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Unfortunately spasms thumb joint order pletal 50 mg line, a third to spasms poster 100 mg pletal otc half of the times shedding occurs without any symptoms at all muscle relaxant uk purchase pletal 50 mg mastercard. Phytoestrogen Answer: B Explanation: Paroxetine (sample brand name: Brisdelle) is the only non-hormonal therapy that is specifically approved for hot flashes (in the United States). This agent has been used for many years for depression but can be taken at a lower dose for hot flashes. Gabapentin (sample brand name: Neurontin) is a drug that is primarily used to treat seizures. It also relieves hot flashes in some women, preferably given as a single bedtime dose or during the daytime as well. Antidepressants are recommended as a first line treatment for hot flashes in women who cannot take estrogen. Paroxetine is the only drug approved in the United States for hot flashes in this class, but each of these agents has been used for hot flashes. Answer: active stage Explanation: First stage of labor the first stage begins with regular uterine contractions and ends with complete cervical dilatation at 10 cm. The latent phase begins with mild, irregular uterine contractions that soften and shorten the cervix. This is followed by the active phase of labor, which usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical dilation and descent of the presenting fetal part. According to Friedman, the active phase is further divided into an acceleration phase, a phase of maximum slope, and a deceleration phase. First Stage: latent>> 3-4cm dilation Active>> from 4cm to 10cm Reference: emedicine. If a woman is not vaccinated, she should talk to her health care provider about any possible risks. The neonates delivered from patients receiving prophylaxis also have less morbidity. In this study, the control group, compared with the antibiotic group, had a significantly shorter duration of latency. External version: If the fetus has not reverted spontaneously, a version may be attempted by applying directed pressure to the maternal abdomen to turn the infant to vertex. Risks of version are placental abruption and cord compression, so be prepared for an emergency C-section if needed. Trial of breech vaginal delivery: Attempt only if delivery is imminent; otherwise contraindicated. Conservative surgical treatment: Endometrial ablation or resection using hysteroscopy. Complete eradication of deep adenomyosis is difficult and results in high treatment failure. Answer:A Explanation: Mullerian agenesis: to development of mullerian duct (no vagina, uterus, cervix) but present with primary amenorrhea and secondary sexual chch. Presence of 2° sexual characteristics (evidence of estrogen production but other anatomic or genetic problems): Etiologies include the following: Mullerian agenesis: Absence of two-thirds of the vagina; uterine abnormalities. Answer A Explanation: 1° Dysmenorrhea Presents with low, midline, spasmodic pelvic pain that often radiates to the back or inner thighs. Cramps occur in the first 13 days of menstruation and may be associated with nausea, diarrhea, headache, and flushing. She is asking the physician if she can use this medication or not while she is pregnant. Answer: A Explanation: the antidepressant Paxil (paroxetine) may cause fetal cardiac malformations, and the drug should be shunned if possible in pregnancy, recommended an advisory committee of the American College of Obstetricians and Gynecologists. The tumor is discrete, round, firm, and often multiple and is composed of smooth muscle and connective tissue. A) suprapubic pressure B) fundus pressure C) hip flexion D) delivery of posterior shoulder. A) uterine atony B) multiparty C)multiple gestation D) macrosomia answer: A Reference: Toronto notes 38-Pregnant pt came with high bp was given magnisum sulfate, which of the following is sign of low maginsum in the body? Magnesium plays an important role in carbohydrate metabolism and its deficiency may worsen insulin resistance, a condition that often precedes diabetes, or may be a consequence of insulin resistance. Face flexed, the lichoer is fair the baby found to be small and the pelvis of mother has? Answer: Postpartum psychosis Explanation: Postpartum psychosis has a dramatic onset, emerging as early as the first 48-72 hours after delivery. In most women, symptoms develop within the first 2 postpartum weeks the mother may have delusional beliefs that relate to the infant (eg, the baby is defective or dying, the infant is Satan or God), or she may have auditory hallucinations that instruct her to harm herself or her infant. A-anti epileptic B-anticoagulant Answer: A Explanation: Drug decreases effectiveness of oral contraceptive pills: Amoxicillin Ampicillin Carbamazepine (Tegretol) Ethosuximide (Zarontin) Metronidazole (Flagyl) Phenobarbital Phenytoin (Dilantin) Primidone (Mysoline) Rifampin (Rifadin) Tetracycline Troglitazone (Rezulin) Reference. Answer: A Explanation: the skin tissue around the vaginal area, called the labia, may look puffy as a result of estrogen exposure. A- smoking cessation B- genetic screen answer: A Explanation: the cause of congenital heart defect: Environmental factors Viral Infections,Medication,Alcohol, and Smoking According to the U. National Library of Medicine and the National Institute of Health, Health Day News reported on November 14, 2006 that a new study indicates that women who smoke during early pregnancy are more likely to have a child with congenital heart defects. The study seems to indicate that women who smoked at some point in the month before conception through the end of the first trimester were 60% more likely to have babies with congenital heart defects. Exposure to second hand smoke also increases the risk of congenital heart defects. References: Toronto notes, first Aid 49- lady in labour of breach presentation cervix fully dilated membrane i think rupture but no preceding in labor for I think 2hs what will you do? Women who are attempting to conceive: Clomiphene +/- metformin is first-line treatment for ovulatory stimulation. Symptom-specific treatment: Cardiovascular risk factors and lipid levels: Diet, weight loss, and exercise plus potentially lipid-controlling medication. Tight maternal glucose control (fasting glucose < 100; one- to two-hour postprandial glucose < 150) improves outcomes. Any patient with grossly abnormal cervix should have a punch biopsy regardless of any previous result. Next step: Obtain a radiograph to determine if bone age is consistent with pubertal onset (> 12 years in girls). If the patient is of short stature (bone age < 12 years) with normal growth velocity, constitutional growth delay (the most common cause of 1° amenorrhea) is the probable cause. Normal pubertal hormone levels: Indicates an anatomic problem Ultrasound may be needed to evaluate the ovaries. Normal breast development and no uterus: Obtain a karyotype to evaluate for androgen insensitivity syndrome. With accurate dating, a small, irregular intrauterine sac without a fetal pole on transvaginal ultrasound is diagnostic of an abnormal pregnancy. Penicillins, erythromycin, cephalosporins, and other commonly used antibiotics have not been found to be associated with an increased risk for birth defects. Nitrazine paper test is (paper turns blue, indicating alkaline pH of amniotic fluid).
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The person with quadriplegia or paraplegia must take responsibility for monitoring (or directing) his or her skin status muscle relaxant tramadol cheap pletal 100 mg otc. Nursing Interventions the patient requires extensive rehabilitation muscle relaxant used during surgery purchase pletal 50 mg, which is less difficult if appropriate nursing management has been carried out during the acute phase of the injury or illness spasms lower stomach buy 100 mg pletal otc. Nursing care is one of the key factors determining the success of the rehabilitation program. The main objective is for the patient to live as independently as possible in the home and community. The muscles of the hands, arms, Chapter 63 involves relieving pressure and not remaining in any position for longer than 2 hours, in addition to ensuring that the skin receives meticulous attention and cleansing. The patient is taught that ulcers develop over bony prominences exposed to unrelieved pressure in the lying and sitting positions. The paraplegic patient is instructed to use mirrors, if possible, to inspect these areas morning and night, observing for redness, slight edema, or any abrasions. While in bed, the patient should turn at 2-hour intervals and then inspect the skin again for redness that does not fade on pressure. The quadriplegic or paraplegic patient who cannot perform these activities is encouraged to direct others to check these areas and prevent ulcers from developing. The patient is taught to relieve pressure while in the wheelchair by doing push-ups, leaning from side to side to relieve ischial pressure, and tilting forward while leaning on a table. The caregiver for the quadriplegic patient will need to perform these activities if the patient cannot do so independently. A wheelchair cushion is prescribed to meet individual needs, which may change in time with changes in posture, weight, and skin tolerance. The diet for the patient with quadriplegia or paraplegia should be high in protein, vitamins, and calories to ensure minimal wasting of muscle and the maintenance of healthy skin, and high in fluids to maintain well-functioning kidneys. A patient with quadriplegia or paraplegia usually has either a reflex or a nonreflex bladder (see Chaps. The nurse emphasizes the importance of maintaining an adequate flow of urine by encouraging a fluid intake of about 2. The patient should empty the bladder frequently so there is minimal residual urine and should pay attention to personal hygiene, because infection of the bladder and kidneys almost always occurs by the ascending route. The perineum must be kept clean and dry and attention given to the perianal skin after defecation. If an external catheter (condom catheter) is used, the sheath is removed nightly; the penis is cleansed to remove urine and is dried carefully, because warm urine on the periurethral skin promotes the growth of bacteria. The female patient who cannot achieve reflex bladder control or self-catheterization may need to wear pads or waterproof undergarments. Surgical intervention may be indicated in some patients to create a urinary diversion. If a cord injury occurs above the sacral segments or nerve roots and there is reflex activity, the anal sphincter may be massaged (digital stimulation) to stimulate defecation. If Management of Patients With Neurologic Trauma 1937 the cord lesion involves the sacral segment or nerve roots, anal massage is not performed because the anus may be relaxed and lack tone. The anal sphincter is massaged by inserting a gloved finger (which has been adequately lubricated) 2. This procedure should be performed at the same time (usually every 48 hours), after a meal, and at a time that will be convenient for the patient at home. The patient also is taught the symptoms of impaction (frequent loose stools; constipation) and cautioned to watch for hemorrhoids. A diet with sufficient fluids and fiber is essential to a successful bowel training program, avoiding constipation, and decreasing the risk of autonomic dysreflexia. The patient and partner benefit from counseling about the range of sexual expression possible, special techniques and positions, exploration of body sensations offering sensual feelings, and urinary and bowel hygiene as related to sexual activity. For men with erectile failure, penile prostheses enable them to have and sustain an erection. Sildenafil (Viagra) is an oral smooth muscle relaxant that causes blood to flow into the penis, resulting in an erection (see Chap. Sexual education and counseling services are included in the rehabilitation services at spinal centers. Small-group meetings in which the patients can share their feelings, receive information, and discuss sexual concerns and practical aspects are helpful in producing effective attitudes and adjustments (Sipski & Alexander, 1997). Each time something new enters their lives (eg, a new relationship, going to work), they are reminded anew of their limitations. To work through this depression, patients must have some hope for relief in the future. Thus, the nurse can encourage them to feel confident in their ability to achieve self-care and relative independence. The role of the nurse ranges from caretaker during the acute phase to teacher, counselor, and facilitator as patients gain mobility and independence. In many cases, family therapy is helpful to help work through issues as they arise. Adjustment to the disability leads to the development of realistic goals for the future, making the best of the abilities that are left intact and reinvesting in other activities and relationships. Rejection of the disability causes self-destructive neglect and noncompliance with the therapeutic program, which leads to more frustration and depression. Crises for which interventions may be sought include social, psychological, marital, sexual, and psychiatric problems. The family usually requires counseling, social services, and other support systems to help them cope with the changes in their lifestyle and socioeconomic status. A major goal of nursing management is to help patients overcome their sense of futility and to encourage them in the emotional adjustment that must be made before they are willing to venture into the outside world. Patients are taught and assisted when necessary, but the nurse should avoid performing activities that patients can do for themselves with a little effort. This approach to care more than repays itself in the satisfaction of seeing a completely demoralized and helpless patient become independent and find meaning in a newly emerging lifestyle. These incapacitating flexor or extensor spasms, which occur below the level of the spinal cord lesion, interfere with both the rehabilitation process and activities of daily living. Spasticity results from an imbalance between the facilitatory and inhibitory effects on neurons that exist normally. The area of the cord distal to the site of injury or lesion becomes disconnected from the higher inhibitory centers located in the brain. Facilitatory impulses, which originate from muscles, skin, and ligaments, thus predominate. Spasticity is defined as a condition of increased muscle tone in a muscle that is weak. The stimulus that precipitates spasm can be either obvious, such as movement or a position change, or subtle, such as a slight jarring of the wheelchair.
- Throat swelling (which may also cause breathing difficulty)
- Falling in of the stoma (prolapse of the colostomy)
- Shock (late stage)
- If the area is actively bleeding, apply direct pressure with a clean, dry cloth until the bleeding is controlled. Raise the area.
- Ask your doctor which medications you should still take on the day of your surgery.
- Having more difficulty reading or writing
- Infection (a slight risk any time the skin is broken)
- Aortic stenosis
- Are you always dizzy or does the dizziness come and go?
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Consequently muscle spasms yahoo answers discount pletal 100 mg otc, liver transplantation (discussed later in this chapter) has become the treatment of choice for fulminant hepatic failure spasms after stroke trusted 50mg pletal. There are three types of cirrhosis or scarring of the liver: Alcoholic cirrhosis spasms under left breastbone buy pletal, in which the scar tissue characteristi- cally surrounds the portal areas. This is most frequently due to chronic alcoholism and is the most common type of cirrhosis. Postnecrotic cirrhosis, in which there are broad bands of scar tissue as a late result of a previous bout of acute viral hepatitis. This type usually is the result of chronic biliary obstruction and infection (cholangitis); it is much less common than the other two types. Management the key to optimizing treatment is rapid recognition of acute liver failure and intensive interventions. Treatment modalities may include plasma exchanges (plasmapheresis) or charcoal hemoperfusion for the removal (theoretically) of potentially harmful metabolites (Kaptanoglu & Blei, 2000); however, more clinical trials are needed to determine their effects or outcomes. Hepatocytes within synthetic fiber columns have been tested as liver support systems (liver assist devices) and a bridge to transplantation. Research into interventions for acute liver failure has begun to focus on techniques that combine the efficacy of a whole liver with the convenience and biocompatibility of hemodialysis. These temporary devices help patients to survive until transplantation is possible. Similar extracorporeal circuits using xenografts will likely be studied in the near future (Maddrey et al. There is a high risk for cerebral edema, a life-threatening complication, in patients with fulminant liver failure with stage 4 encephalopathy. The cause is not fully understood, although disruption of the bloodbrain barrier and plasma leaking into the cerebrospinal fluid has been proposed as one theory (Sherlock & Dooley, 2002). Measures to promote adequate cerebral perfusion include the portion of the liver chiefly involved in cirrhosis consists of the portal and the periportal spaces, where the bile canaliculi of each lobule communicate to form the liver bile ducts. These areas become the sites of inflammation, and the bile ducts become occluded with inspissated (thickened) bile and pus. The liver attempts to form new bile channels; hence, there is an overgrowth of tissue made up largely of disconnected, newly formed bile ducts and surrounded by scar tissue. Initially the liver is enlarged, hard, and irregular, but eventually it atrophies. Pathophysiology Although several factors have been implicated in the etiology of cirrhosis, alcohol consumption is considered the major causative factor. Although nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis, excessive alcohol intake is the major causative factor in fatty liver and its consequences. Cirrhosis, however, has also occurred in people who do not consume alcohol and in those who consume a normal diet and have a high alcohol intake. Some people appear to be more susceptible than others to this disease, whether or not they are alcoholics or malnourished. Other factors may play a role, including exposure to certain chemicals (carbon tetrachloride, chlorinated naphthalene, arsenic, or phosphorus) or infectious schistosomiasis. Twice as many men as women are affected, although women are at greater risk of developing alcohol-induced liver disease for an as yet undiscovered reason. The destroyed liver cells are replaced gradually by scar tissue; eventually the amount of scar tissue exceeds that of the functioning liver tissue. Islands of residual normal tissue and regenerating liver tissue may project from the constricted areas, giving the cirrhotic liver its characteristic hobnail appearance. The disease usually has an insidious onset and a protracted course, occasionally proceeding over a period of 30 or more years. The prognosis of different forms of cirrhosis caused by various liver diseases has been investigated in several studies. The severity of the manifestations helps to categorize the disorder into two main presentations (Chart 39-10). Compensated cirrhosis, with its less severe, often vague symptoms, may be discovered secondarily at a routine physical examination. The hallmarks of decompensated cirrhosis result from failure of the liver to synthesize proteins, clotting factors, and other substances and manifestations of portal hypertension (see the "Hepatic Dysfunction" section of this chapter for clinical manifestations and management of portal hypertension, ascites, varices, and hepatic encephalopathy). Later in the disease, the liver decreases in size as scar tissue contracts the liver tissue. Practically all the blood from the digestive organs is collected in the portal veins and carried to the liver. This can be demonstrated through percussion for shifting dullness or a fluid wave (see. Antibiotic therapy is effective in the treatment and prevention of recurrent episodes of spontaneous bacterial peritonitis. The esophagus, stomach, and lower rectum are common sites of collateral blood vessels. These distended blood vessels form varices or hemorrhoids, depending on their location (see. Because these vessels were not intended to carry the high pressure and volume of blood imposed by cirrhosis, they may rupture and bleed. Approximately 25% of patients develop minor hematemesis; others have profuse hemorrhage from gastric and esophageal varices (Bacon & Di Bisceglie, 2000). A reduced plasma albumin concentration predisposes the patient to the formation of edema. Edema is generalized but often affects lower extremities, upper extremities, and the presacral area. Overproduction of aldosterone occurs, causing sodium and water retention and potassium excretion. Medical Management the management of the patient with cirrhosis is usually based on the presenting symptoms. Vitamins and nutritional supplements promote healing of damaged liver cells and improve the general nutritional status. Potassium-sparing diuretics (spironolactone [Aldactone], triamterene [Dyrenium]) may be indicated to decrease ascites, if present; these diuretics are preferable to other diuretic agents because they minimize the fluid and electrolyte changes common with other agents. Although the fibrosis of the cirrhotic liver cannot be reversed, its progression may be halted or slowed by such measures. Preliminary studies indicate that colchicine, an antiinflammatory agent used to treat the symptoms of gout, may increase the length of survival in patients with mild to moderate cirrhosis. Colchicine is believed to reverse the fibrotic processes in cirrhosis, and this has improved survival (Bacon & Di Bisceglie, 2000). It is also important to document any exposure to toxic agents encountered in the workplace or during recreational activities.
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Participation in routine activities promotes orientation spasms around heart best order for pletal, increases awareness of self muscle relaxant overdose treatment order 50 mg pletal amex. Side rails decrease chance for additional injury from falls; mechanism for securing assistance is available to muscle relaxant high blood pressure buy generic pletal from india patient; independent activities based on faulty judgment may result in injury. Elderly people tend to be more sensitive to medications; abnormal responses (eg, hallucinations, depression) may occur. Use orientation activities and aids (eg, clock, calendar, pictures, introduction of self). Collaborative Problems: Hemorrhage; peripheral neurovascular dysfunction; deep vein thrombosis; pulmonary complications; pressure ulcers related to surgery and immobility Goal: Patient experiences an absence of complications Hemorrhage 1. Changes in pulse, blood pressure, and respirations may indicate development of shock; blood loss and stress may contribute to development of shock. Anemia due to blood loss may develop; bleeding into tissues after hip fracture may be extensive; blood replacement may be needed. Consider preinjury blood pressure values and management of coexisting hypertension, if present. Assess respiratory status: respiratory rate, depth, and duration, breath sounds, sputum. Anesthesia and bed rest diminish respiratory effort and cause pooling of respiratory secretions. Adventitious breath sounds, pain on respiration, shortness of breath, blood tinged sputum, cough, etc. Elevated temperature in the early postoperative period may be due to a respiratory problem. The trauma of surgery will cause swelling; excessive swelling and hematoma formation can compromise circulation and function; edema may be due to coexisting cardiovascular disease. Surgical pain can be controlled; pain due to neurovascular compromise is refractory to treatment with analgesics. Plantar flexion of ankle and flexion of toes indicate functioning of tibial nerve. With coexisting arteriosclerotic Expected Outcomes Patient has clear breath sounds Breath sounds present in all fields Exhibits no shortness of breath, chest pain, or elevated temperature 2. Apply thigh-high elastic compression stockings and/or sequential compression device as prescribed. Elderly people may become dehydrated because of low fluid intake, resulting in hemoconcentration. Body temperature increases with inflammation (magnitude of response minimal in elderly people). Elderly patients are subject to skin breakdown at points of pressure because of diminished subcutaneous tissue. Immobility causes pressure at bony prominences; position changes relieve pressure. Monitor condition of skin at pressure points (eg, heels, sacrum, shoulders); inspect heels at least twice a day. Use special care mattress and other protective devices (eg, heel protectors); support heel off the mattress. Institute care according to protocol at first indication of potential skin breakdown. Encourage patient to express concerns about care at home; explore with patient possible solutions to problems. Lack of knowledge and poor preparation for care at home contribute to patient anxiety, insecurity, and nonadherence to therapeutic regimen. One method of correction for a fracture of the femur in the distal third is two-wire skeletal traction. The patient presents with pain, deformity, obvious hematoma, and considerable edema. Frequently, these fractures are open and involve severe soft tissue damage because there is little subcutaneous tissue in the area. If nerve function is impaired, the patient is unable to dorsiflex the great toe and has diminished sensation in the first web space. Tibial artery damage is assessed by evaluating pulses, skin temperature, and color and by testing the capillary refill response. Symptoms include pain unrelieved by medications and increasing with plantar flexion, tense and tender muscle lateral to tibial crest, and paresthesia. Hip, foot, and knee exercises are encouraged within the limits of the immobilizing device. Partial weight bearing is begun when prescribed and is progressed as the fracture heals in 4 to 8 weeks. Distal fractures with extensive soft tissue damage heal slowly and may require bone grafting. The development of compartment syndrome requires prompt recognition and resolution to prevent permanent functional deficit. Other complications include delayed union, infection, impaired wound edge healing due to limited soft tissue, and loosening of the internal fixation hardware. Because these fractures produce painful respiration, the patient tends to decrease respiratory excursions and refrains from coughing. As a result, tracheobronchial secretions are not mobilized, aeration of the lung is diminished, and a predisposition to pneumonia and atelectasis results. To help the patient cough and take deep breaths, the nurse may splint the chest with her hands. Occasionally, the physician administers intercostal nerve blocks to relieve pain and to permit productive coughing. Chest strapping to immobilize the rib fracture is not used, because decreased chest expansion may result in pneumonia and atelectasis. The pain associated with rib fracture diminishes significantly in 3 or 4 days, and the fracture heals within 6 weeks. In addition to pneumonia and atelectasis, complications may include a flail chest, pneumothorax, and hemothorax. Medical Management Most closed tibial fractures are treated with closed reduction and initial immobilization in a long leg walking cast or a patellar tendonbearing cast. As with other lower extremity fractures, the leg should be elevated to control edema. The cast is changed to a short leg cast or brace in 3 to 4 weeks, which allows for knee motion. At times it is difficult to maintain reduction, and percutaneous pins may be placed in the bone and held in position by an external fixator. Fractures generally result from indirect trauma caused by excessive loading, sudden muscle contraction, or excessive motion beyond physiologic limits. Stable spinal fractures are caused by flexion, extension, lateral bending, or vertical loading.
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Malignant tumors spasms versus spasticity order pletal with mastercard, on the other hand spasms liver buy generic pletal on-line, tend to muscle relaxant gi tract pletal 100mg for sale be hard, the consistency of a pencil eraser, poorly defined, fixed to the skin or underlying tissue, and usually nontender. A physician should evaluate any abnormalities detected during inspection and palpation. Most cancers in men are found at a later stage, possibly because men are not aware of their risk for developing breast cancer. Gynecomastia (overdeveloped mammary glands in the male) is differentiated from the soft, fatty enlargement of obesity by the firm enlargement of glandular tissue beneath and immediately surrounding the areola. The same procedure for palpating the female axillae is used when assessing the male axillae. During palpation, the examiner notes tissue consistency, patient-reported tenderness, or masses. Size, shape, consistency, border delineation, and mobility are included in the description. The breast tissue of the adolescent is usually firm and lobular, whereas that of the postmenopausal woman is more likely to feel thinner and more granular. During pregnancy and lactation, the breasts are firmer and larger, with lobules that are more distinct. Variations in breast tissue occur during the menstrual cycle, pregnancy, and menopause. Therefore, normal changes must be distinguished from those that may signal disease. Also, many women have grainy-textured breast tissue, but these areas are usually less nodular after menses. Because women themselves detect many breast cancers, priority is given to teaching all women how and when to examine their breasts (Chart 48-2). All health care providers, aware of these implications, should encourage women to examine their own breasts and teach them to recognize early changes that may indicate problems. Almost all settings lend themselves to teaching, providing information, and encouraging appropriate care for prevention, detection, and treatment of breast problems. The entire surface of the breast is palpated from the outer edge of the breast to the nipple. Alternative palpation patterns are circular or clockwise, wedge, and vertical strip (below). Patients who have had breast surgery for the treatment of breast cancer are carefully instructed to examine themselves for any nodules or changes in their breasts or along the chest wall that may indicate a recurrence of the disease. The National Alliance for Breast Cancer Organizations, a clearinghouse for lay materials on breast cancer education, is another resource. The procedure takes about 20 minutes and can be performed in an xray department or independent imaging center. Two views are taken of each breast: a craniocaudal view and a mediolateral oblique view. For these views, the breast is mechanically compressed from top to bottom and side to side. Women may experience some fleeting discomfort because maximum compression is necessary for proper visualization. The current mammograms are compared with previous mammograms, and any changes indicate a need for further investigation. Mammography may detect a breast tumor before it is clinically palpable (ie, smaller than 1 cm); however, it has limitations and is not foolproof. The false-negative rate ranges between 5% and 10%; it is generally greater in younger women with greater density of breast tissue. Some patients have very dense breast tissue, making it difficult to detect lesions with mammography. The radiation exposure is equivalent to about 1 hour of exposure to sunlight, so patients would have X-ray tube to have many mammograms in a year to increase their cancer risk. Because the quality of mammography varies widely from one setting to the next, it is important for women to find accredited breast care centers that produce reliable mammograms. Current mammographic screening guidelines from the American Cancer Society recommend a mammogram every year starting at the age of 40 years. A baseline mammogram should be obtained after the age of 35 years and by the age of 40. Younger women who are identified as at a higher risk for breast cancer by family history should seek the opinion of a breast specialist about when to begin screening mammograms. Several studies suggest that screening for high-risk women should begin about 10 years before the age of diagnosis of the family member with breast cancer (Hartmann, Sellers, Schaid et al. In families with a history of breast cancer, a downward shift in age of diagnosis of about 10 years is seen (eg, grandmother diagnosed with breast cancer at age 48, mother diagnosed with breast cancer at age 38, then daughter should begin screening at age 28). Nurses need to provide teaching about screening guidelines for women in the general population and those at high risk so that these women can make informed choices about screening. Despite the decreased mortality associated with mammographic screening, it has not been used equitably across the U. Women with fewer resources (eg, elderly, poor, minority women, women without health insurance) often do not have the means to undergo mammography or the resources for follow-up treatment when lesions are detected. Recent studies have shown that social support contributes to adherence to mammographic screening guidelines (Anderson, Urban & Etzioni, 1999; Faccione, 1999; Lauver, Kane, Bodden et al. Many nurses direct their efforts at educating women about the benefits of mammography. Working to overcome barriers to screening mammography, especially among the elderly and women with disabilities, is an important nursing intervention in the community, and nurses have an important role in the development of educational materials targeted to specific literacy levels and ethnic groups. Galactography Galactography is a mammographic diagnostic procedure that involves injection of less than 1 mL of radiopaque material through a cannula inserted into a ductal opening on the areola, followed by a mammogram. It is performed when the patient has a bloody nipple discharge on expression, spontaneous nipple discharge, or a solitary dilated duct noted on mammography. A transducer is used to transmit high-frequency sound waves through the skin and into the breast, and an echo signal is measured. This technique is 95% to 99% accurate in diagnosing cysts but does not definitively rule out a malignant lesion. Chapter 48 Assessment and Management of Patients With Breast Disorders 1453 For women with dense breasts, the introduction of screening ultrasound examinations has been researched during this past decade. The addition of ultrasonography to breast cancer screening can increase the sensitivity of screening for this population of women, who tend to be either young or on hormone replacement therapy. The largest study showed an increase in cancer detection by 17% with the addition of screening ultrasonography (Kolb, Lichy & Newhouse, 1998). Further research will help provide information on the usefulness of ultrasound as a screening modality.
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The body accomplishes recognition using lymph nodes and lymphocytes for surveillance muscle relaxant gaba generic pletal 100mg without prescription. These lymphocytes patrol the tissues and vessels that drain the areas served by that node muscle relaxants yahoo answers generic pletal 50 mg on-line. Lymphocytes recirculate from the blood to muscle relaxant allergy buy cheap pletal online lymph nodes and from the lymph nodes back into the bloodstream, in a neverending series of patrols. The exact way in which circulating lymphocytes recognize antigens on foreign surfaces is not known; however, recognition is thought to depend on specific receptor sites on the surface of the lymphocytes. The production of antibodies by the B lymphocytes in response to a specific antigen begins the humoral response. Humoral refers to the fact that the antibodies are released into the bloodstream and so reside in the plasma (fluid fraction of the blood). With the initial cellular response, the returning sensitized lymphocytes migrate to areas of the lymph node (other than those areas containing lymphocytes programmed to become plasma cells). Here, they stimulate the residing lymphocytes to become cells that will attack microbes directly rather than through the action of antibodies. The T stands for thymus, signifying that during embryologic development of the immune system, these T lymphocytes spent time in the thymus of the developing fetus, where they were genetically programmed to become T lymphocytes rather than the antibody-producing B lymphocytes. This response is manifested by the increasing number of T lymphocytes (lymphocytosis) seen in the blood smears of people with viral illnesses, such as infectious mononucleosis. For example, during transplantation rejection, the cellular response predominates, whereas in the bacterial pneumonias and sepsis, the humoral response plays the dominant protective role (Chart 50-1). The coupling initiates a series of events that in most instances results in the total destruction of the invading microbes or the complete neutralization of the toxin. The events involve an interplay of antibodies (humoral immunity), complement, and action by the cytotoxic T cells (cellular immunity). Both macrophages and neutrophils have receptors for antibodies and complement; as a result, the coating of microorganisms with antibodies, complement, or both enhances phagocytosis. The engulfed microorganisms are then subjected to a wide range of toxic intracellular molecules. When foreign materials enter the body, a circulating lymphocyte comes into physical contact with the surfaces of these materials. Upon contact, the lymphocyte, with the help of macrophages, either removes the antigen from the surface or in some way picks up an imprint of its structure, which comes into play with subsequent re-exposure to the antigen. In a streptococcal throat infection, for example, the streptococcal organism gains access to the mucous membranes of the throat. A circulating lymphocyte moving through the tissues of the neck comes in contact with the organism. The lymphocyte, familiar with the surface markers on the cells of its own body, recognizes the antigens on the microbe as different (nonself) and the streptococcal organism as antigenic (foreign). Once in the node, the sensitized lymphocyte stimulates some of the resident dormant T and B lymphocytes to enlarge, divide, and proliferate. T lymphocytes differentiate into cytotoxic (or killer) T cells, whereas B lymphocytes produce and release antibodies. Enlargement of the lymph nodes in the neck in conjunction with a sore throat is one example of the immune response. Chart 50-1 Role of Cellular and Humoral Immune Responses Whereas B-cell antibodies are distinctive components of the humoral immune response, cytotoxic T cells are distinguishing components of the cellular immune response. Humoral Immune Response the humoral response is characterized by production of antibodies by the B lymphocytes in response to a specific antigen. Although the B lymphocyte is ultimately responsible for the production of antibodies, both the macrophages of natural immunity and the special T-cell lymphocytes of cellular immunity are involved in recognizing the foreign substance and in producing antibodies. This is probably because the B lymphocytes recognize invading antigens in more than one way and respond in several ways as well. Additionally, the B lymphocytes appear to respond to some antigens by triggering antibody formation directly. In response to other antigens, however, they need the assistance of T cells to trigger antibody formation. Chapter 50 T cells (or T lymphocytes), part of a surveillance system dispersed throughout the body, recycle through the general circulation, tissues, and lymphatic system. With the assistance of macrophages, the T lymphocytes are believed to recognize the antigen of a foreign invader. The T lymphocyte picks up the antigenic message, or "blueprint," of the antigen and returns to the nearest lymph node with that message. B lymphocytes stored in the lymph nodes are subdivided into thousands of clones, each responsive to a single group of antigens having almost identical characteristics. When the antigenic message is carried back to the lymph node, specific clones of the B lymphocyte are stimulated to enlarge, divide, proliferate, and differentiate into plasma cells capable of producing specific antibodies to the antigen. Other B lymphocytes differentiate into B-lymphocyte clones with a memory for the antigen. These memory cells are responsible for the more exaggerated and rapid immune response in a person who is repeatedly exposed to the same antigen. All immunoglobulins are glycoproteins and contain a certain amount of carbohydrate. The carbohydrate concentration, which ranges from approximately 3% to 13%, is dependent upon the class of the antibody. Each antibody molecule consists of two subunits, each of which contains a light and a heavy peptide chain. Each subunit has a portion that serves as a binding site for a specific antigen referred to as the Fab fragment. An additional portion, known as the Fc fragment, allows the antibody molecule to take part in the complement system. Antibodies defend against foreign invaders in several ways, and the type of defense employed depends on the structure and composition of both the antigen and the immunoglobulin. One antibody can act as a cross-link between two antigens, causing them to bind or clump together. This clumping effect, referred to as agglutination, helps clear the body of the in- Assessment of Immune Function 1527 vading organism by facilitating phagocytosis. In this process, the antigenantibody molecule is coated with a sticky substance that also facilitates phagocytosis. Antibodies also promote the release of vasoactive substances, such as histamine and slow-reacting substance, two of the chemical mediators of the inflammatory response. Antibodies do not function in isolation but rather mobilize other components of the immune system to defend against the invader. Their usual role is to focus components of the natural immune system on the invader. This includes activation of the complement system and activation of phagocytosis (Delves & Roitt, 2000a).
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Place the palm of the other hand anterior to spasms hamstring buy generic pletal pills the kidney with fingers above the umbilicus muscle relaxant tinidazole buy generic pletal on line. This is an important part of testing for neurological causes of bladder dysfunction because the sacral area muscle relaxant for bruxism purchase pletal 50 mg on line, which innervates the lower extremities, is the same peripheral nerve area responsible for urinary continence. These tests evaluate possible supraspinal causes for urinary incontinence (Appell, 1999). Gerontologic Considerations Upper and lower urinary tract function changes with age. Tubular function, including reabsorption and concentrating ability, is also reduced with increasing age. This steady decrease in glomerular filtration, combined with the use of multiple medications whose metabolites clear the body via the kidneys, puts the older individual at higher risk for adverse drug effects and drug-to-drug interactions (Schafer, 2001). Structural or functional abnormalities that occur with aging may prevent complete emptying of the bladder. This may be due the urinalysis provides important clinical information on kidney function and helps diagnose other diseases, such as diabetes. The urine culture determines if bacteria are present in the urine, as well as their strains and concentration. Urine culture and sensitivity also identify the antimicrobial therapy that is best suited for the particular strains identified, taking into consideration the antibiotics that have the best rate of resolution in that particular geographic region. Appropriate evaluation of any abnormality can assist in detecting serious underlying diseases. Common causes include acute infection (cystitis, urethritis, or prostatitis), renal calculi, and neoplasm. Protein in the urine (proteinuria) may be a benign finding, or it may signify serious disease. Occasional loss of up to 150 mg/day of protein in the urine, primarily albumin and Tamm-Horsfall protein, is considered normal and usually does not require further evaluation. A dipstick examination, which can detect from 30 to 1,000 mg/dL of protein, should be used as a screening test only, because urine concentration, pH, hematuria, and radiocontrast materials all affect the results. Because dipstick analysis does not detect protein concentrations of less than 30 mg/dL, the test cannot be used for early detection of diabetic nephropathy. Microalbuminuria (excretion of 20 to 200 mg/dL of protein in the urine) is an early sign of diabetic nephropathy. Common benign causes of transient proteinuria are fever, strenuous exercise, and prolonged standing. Renal function can be assessed most accurately if several tests are performed and their results analyzed together. Common tests of renal function include renal concentration tests, creatinine clearance, and serum creatinine and blood urea nitrogen levels. General Ultrasonography Ultrasonography is a noninvasive procedure that uses sound waves passed into the body through a transducer to detect abnormalities of internal tissues and organs. Abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size, or obstructions can be identified. Ultrasonography requires a full bladder; therefore, fluid intake should be encouraged before the procedure. These tests also provide information on the effectiveness of the kidney in carrying out its excretory function. The usual behavioral interventions include a program of pelvic muscle strengthening. Despite the well-documented safety and efficacy of this intervention, high rates of patient withdrawal have been reported. To be eligible for inclusion in the study, subjects had to be 50 years old or older. They also had to complete an initial clinic visit and perform pelvic floor exercises augmented with biofeedback prescribed by the clinician. Those who completed the 7-day bladder diary before the program study was initiated were much more likely to complete the program than those who did not complete the diary. Nursing Implications Completion of a 7-day voiding diary before beginning a behavioral continence program is usually considered pivotal for an accurate record of day-to-day bladder status, and the data obtained from the review are important in assessing the effectiveness of the treatment. They are used in evaluating genitourinary masses, nephrolithiasis, chronic renal infections, renal or urinary tract trauma, metastatic disease, and soft tissue abnormalities. Nursing care guidelines for patient preparation and test precautions for any imaging procedure requiring a contrast agent (also called contrast medium) are explained in Chart 43-3. Bladder Ultrasonography Bladder ultrasonography is a noninvasive method of measuring urine volume in the bladder. Concentrating ability is lost early in kidney disease; hence, these test findings may disclose early defects in renal function. Test measures volume of blood cleared of endogenous creatinine in 1 minute, which provides an approximation of the glomerular filtration rate. In normal function, level of creatinine, which is regulated and excreted by the kidneys, remains fairly constant in body. Test values are affected by protein intake, tissue breakdown, and fluid volume changes. A scintillation camera is placed behind the kidney with the patient in a supine, prone, or seated position. The technetium scan provides information about kidney perfusion; the hippurate scan provides information about kidney function. Nuclear scans are used to evaluate acute and chronic renal failure, renal masses, and blood flow before and after kidney transplantation. The radioisotope is injected at a specified time before the study to achieve the proper concentration in the kidneys. After the procedure is completed, the patient is encouraged to drink fluids to promote excretion of the radioisotope by the kidneys. The following guidelines can help the nurse and other caregivers respond quickly in the event of a problem. Nursing Actions for Room Preparation Have emergency equipment and medications available in case the patient has an anaphylactic reaction to the contrast agent. Emergency supplies include epinephrine, corticosteroids, and vasopressors; oxygen; and airway and suction equipment. Contrast agents should be used with caution in older patients and patients who have diabetes mellitus, multiple myeloma, renal insufficiency, or volume depletion. A nephrotomogram may be carried out as part of the study to visualize different layers of the kidney and the Chapter 43 diffuse structures within each layer and to differentiate solid masses or lesions from cysts in the kidneys or urinary tract. Intravenous urography may be used as the initial assessment of any suspected urologic problem, especially lesions in the kidneys and ureters. After the contrast agent (sodium diatrizoate or meglumine diatrizoate) is administered intravenously, multiple x-rays are obtained to visualize drainage structures. Infusion drip pyelography requires an intravenous infusion of a large volume of a dilute contrast agent to opacify the renal parenchyma and fill the urinary tract.
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It is important to back spasms 6 months pregnant generic pletal 100 mg on-line help patients with a colostomy out of bed on the first postoperative day and encourage them to spasms diaphragm hiccups buy pletal 100 mg line begin participating in managing the colostomy spasms in lower back order 50 mg pletal with visa. The diet is individualized as long as it is well balanced and does not cause diarrhea or constipation. The patient avoids foods that cause excessive odor and gas, including foods in the cabbage family, eggs, fish, beans, and high-cellulose products such as peanuts. It is important to determine whether the elimination of specific foods is causing any nutritional deficiency. Nonirritating foods are substituted for those that are restricted so that deficiencies are corrected. The nurse advises the patient to experiment with an irritating food several times before restricting it, because an initial sensitivity may decrease with time. The nurse can help the patient identify any foods or fluids that may be causing diarrhea, such as fruits, high-fiber foods, soda, coffee, tea, or carbonated beverages. Paregoric, bismuth subgallate, bismuth subcarbonate, or diphenoxylate with atropine (Lomotil) help control the diarrhea. It is important to help the patient splint the abdominal incision during coughing and deep breathing to lessen tension on the edges of the incision. The nurse monitors temperature, pulse, and respiratory rate for elevations, which may indicate an infectious process. If the patient has a colostomy, the stoma is examined for swelling (slight edema from surgical manipulation is normal), color (a healthy stoma is pink or red), discharge (a small amount of oozing is normal), and bleeding (an abnormal sign). If the malignancy has been removed using the perineal route, the perineal wound is observed for signs of hemorrhage. This process is hastened by mechanical irrigation of the wound or with sitz baths performed two or three times each day initially. The condition of the perineal wound and any bleeding, infection, or necrosis are documented. It is important to frequently assess the abdomen, including decreasing or changing bowel sounds and increasing abdominal girth, to detect bowel obstruction. The nurse monitors vital signs for increased temperature, pulse, and respirations and for de- creased blood pressure, which may indicate an intra-abdominal infectious process. It is important to report rectal bleeding immediately because it indicates hemorrhage. The nurse monitors hematocrit and hemoglobin levels and administers blood component therapy as prescribed. Elevated white blood cell counts and temperature or symptoms of shock are reported because they may indicate sepsis. Pulmonary complications are always a concern with abdominal surgery; patients older than 50 years of age are at risk, especially if they are or have been receiving sedatives or are being maintained on bed rest for a prolonged period. Frequent activity (eg, turning the patient from side to side every 2 hours), deep breathing, coughing, and early ambulation can reduce the risks for these complications. The incidence of complications related to the colostomy is about one half that seen with an ileostomy. Some common complications are prolapse of the stoma (usually from obesity), perforation (from improper stoma irrigation), stoma retraction, fecal impaction, and skin irritation. Leakage from an anastomotic site can occur if the remaining bowel segments are diseased or weakened. Leakage from an intestinal anastomosis causes abdominal distention and rigidity, temperature elevation, and signs of shock. The nurse manages the colostomy and teaches the patient about its care until the patient can take over. Care of the peristomal skin is an ongoing concern because excoriation or ulceration can develop quickly. The presence of such irritation makes adhering the ostomy appliance difficult, and adhering the ostomy appliance to irritated skin can worsen the skin condition. The effluent discharge and the degree to which it is irritating vary with the type of ostomy. With a transverse colostomy, the stool is soft and mushy and irritating to the skin. With a descending or sigmoid colostomy, the stool is fairly solid and less irritating to the skin. If the patient wants to bathe or shower before putting on the clean appliance, micropore tape applied to the sides of the pouch will keep it secure during bathing. To remove the appliance, the patient assumes a comfortable sitting or standing position and gently pushes the skin down from the faceplate while pulling the pouch up and away from the stoma. Gentle pressure prevents the skin from being traumatized and any liquid fecal contents from spilling out. The nurse advises the patient to protect the peristomal skin by then washing the area gently with a moist, soft cloth and a mild soap. While the skin is being cleansed, a gauze dressing can cover the stoma, or a vaginal tampon can be inserted gently to absorb excess drainage. After cleansing, the patient pats the skin completely dry with a gauze pad, taking care not to rub the area. The patient can lightly dust nystatin (Mycostatin) powder on the peristomal skin if irritation or yeast growth is present. Smoothly applying the drainage appliance for a secure fit requires practice and a well-fitting appliance. Mechanical obstruction Intra-abdominal Septic Conditions Peritonitis Evaluate patient for nausea, hiccups, chills, spiking fever, tachycardia. Monitor for evidence of constant or generalized abdominal pain, rapid Intraperitoneal infection pulse, and elevation of temperature. Administer parenteral fluids as prescribed to correct fluid and electrolyte deficits. The stoma is measured to determine the correct size for the pouch; the pouch opening should be about 0. After the skin is cleansed according to the previously described procedure, the patient applies the peristomal skin barrier (ie, wafer, paste, or powder). Mild skin irritation may require dusting the skin with karaya or Stomahesive powder before attaching the pouch. The patient removes the backing from the adherent surface of the appliance, and places the bag down over the stoma for 30 seconds. The patient empties or changes the drainage appliance when it is one-third to one-fourth full so that the weight of its contents does not cause the appliance to separate from the adhesive disk and spill the contents. Most appliances are disposable and odor resistant; commercially prepared deodorizers are available. As soon as the patient has learned a routine for evacuation, bags may be dispensed with, and a closed ostomy appliance or a simple dressing of disposable tissue (often covered with plastic wrap) is used, held in place by an elastic belt. Except for gas and a slight amount of mucus, nothing escapes from the colostomy opening between irrigations. Colostomy plugs that expand on insertion to prevent passage of flatus and feces are available. A stoma does not have voluntary muscular control and may empty at irregular intervals.
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In addition infantile spasms 8 month old buy discount pletal 100 mg online, patients may require increased amounts of insulin or may need to spasms sphincter of oddi purchase generic pletal pills switch from oral antidiabetic agents to muscle relaxant you mean whiskey cheap pletal generic insulin during illnesses. Diabetic microvascular disease (or microangiopathy) is characterized by capillary basement membrane thickening. Researchers believe that increased blood glucose levels react through a series of biochemical responses to thicken the basement membrane to several times its normal thickness. Similarly, about one in every four individuals starting dialysis has diabetic nephropathy. Extraocular muscle palsy Glaucoma Deterioration of the small blood vessels that nourish the retina Early stage, asymptomatic retinopathy. Blood vessels within the retina develop microaneurysms that leak fluid, causing swelling and forming deposits (exudates). Represents increased destruction of retinal blood vessels Abnormal growth of new blood vessels on the retina. Ruptured blood vessels in the vitreous form scar tissue, which can pull on and detach the retina. Opacity of the lens of the eye; cataracts occur at an earlier age in patients with diabetes. For some patients, visual changes related to lens swelling may be the first symptoms of diabetes. It may take up to 2 months of improved blood glucose control before hyperglycemic swelling subsides and vision stabilizes. Therefore, patients are advised not to change eyeglass prescriptions during the 2 months after discovery of hyperglycemia. The involvement of various cranial nerves responsible for ocular movements may lead to double vision. Epidemiologic evidence suggests that 10% to 50% of patients with preproliferative retinopathy will develop proliferative retinopathy within a short time (possibly as little as 1 year). As with background retinopathy, if visual changes occur during the preproliferative stage, they are usually caused by macular edema. Proliferative retinopathy is characterized by the proliferation of new blood vessels growing from the retina into the vitreous. The visual loss associated with proliferative retinopathy is caused by this vitreous hemorrhage and/or retinal detachment. When there is a hemorrhage, the vitreous becomes clouded and cannot transmit light, resulting in loss of vision. Another consequence of vitreous hemorrhage is that resorption of the blood in the vitreous leads to the formation of fibrous scar tissue. This scar tissue may place traction on the retina, resulting in retinal detachment and subsequent visual loss. Patient preparation includes explaining: the steps of the procedure the fact that the procedure is painless the potential side effects the type of information the technique can provide That the flash of the camera may be slightly uncomfortable for a short time Medical Management the first focus of management is on primary and secondary prevention. The progression of retinopathy was decreased by 54% in patients with very mild to moderate nonproliferative retinopathy at the time of initiation of treatment. For advanced cases, the main treatment of diabetic retinopathy is argon laser photocoagulation. The laser treatment destroys leaking blood vessels and areas of neovascularization. For patients at increased risk for hemorrhaging, panretinal photocoagulation may significantly reduce the rate of progression to blindness. Panretinal photocoagulation involves the systematic application of multiple (more than 1,000) laser burns throughout the retina (except in the macular region). This stops the widespread growth of new vessels and hemorrhaging of damaged vessels. The role of "mild" panretinal photocoagulation (with only a third to a half as many laser burns) in the early stages of proliferative retinopathy or in patients with preproliferative changes is being investigated. For macular edema, focal photocoagulation is used to apply smaller laser burns to specific areas of microaneurysms in the macular region. Photocoagulation treatments are usually performed on an outpatient basis, and most patients can return to their usual activities by the next day. For some patients, limitations may be placed on activities involving weight bearing or bearing down. In nonproliferative and preproliferative retinopathy, blurry vision secondary to macular edema occurs in some patients, although many patients are asymptomatic. Even patients with a significant degree of proliferative retinopathy and some hemorrhaging may not experience major visual changes. However, symptoms indicative of hemorrhaging include floaters or cobwebs in the visual field, or sudden visual changes including spotty or hazy vision, or complete loss of vision. Assessment and Diagnostic Findings Diagnosis is by direct visualization with an ophthalmoscope or with a technique known as fluorescein angiography. Dye is injected into an arm vein and is carried to various parts of the body through the blood, but especially through the vessels of the retina of the eye. This technique allows the ophthalmologist, using special instruments, to see the retinal vessels in bright detail and gives useful information that cannot be obtained with just an ophthalmoscope. Side effects of this diagnostic procedure may include nausea during the dye injection; yellowish, fluorescent discoloration of Chapter 41 Assessment and Management of Patients With Diabetes Mellitus 1191 patients, the treatment does not cause intense pain, although they may report varying degrees of discomfort. A few patients may experience slight visual loss, loss of peripheral vision, or impairments in adaptation to the dark. For most patients, however, the risk of slight visual changes from the laser treatment itself is much less than the potential for loss of vision from progression of retinopathy. When a major hemorrhage into the vitreous occurs, the vitreous fluid becomes mixed with blood and prevents light from passing through the eye; this can cause blindness. A vitrectomy is a surgical procedure in which vitreous humor filled with blood or fibrous tissue is removed with a special drill-like instrument and replaced with saline or another liquid. A vitrectomy is performed on patients who already have visual loss and in whom the vitreous hemorrhage has not cleared on its own after 6 months. The purpose is to restore useful vision; recovery to near-normal vision is not usually expected. Other strategies that may slow the progression of diabetic retinopathy include: Although retinopathy occurs bilaterally, the severity may differ in the two eyes. For example, a patient who is blind due to diabetic retinopathy may also have peripheral neuropathy and may experience impairment of manual dexterity and tactile sensation. Education focuses on prevention through regular ophthalmologic examinations and blood glucose control and self-management of eye care regimens. The effectiveness of early diagnosis and prompt treatment is emphasized in teaching the patient and family. Nursing care for the patient with low vision or loss of vision is discussed in detail in Chapter 58.
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If the patient cannot take fluids without vomiting spasms between ribs 50 mg pletal, or if elevated glucose or ketone levels persist muscle relaxant suppository buy pletal, the physician must be contacted muscle relaxant effects discount 50mg pletal with mastercard. In addition, a supply of urine test strips (for ketone testing) and blood glucose test strips should be available. Diabetes self-management skills (including insulin administration and blood glucose testing) should be assessed to ensure that an error in insulin administration or blood glucose testing did not occur. Assessment and Diagnostic Findings Blood glucose levels may vary from 300 to 800 mg/dL (16. Some patients have lower glucose values, and others have values of 1,000 mg/dL (55. Evidence of ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH (6. Accumulation of ketone bodies (which precipitates the acidosis) is reflected in blood and urine ketone measurements. Sodium and potassium levels may be low, normal, or high, depending on the amount of water loss (dehydration). Despite the plasma concentration, there has been a marked total body depletion of these (and other) electrolytes. Insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. If usual meal plan cannot be followed, substitute soft foods (eg, 1/3 cup regular gelatin, 1 cup cream soup, 1/2 cup custard, 3 squares graham crackers) six to eight times per day. If vomiting, diarrhea, or fever persists, take liquids (eg, 1/2 cup regular cola or orange juice, 1/2 cup broth, 1 cup Gatorade) every 1/2 to 1 hour to prevent dehydration and to provide calories. Report nausea, vomiting, and diarrhea to the physician, because extreme fluid loss may be dangerous. For patients with type 1 diabetes, inability to retain oral fluids, may warrant hospitalization to avoid diabetic ketoacidosis and possibly coma. Although the initial plasma concentration of potassium may be low, normal, or even high, there is a major loss of potassium from body stores and an intracellular to extracellular shift of potassium. Insulin administration, which enhances the movement of potassium from the extracellular fluid into the cells. Frequent (every 2 to 4 hours initially) electrocardiograms and laboratory measurements of potassium are necessary during the first 8 hours of treatment. Potassium replacement is withheld only if hyperkalemia is present or if the patient is not urinating. In addition, fluid replacement enhances the excretion of excessive glucose by the kidneys. After the first few hours, half-normal saline solution is the fluid of choice for continued rehydration, if the blood pressure is stable and the sodium level is not low. Moderate to high rates of infusion (200 to 500 mL per hour) may continue for several more hours. Monitoring fluid volume status involves frequent measurements of vital signs (including monitoring for orthostatic changes in blood pressure and heart rate), lung assessment, and monitoring intake and output. Monitoring for signs of fluid overload is especially important for older patients, those with renal impairment, or those at risk for heart failure. Insulin is usually infused intravenously at a slow, continuous rate (eg, 5 units per hour). Thus, an initial insulin infusion rate of 5 units per hour would equal 25 mL per hour. The insulin is often infused separately from the rehydration solutions to allow frequent changes in the rate and content of rehydration solutions. Insulin must be infused continuously until subcutaneous administration of insulin resumes. Any interruption in adminis- Chapter 41 Assessment and Management of Patients With Diabetes Mellitus 1183 tration may result in the reaccumulation of ketone bodies and worsening acidosis. Even if blood glucose levels are dropping to normal, the insulin drip must not be stopped; rather, the rate or concentration of the dextrose infusion should be increased. The basic biochemical defect is lack of effective insulin (ie, insulin resistance). To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. This condition occurs most often in older people (ages 50 to 70) with no known history of diabetes or with mild type 2 diabetes. Instead, they may tolerate polyuria and polydipsia until neurologic changes or an underlying illness (or family members or others) prompts them to seek treatment. Urine output is monitored to ensure adequate renal function before potassium is administered to prevent hyperkalemia. The electrocardiogram is monitored for dysrhythmias indicating abnormal potassium levels. Vital signs, arterial blood gases, and other clinical findings are recorded on a flow sheet. The mortality rate ranges from 10% to 40%, usually related to an underlying illness. The blood glucose level is usually 600 to 1,200 mg/dL, and the osmolality exceeds 350 mOsm/kg. Mental status changes, focal neurologic deficits, and hallucinations are common secondary to the cerebral dehydration that results from extreme hyperosmolality. The patient is asked to describe symptoms that preceded the diagnosis of diabetes, such as polyuria, polydipsia, polyphagia, skin dryness, blurred vision, weight loss, vaginal itching, and nonhealing ulcers. The blood glucose and, for patients with type 1 diabetes, urine ketone levels are measured. Laboratory values are monitored for metabolic acidosis (ie, decreased pH and decreased bicarbonate level) and for electrolyte imbalance. Once these complications are resolving, nursing care then focuses on long-term management of diabetes, as discussed in this section. Other therapeutic modalities are determined by the underlying illness of the patient and the results of continuing clinical and laboratory evaluation. Treatment is continued until metabolic abnormalities are corrected and neurologic symptoms clear. The patient is asked about major concerns and fears about diabetes; this allows the nurse to assess for any misconceptions or misinformation regarding diabetes. Coping skills are assessed by asking how the patient has dealt with difficult situations in the past. Any misconceptions the patient or family may have regarding diabetes are dispelled (see Table 41-7).