barotrauma / autopeep +++++ +++ Atelectasis + Management: 1. Corticosteroids: Dose: Study: Solumedrol at 125 or 40mg better than 15mg Usual 60-125mg every 6-8 hrs overnight Type: No specifics c. Oxygenation: Usually not a major problem – if hypoxic likely to represent mucus plugging + lobar collapse. Hypoventilation reflects an inability to get sufficient air to the alveoli for gas exchange due to severe air-trapping. In addition there is complex V/Q mismatching with high airway pressures (peep) creating areas of lung without effective perfusion (essentially dead space). Synchrony: Tachypnea, air-trapping, and severe acidosis make it impossible for patient to synchronize – requires heavy sedation + paralysis d. Barotrauma: High air pressure generally reflects dynamic (airway resistance = peak – plateau pressure) but static (plateau pressure) is also increased due to air-trapping. If initial ventilation strategy results in significant stacking of breaths and thus autopeep or dynamic hyperinflation - eventually this will cause decreased venous return with hypotension, shock, cardiac arrest etc. The aim is to limit minute ventilation and maximize expiratory time, and thus reduce the risk of air- trapping. Daily Transcranial Doppler exams may detect impending spasm before clinical symptoms (stroke) develop. Other treatments of vasospasm include angiography w/angioplasty, and/or intra-arteial milrinone or papaverine (case reports). Refractory status epilepticus- continual seizures after 1-2 meds have been tried 20% of these patients go on to have persistent neurological defects- behavior, memory, emotional Incidence of status epilepticus- Less than 1 % of all seizures Management – 1. Hypertensive emergency- increase in systolic and diastolic blood pressure leading to end-organ damage A. The clinical differentiation between these two entities is the presence or absence of end organ damage not the level of blood pressure elevation. The aim is to lessen pulsatile load and force of left ventricular contraction to slow the propagation of the dissection. Definition: Hyponatremia is generally defined as a plasma sodium level of less than 135 mEq per L (135 mmol per L). Pseudohyponatremia: This condition results from increased percentage of large molecular particles in the serum relative to sodium. These large molecules do not contribute to plasma osmolality resulting in a state in which the relative sodium concentration is decreased, but the overall osmolality remains unchanged. Glucose molecules exert an osmotic force and draw water from the intracellular compartment into the plasma, thereby causing a diluting effect. Hypervolemic hyponatremic conditions: congestive heart failure, liver cirrhosis, and renal diseases such as nephrotic syndrome. Treatment: Step 1: Based on Na levels and severity of symptoms decide whether immediate treatment is required. In patients with chronic hyponatremia, overzealous and rapid correction should be avoided because it can lead to central pontine myelinolysis. In central pontine myelinolysis, neurologic symptoms usually occur one to six days after correction and are often irreversible. In patients with hypernatremia and depletion of total body Na content (ie, who have volume depletion), the free water deficit is greater than that estimated by the formula. Dialysis (diffusion): The movement of solutes from a high concentration compartment to a low concentration compartment. An electrolyte solution (dialysate) runs countercurrent to blood across a semi-permeable (small pore) filter. Ultra-filtration (convection) – Solute is carried (in solution) across a semipermeable membrane in response to a transmembrane pressure gradient (a process known as solvent drag). The rate of ultrafiltration depends upon the porosity of the membrane and the hydrostatic pressure of the blood. Intermittent hemodialysis is the most efficient – Large amounts of fluid can be removed and electrolyte abnormalities can be rapidly corrected.