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Urinary tract infections are the most commonly occurring nosocomial infections spasms in head buy carbamazepine 100 mg with mastercard, accounting for 40% of them spasms quadriplegia buy carbamazepine with amex. Every year spasms in back purchase generic carbamazepine pills, about 1 million patients in acute-care hospitals develop nosocomial urinary tract infections, and about 80% of these are associated with the use of indwelling urinary catheters (Phillips, 2000). Most urinary tract infections follow instrumentation of the urinary tract, usually catheterization. The pathogens responsible for catheter-associated urinary tract infections include Escherichia coli and Klebsiella, Proteus, Pseudomonas, Enterobacter, Serratia, and Candida species. Catheters impede most of the natural defenses of the lower urinary tract by obstructing the periurethral ducts, irritating the bladder mucosa, and providing an artificial route for organisms to enter the bladder. Organisms may be introduced from the urethra into the bladder during catheterization, or they may migrate along the epithelial surface of the urethra or external surface of the catheter. The spout of the urinary drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter, and bladder. Scanning electron microscopy has demonstrated that thick layers (biofilms) of organisms often colonize the internal surfaces of catheters and drainage systems (Doyle et al. Suprapubic catheterization allows bladder drainage by inserting a catheter or tube into the bladder through a suprapubic (above the pubis) incision or puncture. The catheter is threaded through the trocar cannula, which is then removed, leaving the catheter in place. Suprapubic catheters may also be used on a long-term basis for women with urethral destruction secondary to long-term indwelling urethral catheters (Addison, 1999a, 1999b). For insertion of the suprapubic catheter, the patient is placed in a supine position and the bladder distended by administering oral or intravenous fluids or by instilling sterile saline solution into the bladder through a urethral catheter. The suprapubic area is prepared as for surgery and the puncture site located about 5 cm (2 in) above the symphysis pubis. The bladder is entered through an incision or through a puncture made by a small trocar (pointed instrument). The catheter or suprapubic drainage tube is threaded into the bladder and secured with sutures or tape; the area around the catheter is covered with a sterile dressing. The catheter is connected to a sterile closed drainage system, and the tubing is secured to prevent tension on the catheter. After the patient voids, the catheter is unclamped, and the residual urine (the amount of urine remaining) is measured. If the amount of residual urine is less than 100 mL on two separate occasions (morning and evening), the catheter is usually removed. If the patient complains of pain or discomfort, however, the suprapubic catheter is usually left in place until the patient can void successfully. When a suprapubic catheter remains in place indefinitely, it is changed regularly at 6- to 12-week intervals (Gujral et al. Patients can usually void sooner after surgery than those with urethral catheters, and they may be more comfortable. The catheter allows greater mobility, permits measurement of residual urine without urethral instrumentation, and presents less risk of bladder infection. The suprapubic catheter is removed when it is no longer necessary, and a sterile dressing is placed over the site. The patient requires liberal amounts of fluid to prevent encrustation around the catheter. Other potential problems include the formation of bladder stones, acute and chronic infections, and problems collecting urine. An enterostomal therapist may be consulted to assist the patient and family in selecting the most suitable urine collection system and to teach them about its use and care. Encrustations arising from urinary salts may serve as a nucleus for stone formation; however, using silicone catheters results in significantly less crust formation. An accurate record of fluid intake and urine output provides essential information about the adequacy of renal function and urinary drainage. The nurse observes the catheter to make sure that it is properly anchored, to prevent pressure on the urethra at the penoscrotal junction in male patients, and to prevent tension and traction on the bladder in both male and female patients. Patients at high risk for urinary tract infection from catheterization need to be identified and monitored carefully. These include women, older adults, and patients who are debilitated, malnourished, chronically ill, immunosuppressed, or diabetic. They are observed for signs and symptoms of urinary tract infection: cloudy malodorous urine, hematuria, fever, chills, anorexia, and malaise. Urine cultures provide the most accurate means of assessing a patient for infection. Bladder ultrasonography can be used for noninvasive measurement of bladder volume. A portable bladder scan can be performed to assess the volume of urine in the bladder, the degree of bladder emptying, and therefore the need for catheterization (Phillips, 2000; Schott-Baer & Reaume, 2001). Therefore, any subtle change in physical condition or mental status must be considered a possible indication of infection and promptly investigated because sepsis may occur before the infection is diagnosed. Figure 44-3 summarizes the sequence of events leading to infection and leakage of urine that often follow long-term use of an indwelling catheter in elderly patients. The catheter is a foreign body in the urethra and produces a reaction in the urethral mucosa with some urethral discharge. Vigorous cleaning of the meatus while the catheter is in place is discouraged, however, because the cleaning action can move the catheter to and fro, increasing the risk of infection. To remove obvious encrustations from the external catheter surface, the area can be washed gently with soap during the daily bath. The catheter is anchored as securely as possible to prevent it from moving in the Urine cultures are obtained as prescribed or indicated in monitoring the patient for infection; many catheters have an aspiration (puncture) port from which a specimen can be obtained. Controversy exists about the usefulness of taking cultures and treating bacteriuria in patients who have symptoms of infection and who have indwelling catheters. Bacteriuria is considered to be inevitable, and overtreatment may lead to resistant strains of bacteria (Suchinski et al. The catheter is secured properly to prevent it from moving, causing traction on the urethra, or being unintentionally removed, and care is taken to ensure that the catheter position permits leg movement. In male patients, the drainage tube (not the catheter) is taped laterally to the thigh to prevent pressure on the urethra at the penoscrotal junction, which can eventually lead to formation of a urethrocutaneous fistula. In female patients, the drainage tubing attached to the catheter is taped to the thigh to prevent tension and traction on the bladder. Care is taken to ensure that any patient who is confused does not remove the catheter with the retention balloon still inflated. This could cause bleeding and considerable injury to the urethra (Phillips, 2000). As a result, the detrusor may not immediately respond to bladder filling when the catheter is removed, resulting in either urine retention or urinary incontinence. This condition, known as postcatheterization detrusor instability, can be managed with bladder retraining (Chart 44-6). Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours.
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Discharge caused by Trichomonas species infection is usually frothy muscle relaxant wiki buy cheap carbamazepine line, copious muscle relaxant at walgreens buy cheap carbamazepine 100 mg, and malodorous muscle relaxant gel generic carbamazepine 200mg without prescription. Discharge caused by Candida species infection is usually thick and white-yellow and has a cottage-cheese appearance. Table 46-3 summarizes the characteristics of vaginal discharge found in different conditions. It is smooth in young girls and thickens after puberty, with many rugae (folds) and redundancy in the epithelium. In menopausal women, the vagina thins and has fewer rugae because of decreased estrogen. Bimanual Palpation To complete the pelvic examination, the examiner performs a bimanual examination from a standing position. The examination is performed with the forefinger and middle finger of the gloved and lubricated hand. These fingers are placed in the vaginal orifice, while the other fingers are held tightly out of the way, with the thumb completely adducted. The fingers are advanced vertically along the vaginal canal, and the vaginal wall is palpated. Any firm part of the vaginal wall may represent old scar tissue from childbirth trauma but may also require further evaluation. Movement of the abdominal wall causes the body of the uterus to descend, and the pear-shaped organ becomes freely movable between the abdominal examining hand and the fingers of the pelvic examining hand. Fixation of the uterus in the pelvis may be a sign of endometriosis or malignancy. The body of the uterus is normally twice the diameter and twice the length of the cervix, curving anteriorly toward the abdominal wall. The fingers of the hand examining the pelvis are moved first to one side, then to the other, while the hand palpating the abdominal area is moved correspondingly to either side of the abdomen and downward. The adnexa (ovaries and fallopian tubes) are trapped between the two hands and palpated for an obvious mass, tenderness, and mobility. Commonly, the ovaries are slightly tender, and the patient is informed that slight discomfort on palpation is normal. To prevent cross-contamination between the vaginal and rectal orifices, the examiner puts on new gloves. A gentle movement of these fingers toward each other compresses the posterior vaginal wall and the anterior rectal wall and assists the examiner in identifying the integrity of these structures. Ongoing explanations are provided to reassure and educate the patient about the procedure. Pap smears that reveal mild inflammation or atypical squamous cells are usually repeated in 3 to 6 months, with findings often returning to normal. Patients are apprehensive because many women incorrectly assume that an abnormal Pap smear means cancer. If a specific infection is causing inflammation, it is treated appropriately, and the Pap smear is repeated. If the repeat Pap smear reveals atypical squamous cells, then a colposcopy is appropriate. If the Pap smear results are abnormal, prompt notification, evaluation, and treatment are crucial. Many women do not adhere to recommendations-particularly young women, those of low socioeconomic status, minorities, women who have difficulty coping with the diagnosis, and those without social support. Fear, lack of understanding, and childcare responsibilities have all been identified by women as reasons for poor follow-up. Women with a history of abuse, obese women, and women who had a negative gynecologic experience may also find returning for follow-up difficult (Wee, McCarthy, Davis & Phillips, 2000). Intensive telephone counseling, tracking systems, brochures, videos, and financial incentives have all been used to encourage followup. Nurses can provide clear explanations and emotional support along with a carefully designed follow-up protocol designed to meet the needs of their specific patient population (DeRemer Abercrombie, 2001). Yearly examinations can help prevent problems of the reproductive tract in aging women. If a woman delivered her children at home, she may never have had a pelvic examination. An important role of the nurse is to encourage an annual gynecologic examination for all women. The nurse can make the examination a time for education and reassurance rather than a time of embarrassment. Perineal pruritus is common in elderly women and should be evaluated because it may indicate a disease process (diabetes or malignancy). It may also indicate vulvar dystrophy, a thickened or whitish discoloration of tissue that needs biopsy to rule out abnormal cells. With relaxing pelvic musculature, uterine prolapse and relaxation of the vaginal walls can occur. Appropriate evaluation and surgical repair can provide relief if the patient is a candidate for surgery. After surgery, the patient needs to know that tissue repair and healing may require additional time. Pessaries (latex devices that provide support) are often used if surgery is contraindicated or before surgery to see if surgery can be avoided. Use of a pessary requires the patient to have routine gynecologic examinations to monitor for irritation or infection. George Papanicolaou discovered the value of examining exfoliated cells for malignancy in the 1930s. Due to the effectiveness of the Pap smear as a screening method, cervical cancer is now less common than breast or ovarian cancer. A Thin-prep Pap specimen is immersed in a solution rather than being placed on a slide. The patient should be instructed not to douche before this examination to avoid washing away cellular material. The Pap smear should be performed when the patient is not menstruating because blood usually interferes with interpretation. The proper technique for obtaining a cervical specimen for cytologic study is described in Chart 46-6. The Bethesda Classification system (Chart 46-7) has been developed to promote consistency in reporting Pap smear results and to assist in standardizing management guidelines (Solomon, Davey, Kurman et al. The colposcope is a portable microscope (magnification from 10Ч to 25Ч) that allows the examiner to visualize the cervix and obtain a sample of abnormal tissue for analysis. Nurse practitioners and gynecologists require special training in this diagnostic technique. After inserting a speculum and visualizing the cervix and vaginal walls, the examiner applies acetic acid to the cervix.
- Congenital cardiovascular malformations
- Congenital hypomyelination neuropathy
- X-linked severe combined immunodeficiency
- Pseudomonas infection
- Hyperinsulinism in children, congenital
- Vitamin D resistant rickets
- Geleophysic dwarfism
- Gestational trophoblastic disease
- Sickle cell anemia
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The current mammograms are compared with previous mammograms muscle relaxer jokes cheap 200 mg carbamazepine with visa, and any changes indicate a need for further investigation muscle relaxer 800 mg order carbamazepine without a prescription. Mammography may detect a breast tumor before it is clinically palpable (ie spasms behind knee buy cheap carbamazepine 100mg line, 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. The biopsy involves excising the lesion and sending it to the laboratory for pathologic examination. Depending on the clinical situation, a frozen section may be done at the time of the biopsy (a small piece of the mass or lesion is given a provisional diagnosis by the pathologist), so that the surgeon can provide the patient with a diagnosis in the recovery room. Complete excision of the area may not be possible or immediately beneficial to the patient, depending on the clinical situation. This procedure is used when a tumor is relatively large and close to the skin surface and the surgeon strongly suspects that the lesion is a carcinoma. A long, thin wire is inserted, usually painlessly, through a needle before the excisional biopsy under mammographic guidance to ensure that the wire tip designates the area to undergo biopsy. The wire remains in place after the needle is withdrawn to ensure a precise biopsy. The patient is then taken to the operating room, where the surgeon follows the wire down and excises the area around the wire tip. The tissue removed is x-rayed at the time of the procedure; these specimen x-rays, along with follow-up mammograms taken several weeks later (after the site has healed), verify that the area of concern was located and removed. It is a highly sensitive, although not specific, test and serves as an adjunct to mammography. A surgeon performs the procedure when there is a palpable lesion, or a radiologist performs it under x-ray guidance for nonpalpable lesions. Injection of a local anesthetic may or may not be used, but most times the surgeon or radiologist inserts a 21- or 22-gauge needle attached to a syringe into the site to be sampled. This cytologic material is spread on a slide and sent to the laboratory for analysis. False-negative or false-positive results are possible, and clinical follow-up depends on the level of suspicion about the breast lesion. Stereotactic Biopsy Stereotactic biopsy, also an outpatient procedure, is performed for nonpalpable lesions found on mammography. The patient lies prone on a special table, and the breast is positioned through an opening in the table and compressed for a mammogram. Next, a local anesthetic is injected into the entry site on the breast, a core needle is inserted, and samples of the tissue are taken for pathologic examination. If the lesion is small, a clip is placed at the site of the biopsy, so that a specific area can be visualized again as another mammogram is performed. This technique allows ac- Nursing Care of the Patient Undergoing a Breast Biopsy Breast biopsies are one of the most common ambulatory surgical procedures performed, with 80% of the results negative for malignancy (Norris, 2001). The nurse also must give the patient an opportunity to address issues and concerns related to the biopsy. The nurse instructs the patient to avoid use of agents that can interfere with blood clotting and increase the risk for bleeding. Among these agents are nonsteroidal anti-inflammatory drugs, vitamin E supplements, herbal substances (such as gingko biloba and garlic supplements), warfarin, and products containing aspirin. The patient may be instructed not to eat or drink after midnight, depending on the type of biopsy planned. Most breast biopsy procedures today are performed with the use of moderate sedation and local anesthesia; thus, the recovery period is relatively brief. Postoperative assessment includes monitoring the effects of the anesthesia and inspection of the dressing covering the incision.
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A combination of physiotherapy spasms homeopathy 400 mg carbamazepine with amex, psychotherapy yellow round muscle relaxant pill purchase 100 mg carbamazepine with mastercard, medication therapy muscle relaxant natural remedies order line carbamazepine, and support group participation may help reduce the depression that often occurs. These feelings may be due, in part, to physical slowness and the great effort that even small tasks require. Patients are assisted and encouraged to set achievable goals (eg, improvement of mobility). Because parkinsonism tends to lead to withdrawal and depression, patients must be active participants in their therapeutic program, including social and recreational events. There should be a planned program of activity throughout the day to prevent too much daytime sleeping as well as disinterest and apathy. Every effort should be made to encourage patients to carry out the tasks involved in meeting their own daily needs and to remain independent. Doing things for the patient merely to save time is contrary to the basic goal of improving coping abilities and promoting a positive self-concept. Care must be taken not to overwhelm the patient and family with too much information early in the disease process. The education plan should include a clear explanation of the disease, assisting the patient to remain functionally independent as long as possible. Every effort is made to explain the nature of the disease and its management to offset disabling anxieties and fears. The patient and family must be taught about the effects and side effects of medications and about the importance of reporting side effects to the physician (Chart 65-4). Family members often serve as caregivers, with home care or community services available to assist in meeting health care needs as the disease progresses. The family caregiver may be under considerable stress from living with and caring for a person with a significant disability. Providing information about treatment and care prevents many unnecessary problems. The caregiver is included in the plan and may be advised to learn stress reduction techniques, to include others in the caregiving process, to obtain periodic relief from responsibilities, and to have a yearly health assessment. Allowing family members to express feelings of frustration, anger, and guilt is often helpful to them. In the advanced stages, patients usually enter long-term care facilities when family support is absent. Periodically, admission to an acute care facility may be necessary for changes in medical management or treatment of complications. Nurses provide support, education, and monitoring of patients over the course of illness. The nurse involved in home and continuing care needs to remind patients and family members of the need to address health promotion needs such as screening for hypertension and stroke risk assessments in this predominantly elderly population. Redefinition: Coping with normal results from predictive gene testing for neurodegenerative disorders. Purpose Predictive testing for an inherited neurodegenerative disease is a source of intense stress for adults. The purpose of this study was to describe the psychosocial impact and coping process of normal (negative) results from predictive testing for an inherited neurodegenerative disease. Study Sample and Design the study used a qualitative, descriptive design and the constant comparative method of data analysis. The sample included 8 females, the age range was 33 to 59 years, 80% were married, and 80% had known they were at risk for one of the diseases for more than 5 years. The redefinition occurred in the following three domains: redefinition of self, relationships with family, and role in society. The process evolved from a personal level at 1 month to a more future-oriented perspective at 6 months following normal gene test results. The coping process following negative results (ie, absence of gene for the disease) evolves from a personal focus at 1 month to a broader future perspective at 6 months after testing. These components of the redefinition process are important considerations in planning interventions to promote coping with normal gene results within at-risk families during an extremely stressful time. Researchers now believe that a building block for protein called glutamine abnormally collects in the cell nucleus, causing cell death. Onset usually occurs between the ages of 35 and 45 years, although about 10% of patients are children. Patients succumb in 10 to 20 years to heart failure, pneumonia, or infection, or as a result of a fall or choking. Clinical Manifestations the most prominent clinical features of the disease are abnormal involuntary movements (chorea), intellectual decline, and, often, emotional disturbance. As the disease progresses, a constant writhing, twisting, uncontrollable movement may involve the entire body. These motions are devoid of purpose or rhythm, although patients may try to turn them into purposeful movement. Facial movements Pathophysiology the basic pathology involves premature death of cells in the striatum (caudate and putamen) of the basal ganglia, the region deep within the brain involved in the control of movement. There is also loss of cells in the cortex, the region of the brain associated with thinking, memory, perception, and judgment, and in the Chapter 65 Management of Patients With Oncologic or Degenerative Neurologic Disorders 1987 produce tics and grimaces. Speech is affected, becoming slurred, hesitant, often explosive, and eventually unintelligible. Chewing and swallowing are difficult, and there is a constant danger of choking and aspiration. As with speech, the gait becomes disorganized to the point that ambulation eventually is impossible. Although independent ambulation should be encouraged for as long as possible, a wheelchair usually becomes necessary. Eventually, the patient is confined to bed when the chorea interferes with walking, sitting, and all other activities. Initially, the patient generally is aware that the disease is responsible for the myriad dysfunctions that are occurring. The mental and emotional changes that occur may be more devastating to the patient and family than the abnormal movements. In the early stages, patients are particularly subject to uncontrollable fits of anger, profound, often suicidal depression, apathy, anxiety, psychosis, or euphoria (Hofmann, 1999). Hallucinations, delusions, and paranoid thinking may precede the appearance of disjointed movements. Psychotherapy aimed at allaying anxiety and reducing stress may be beneficial (Hofman, 1999). Surgically implanted fetal neural allografts are being tested in hopes of improving the functional, motor, and cognitive function of patients (BachoudLevi, Remy, Nguyen et al. The needs of the patient and family for education depend on the nature and severity of physical, cognitive, and psychological changes experienced by the patient.
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One explanation for this could be difficulty collecting from particular providers muscle relaxant list by strength purchase carbamazepine 100mg on line. Management should consider identifying the sources of that data and offering outreach or training to muscle relaxant jaw clenching buy 200 mg carbamazepine amex prevent this problem from occurring in the future muscle relaxer x buy carbamazepine pills in toronto. The Cumulative Plan Activity Report is delivered to users on the second business day of each month. Field Description A service year of 9999 on a Monthly or Cumulative Plan Activity Report indicates that the data submitted have not been appropriately stored and have been rejected. The submission numbers are higher for previous months than the more current dates of service months, which indicate a lag between the dates of service provided, collected, and submitted. Comparing Figure 8K to the Cumulative Plan Activity Report (Figure 8M) illustrates April transactions accounted for very few of the January, February, and March numbers indicating collection and submission problems in the month of April. This can be explained by new staff, competing internal priorities, or system implications. Management should consider the root cause of this decline to prevent this in the future. The report shows the plan corrected the previously submitted errors and began submitting data more accurately. This includes files submitted in test and production arrayed by error code and provider type. Total number of diagnosis clusters submitted during the report period the total number of diagnosis clusters submitted during the report period and accepted without errors. The total number of diagnosis clusters submitted during the report period and rejected with errors. Identifies the principal inpatient provider source and the quantity of each error code associated with principal inpatient during the report period. Identifies the other inpatient provider source and the quantity of each error code associated with other inpatient during the report period. Identifies the outpatient provider source and the quantity of each error code associated with outpatient during the report period. Identifies the physician provider source and the quantity of each error code associated with physician during the report period. There were also high counts of rejected clusters associated with error codes 408 and 409. Management should investigate possible discrepancies between their internal enrollment systems and the common tables. Because this report provides a summary of the status of data submitted for each month, it allows organizations to check, on a monthly basis, the number of diagnosis clusters submitted overall, the number of clusters submitted by data source (hospital inpatient, hospital outpatient, and physician), and the status of those clusters. Reading the report from left to right, the report identifies the number of clusters submitted in the reporting month (April 2004 in Figure 8M) for every month in the data collection period. Example: 10 Figure 8P on the next page illustrates a Cumulative Plan Activity Report for April 2004. This plan is doing well because it is submitting the vast majority of its hospital inpatient data for service through dates within 90 days of the report date. If the organization is submitting data at about the same pace received, then the number of clusters seems appropriate, at least for hospital inpatient. Consistent collection lags of more than 90 days may cause problems in submitting data in a timely manner. The plan in this example has a rejection rate for hospital inpatient services at about nine percent during April. If the other provider type information reflects a similar rate of rejected data, it is higher than it should be and a cause for investigation. Low submission months or significant spikes in the data submitted for a month may indicate a problem in either data collection from providers and physicians, or issues related to data submission. Generally, each quarter of data should reflect about 25 percent of the expected data for the collection period. For an organization just starting operations, a steady increase in data submissions from month to month is expected. If data are not submitted in a timely and consistent manner, there may be a data collection issue. Also, it may be necessary to check that third party billers used by providers (especially large volume providers) are current on risk adjustment procedures and the importance of timely filing. When necessary, they should obtain the proper documentation to support diagnoses and maintain an efficient system for tracking diagnoses back to medical records. Example: 11 If the appropriate amount of data are collected from providers and physicians for a month or quarter, but only a fraction of the data are submitted, there may be an over filtering issue, i. If an organization is submitting well above the benchmark levels, it should check to see if proper filtering occurred before submission. Submitting data from these non-covered provider types violates the instructions and will probably cause the diagnostic-to-beneficiary ratios to be high. Learning Objectives (Slide 3) At the completion of this module, participants will: Understand the systems and processes used to calculate the risk scores. Determine how the organization can use risk adjustment processing and management reports to ensure the accuracy of payment. Figure 9A - Risk Score Calculation Process Risk Adjustment Processing System Component Demographics Provides all of the diagnoses submitted in the diagnosis clusters. These data include all diagnoses for the data collection period from the three types of data sources: physician services, hospital outpatient, and hospital inpatient. Each model determines a new enrollee factor for individuals who had fewer than 12 months of Part B enrollment during the data collection period. Only the most severe disease classification within a hierarchy is shown in the output. Based on this information, an output file is created and sent to the payment system. Note: For each risk adjustment model run, the process is repeated, updating the data used for the model to include new diagnoses received for the data collection period, as well as changes in any of the demographic factors. This section of the training module describes each of the tools, identifies the method of access and timeframe, and provides information on how an organization can use the tool to increase the accuracy of payment projections. Organizations that employ automated update processes for their databases typically use the Return File. To use this report, an individual at the health plan normally downloads the report, prints it, and then manually updates their diagnosis records to indicate which diagnoses were rejected. This sample database includes only the minimal components required for verifying the accuracy of the number of clusters stored for risk score calculation and elements that define a duplicate cluster. The cumulative report reflects the total number of diagnoses stored to date for the H number. The database should reflect all diagnosis clusters stored for the health plan for the data collection period. The program assigns each beneficiary to an appropriate age/sex grouping, and adds in the interactions for Medicaid, disabled, and previously disabled.
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Between 7% and 10% of women in the United States are affected by this disorder (Olive & Pritts spasms left upper abdomen generic carbamazepine 400 mg with amex, 2001) spasms top of stomach discount carbamazepine american express. In order of frequency muscle relaxant 800 mg cheap carbamazepine 100mg on-line, pelvic endometriosis involves the ovary, uterosacral ligaments, cul-de-sac, rectovaginal septum, uterovesical peritoneum, cervix, outer surface of the uterus, umbilicus, laparotomy scar tissue, hernial sacs, and appendix. Endometriosis has been diagnosed more frequently as a result of the increased use of laparoscopy. There is a high incidence among patients who bear children late and among those who have fewer children. In countries where tradition favors early marriage and early childbearing, endometriosis is rare. There also appears to be a familial predisposition to endometriosis; it is more common in women whose close female relatives are affected. Other factors that may suggest increased risk include a shorter menstrual cycle (less than every 27 days), flow longer than 7 days, outflow obstruction, and younger age at menarche. Characteristically, endometriosis is found in young, nulliparous women between the ages of 25 and 35 years. Assessment and Diagnostic Findings A health history, including an account of the menstrual pattern, is necessary to elicit specific symptoms. On bimanual pelvic examination, fixed tender nodules are sometimes palpated and uterine mobility may be limited, indicating adhesions. In stage 1, the patient has superficial or minimal lesions; stage 2, mild involvement; stage 3, moderate involvement; and stage 4, deep involvement and dense adhesions, with obliteration of the cul-de-sac. If the woman does not have symptoms, routine examination may be all that is required. Pregnancy often alleviates symptoms because neither ovulation nor menstruation occurs. Hormonal therapy is effective in suppressing endometriosis and relieving dysmenorrhea (menstrual pain). Side effects that may occur with oral contraceptives include fluid retention, weight gain, or nausea. Several types of hormonal therapy are also available in addition to the oral contraceptives. A synthetic androgen, danazol (Danocrine), causes atrophy of the endometrium and subsequent amenorrhea. The medication inhibits the release of gonadotropin with minimal overt sex hormone stimulation. The drawbacks of this medication are that it is expensive and may cause troublesome side effects such as fatigue, depression, weight gain, oily skin, decreased breast size, mild acne, hot flashes, and vaginal at- Pathophysiology Misplaced endometrial tissue responds to and depends on ovarian hormonal stimulation. During menstruation, this ectopic tissue bleeds, mostly into areas having no outlet, which causes pain and adhesions. The lesions are typically small and puckered, with a blue/brown/gray powder-burn appearance and brown or blueblack appearance, indicating concealed bleeding. They may also have an atypical appearance as red, white, petechial, and reddishbrown implants. Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as a pseudo- Chapter 47 Management of Patients With Female Reproductive Disorders 1429 rophy. Side effects are related to low estrogen levels (eg, hot flashes and vaginal dryness). Leuprolide, another medication, is injected monthly to suppress hormones, induce an artificial menopause, and thereby avoid menstrual effects and relieve endometriosis. Most women continue treatment despite side effects, and symptoms diminish for 80% to 90% of women with mild to moderate endometriosis. Assisted reproductive techniques may be warranted and effective in women with infertility secondary to endometriosis (Olive & Pritts, 2002). Hormonal medications are not used, however, in patients with a history of abnormal vaginal bleeding or liver, heart, or kidney disease. Bone density is followed carefully because of the risk of bone loss; hormone therapy is usually short-term. Laparoscopy may be used to fulgurate (cut with high-frequency current) endometrial implants and to release adhesions. Laser therapy vaporizes or coagulates the endometrial implants, thereby destroying this tissue. Other surgical options include endocoagulation and electrocoagulation, laparotomy, abdominal hysterectomy, oophorectomy, bilateral salpingo-oophorectomy, and appendectomy. For women older than 35 or those willing to sacrifice reproductive capability, total hysterectomy is an option. Malignant Conditions Malignant tumors of the female reproductive system (excluding breast cancer) occur in 274,000 women and are estimated to kill more than 27,000 women in the United States each year. Estimated incidence and estimated mortality for the United States in 2000 are (American Cancer Society, 2002): Cervical cancer (estimates do not include in situ cancers): 13,000 new cases, 4,100 deaths Uterine cancer: 39,300 new cases, 6,600 deaths Ovarian cancer: 23,300 new cases, 13,900 deaths Vaginal cancer: 2,000 new cases, 800 deaths Vulvar cancer: 3,800 new cases, 800 deaths Although some cancers are difficult to detect or prevent, yearly pelvic examination with a Pap smear is a painless and relatively inexpensive method of early detection. Health care providers can encourage women to follow this health practice by providing nonstressful examinations that are educational and supportive and offering an opportunity for the patient to ask questions and clarify misinformation. If more women understood that the pelvic examination and Pap smear do not have to be uncomfortable or embarrassing, early detection rates would undoubtedly improve, and lives would be saved. During the past 20 years, the incidence of invasive cervical cancer has decreased from 14. It is less common than it once was because of early detection of cell changes by Pap smear. However, it is still the third most common female reproductive cancer and affects about 13,000 women in the United States every year (American Cancer Society, 2002). Cervical cancer occurs most commonly in women ages 30 to 45, but it can occur as early as age 18. Patient goals include relief of pain, dysmenorrhea, dyspareunia, and avoidance of infertility. As the treatment progresses, the woman with endometriosis and her partner may find that pregnancy is not easily possible, and the psychosocial impact of this realization must be recognized and addressed. Alternatives, such as in vitro fertilization or adoption, may be discussed at an appropriate time and referrals offered. The Endometriosis Association (listed at the end of this chapter) is a helpful resource for patients seeking further information and support for this condition, which can cause disabling pain and severe emotional distress. Most cancers originate in squamous cells, while the remainder are adenocarcinomas or mixed adenosquamous carcinomas. Most cervical cancers, if not detected and treated, spread to regional pelvic lymph nodes, and local recurrence is not uncommon. If symptoms are present, they may go unnoticed as a thin watery vaginal discharge often noticed after intercourse or douching.
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The epidermis is the outermost layer of the skin and is composed of several layers of keratinocytes that change character as they migrate to muscle relaxant m 58 59 100 mg carbamazepine sale the surface kidney spasms causes purchase carbamazepine 200 mg without prescription. The stratum corneum muscle relaxant 1 buy carbamazepine 200 mg on-line, the outer layer Temperature Regulation the body continuously produces heat as a result of the metabolism of food, which produces energy. Three major physical processes are involved in loss of heat from the body to the environment. The first process, radiation, is the transfer of heat to another object of Chapter 55 lower temperature situated at a distance. The second process, conduction, is the transfer of heat from the body to a cooler object in contact with it. Heat transferred by conduction to the air surrounding the body is removed by the third process, convection, which consists of movement of warm air molecules away from the body. Heat is conducted through the skin into water molecules on its surface, causing the water to evaporate. The water on the skin surface may be from insensible perspiration, sweat, or the environment. When the ambient temperature is very high, however, radiation and convection are ineffective, and evaporation becomes the only means for heat loss. Under normal conditions, metabolic heat production is balanced by heat loss, and the internal temperature of the body is maintained constant at approximately 37°C (98. The rate of heat loss depends primarily on the surface temperature of the skin, which is a function of the skin blood flow. Under normal conditions, the total blood circulated through the skin is approximately 450 mL per minute, or 10 to 20 times the amount of blood required to provide necessary metabolites and oxygen. Blood flow through these skin vessels is controlled primarily by the sympathetic nervous system. Increased blood flow to the skin results in more heat delivered to the skin and a greater rate of heat loss from the body. In contrast, decreased skin blood flow decreases the skin temperature and helps conserve heat for the body. When the temperature of the body begins to fall, as occurs on a cold day, the blood vessels of the skin constrict, thereby reducing heat loss from the body. Sweating does not occur until the core body temperature exceeds 37°C, regardless of skin temperature. In extremely hot environments, the rate of sweat production may be as high as 1 L per hour. Under some circumstances (eg, emotional stress), sweating may occur as a reflex and may be unrelated to the need to lose heat from the body. Assessment of Integumentary Function 1643 Vitamin Production Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus. Before conducting a skin assessment, the nurse needs to be aware of significant changes that occur with aging. The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Cellular changes associated with aging include a thinning at the junction of the dermis and epidermis. This results in fewer anchoring sites between the two skin layers, so that even minor injury or stress to the epidermis can cause it to shear away from the dermis. This phenomenon of aging may account for the increased vulnerability of aged skin to trauma. With increasing age, the epidermis and dermis thin and flatten, causing wrinkles, sags, and overlapping skin folds. Loss of the subcutaneous tissue substances of elastin, collagen, and subcutaneous fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. These vascular changes contribute to the delayed wound healing commonly seen in the elderly patient. Sweat and sebaceous glands decrease in number and functional capacity, leading to dry and scaly skin. Reduced hormonal levels of androgens are thought to contribute to declining sebaceous gland function. Hair growth gradually diminishes, especially over the lower legs and dorsum of the feet. Other functions affected with normal aging include the barrier function of skin, sensory perception, and thermoregulation. Photoaging, or damage from excessive sun exposure, has detrimental effects on the normal aging of skin. A lifetime of outdoor work or outdoor activities (eg, construction work, lifeguarding, sunbathing) without prudent use of sunscreens can lead to profound wrinkling; increased loss of elasticity; mottled, pigmented areas; cutaneous atrophy; and benign or malignant lesions. Recognizing these lesions enables the examiner to assist the patient to feel less anx- Immune Response Function Research findings (Demis, 1998) indicate that several dermal cells (ie, Langerhans cells, interleukin-1producing keratinocytes, and subsets of T lymphocytes) and three varieties of human leukocyte antigen (ie, protein marker on white blood cells indicating the type of cell) are important components of the immune system. Ongoing research is expected to more clearly define the role of these dermal cells in immune function. Gerontologic Considerations the skin undergoes many physiologic changes associated with normal aging. Chart 55-1 summarizes some skin lesions that are expected to appear as the skin ages. These are normal and require no special attention unless the skin becomes infected or irritated. If indicated, refer for further genetic counseling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing, and gene-based interventions. Provide support to families with newly diagnosed geneticrelated integumentary conditions. Participate in management and coordination of care for patients with genetic conditions and for individuals predisposed to develop or pass on a genetic condition. Note gender of affected individuals (eg, mostly females with incontinentia pigmenti, mostly males with hypohidrotic ectodermal dysplasia). Inquire about the presence of other clinical features, such as unusual hair, teeth, or nails; thrombocytopenia; recurrent infections. The names of cosmetics, soaps, shampoos, and other personal hygiene products are obtained if there have been any recent skin problems noticed with the use of these products. The health history contains specific information about the onset, signs and symptoms, location, and duration of any pain, itching, rash, or other discomfort experienced by the patient. The accompanying assessment chart lists selected questions useful in obtaining appropriate information (Chart 55-2). Assessment of Integumentary Function 1645 Assessing General Appearance the general appearance of the skin is assessed by observing color, temperature, moisture or dryness, skin texture (rough or smooth), lesions, vascularity, mobility, and the condition of the hair and nails. Skin color varies from person to person and ranges from ivory to deep brown to almost pure black. The skin of exposed portions of the body, especially in sunny, warm climates, tends to be more pigmented than the rest of the body.
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There is a new enrollee dialysis model that is used for beneficiaries without sufficient Medicare history for risk adjustment spasms before falling asleep discount generic carbamazepine canada. If a beneficiary receives a kidney transplant muscle relaxant headache buy generic carbamazepine 200mg, the plan is paid using the transplant model for the month of the transplant and the two subsequent months spasms back pain and sitting purchase genuine carbamazepine on-line, regardless of whether the beneficiary returns to dialysis status during that time period. The transplant model uses the Medicare costs for these months to assign a factor to each of the months. There are two sets of factors, one for a kidney transplant and one for a simultaneous kidney/pancreas transplant. After the three-month transplant period, the plan is paid under a model similar to the M+C general model but with added factors indicating either that the beneficiary had a kidney transplant within 9 months or the transplant was further in the past. There are five tables with more detail on the model structure for each of the tiers. One of the tables has the hierarchical structure of the models reflecting that, for closely related disease groups, a code for a higher cost group will take precedence over a code for a related lower group. The payment factor for a transplant is based on the average Medicare costs for transplant admissions and the two months subsequent to discharge. Instead of a dialysis risk factor being the basis for payment in those months, a transplant factor is used and applied to the dialysis ratebook. After the three months, payment is made at the functioning graft rate or at the dialysis rate, as appropriate. The factor is higher during the months immediately after the transplant period to account for a high level of monitoring and services. For payment in any month, duration is measured from the month of transplant to the first day of that month. Learning Objectives (Slide 3) At the completion of this module, participants will be able to: Identify common risk adjustment terminology. The Medicare Beneficiary Database maintains Medicare beneficiary eligibility data. Each quarterly submission should represent approximately one-fourth of the data that the M+C organization will submit during a data collection year. If the data fail the front-end checks, the complete file is rejected at the front end. Interim hospital inpatient bills (112, 113, and 114 bill types) must not be submitted. If an M+C organization receives interim bills, the organization should submit the hospital inpatient diagnoses on receipt of the final bill (114). This will require M+C organizations to meet three submission deadlines-the first Friday in September, the first Friday in March of each year, and a yearly reconciliation deadline of May 15 beginning in 2005. The only exception would be from midnight Saturday through noon Sunday when systems and equipment are routinely maintained. Finally, the site provides up-to-date system status alerts and answers to frequently asked questions about risk adjustment. Onsite consultation visits provide M+C organizations with the opportunity to gain valuable information about risk adjustment data submission and data validation processes. The program presents the basics about the risk adjustment process for M+C organizations and staff new to risk adjustment. The collection of data from the appropriate risk adjustment sources and formats is critical for accurate risk adjusted payment for your organization. Learning Objectives (Slide 3, 3) At the completion of this module, participants will be able to: Identify the data elements required for risk adjustment. Discuss factors to consider when determining the method for collection of diagnostic data. For inpatient services, these dates are different, reflecting the dates of admission to and discharge from a facility. Date span is the number of days between the From Date and Through Date for a reported diagnosis. For risk adjustment, the date span is important to determine if the reported diagnosis cluster falls within the data reporting period. M+C organizations are responsible for determining provider type based on the source of the data. These sources are hospital inpatient facilities, hospital outpatient facilities, and physicians. A network hospital should have a Medicare provider billing number as a hospital inpatient facility. Table 3B identifies covered and non-covered facilities with regard to risk adjustment data collection. When submitting hospital inpatient data, M+C organizations must make a distinction between the principal diagnosis and other diagnoses. As with hospital inpatient facilities, the M+C organization must determine which facilities are Medicare certified, network, or non-network. The Medicare provider number is the most appropriate indicator in determining the appropriateness of the covered hospital entities for the purposes of risk adjustment data collection. Table 3D illustrates the steps M+C organizations may use to identify the provider numbers of facilities. Obtain the provider number and determine if the number is in an acceptable range for risk adjustment. Hospital inpatient (and hospital outpatient) data have associated Medicare provider numbers. All network hospital/facilities must be Medicare certified and will have a Medicare provider number. The first two characters are numerals and represent the state/territory as illustrated in Table 3E. The third character may be a numeral or a letter, with the exception of U, W, Y, Z, 5 or 6. These exceptions indicate that the service was provided in a swing bed component of a hospital or a skilled nursing facility. As an additional check, refer to Tables 3F and 3G, which provide the only acceptable ranges for hospital facilities. The tables reflect the range of provider numbers for risk adjustment covered hospital entities. Risk adjustment data are not acceptable when received from facilities with numbers outside the ranges. Skilled nursing facilities and home health care are not covered entities for risk adjustment data. The following two tables (3F and 3G) provide the range of potential characters for inpatient and outpatient facility services. This web-based search database allows M+C organizations the opportunity to access the Medicare provider number by entering key words, city, state, zip code, or area code. When using the search tool, users should be aware of the following: the most effective search option is to select the state where the provider is located.
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Because your procedure may require use of contrast material that is swallowed or injected into your bloodstream muscle spasms 6 letters proven carbamazepine 100 mg, the radiologist or technologist may ask if you have allergies of any kind muscle relaxer 800 mg order cheapest carbamazepine, including allergies to muscle relaxants knee pain purchase carbamazepine 200mg free shipping food or drugs, hay fever, hives or allergic asthma. The radiologist should also know if you have any serious health problems and what surgeries you have undergone. Women should always tell their doctor and technologist if there is a chance they are pregnant. Pregnant women should not receive gadolinium contrast unless absolutely necessary. If you have claustrophobia (fear of enclosed spaces) or anxiety, you may want to ask your doctor to prescribe a mild sedative prior to your exam. If you have the pamphlet, bring it to the attention of the scheduler before the exam. You should also bring any pamphlet to your exam in case the radiologist or technologist has any questions. However, a recently placed artificial joint may require the use of a different imaging exam. Tell the technologist or radiologist about any shrapnel, bullets, or other metal that may be in your body. Foreign bodies near and especially lodged in the eyes are very important because they may move or heat up during the scan and cause blindness. Tooth fillings, braces, eyeshadows and other cosmetics usually are not affected by the magnetic field. Your child may need to be sedated in order to hold still adequately during the procedure. If this is the case, you will be given instructions for your child about not eating or drinking several hours prior to sedation and the examination. Your child will be discharged when the nurses and physicians believe he/she is sufficiently awake to be safely sent home. They are especially helpful for examining larger patients or those with claustrophobia. Instead, radio waves re-align hydrogen atoms that naturally exist within the body. As the hydrogen atoms return to their usual alignment, they emit different amounts of energy depending on the type of body tissue they are in. Other coils are located in the machine and, in some cases, are placed around the part of the body being imaged. These coils send and receive radio waves, producing signals that are detected by the machine. A computer processes the signals and creates a series of images, each of which shows a thin slice of the body. Straps and bolsters may be used to help you stay still and maintain your position. Devices that contain coils capable of sending and receiving radio waves may be placed around or next to the area of the body being scanned. The technologist will perform the exam while working at a computer outside of the room. Sedation may be arranged for anxious patients, but fewer than one in 20 require it. If contrast material is used, there may be brief discomfort during initial placement of the intravenous catheter line. The oral contrast used at some institutions may have an unpleasant taste and cause temporary fullness, but most patients tolerate it well. You will know when images are being recorded because you will hear and feel loud tapping or thumping sounds. You will be provided with earplugs or headphones to reduce the sounds made by the scanner. However, you will be asked to keep the same position without moving as much as possible. However, the technologist will be able to see, hear and speak with you at all times using a two-way intercom. Many facilities allow a friend or parent to stay in the room if they have also been screened for safety. Children will be given appropriately sized earplugs or headphones during the exam. Some patients may have a temporary metallic taste in their mouth after the contrast injection. On very rare occasions, a few patients experience side effects from the contrast material. It is very rare that patients experience hives, itchy eyes or other allergic reactions to the contrast material. A radiologist, a doctor trained to supervise and interpret radiology exams, will analyze the images. The radiologist will send a signed report to your primary care or referring physician, who will share the results with you. However, it may cause implanted medical devices to malfunction or cause distortion of the images. Nephrogenic systemic fibrosis is a recognized, but rare, complication related to injection of gadolinium contrast. Your doctor will carefully assess your kidney function before considering a contrast injection. If you have an allergic reaction, a doctor will be available for immediate assistance. Also, the oral contrast used at some institutions may have an unpleasant taste and cause temporary fullness, but most patients tolerate it well. High-quality images depend on your ability to remain perfectly still and follow breath-holding instructions while the images are being recorded. If you are anxious, confused or in severe pain, you may find it difficult to lie still during imaging. This is because some techniques time the imaging based on the electrical activity of the heart. Disclaimer this information is copied from the RadiologyInfo Web site. To ensure that, each section is reviewed by a physician with expertise in the area presented. However, it is not possible to assure that this Web site contains complete, up-to-date information on any particular subject. Do not attempt to draw conclusions or make diagnoses by comparing these images to other medical images, particularly your own. Only qualified physicians should interpret images; the radiologist is the physician expert trained in medical imaging. Commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method is prohibited. The aim of this study was to assess the change in presentation and management of pancreatic cystic lesions evaluated at a single institution over 15 years.
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Anterior to muscle relaxant online discount 400 mg carbamazepine it are the bladder and the urethra muscle relaxant tizanidine discount carbamazepine 200 mg online, and posterior to spasms 1983 wikipedia order carbamazepine 200mg without prescription it lies the rectum. The upper part of the vagina, the fornix, surrounds the cervix (the inferior part of the uterus). The size of the uterus varies, depending on parity (number of viable births) and uterine abnormalities (eg, fibroids, which are a type of tumor that may distort the uterus). A nulliparous woman (one who has not completed a pregnancy to the stage of fetal viability) usually has a smaller uterus than a multiparous woman (one who has completed two or more pregnancies to the stage of fetal viability). The uterus lies posterior to the bladder and is held in position by several ligaments. The round ligaments extend anteriorly and laterally to the internal inguinal ring and down the inguinal canal, where they blend with the tissues of the labia majora. The broad ligaments are folds of peritoneum extending from the lateral pelvic walls and enveloping the fallopian tubes. The uterus has two parts: the cervix, which projects into the vagina, and a larger upper part, the fundus or body, which is covered posteriorly and partly anteriorly by peritoneum. The triangular inner portion of the fundus narrows to a small canal in the cervix that has constrictions at each end, referred to as the external os and internal os. From here, the oviducts or fallopian (or uterine) tubes extend outward, and their lumina are internally continuous with the uterine cavity. Other anatomic structures that affect the female reproductive system include the hypothalamus and pituitary gland of the endocrine system. External Genitalia the external genitalia (the vulva) include two thick folds of tissue called the labia majora and two smaller lips of delicate tissue called the labia minora, which lie within the labia majora. The upper portions of the labia minora unite, forming a partial covering for the clitoris, a highly sensitive organ composed of erectile tissue. Between the labia minora, below and posterior to the clitoris, is the urinary meatus. The ovum usually finds its way into the fallopian tube, where it is carried to the uterus. If it meets a spermatozoon, the male reproductive cell, a union occurs and conception takes place. After the discharge of the ovum, the cells of the graafian follicle undergo a rapid change. Gradually, they become yellow (corpus luteum) and produce progesterone, a hormone that prepares the uterus for receiving the fertilized ovum. The Menstrual Cycle the menstrual cycle is a complex process involving the reproductive and endocrine systems. Several different estrogens are produced by the ovarian follicle, which consists of the developing ovum and its surrounding cells. Estrogens are responsible for developing and maintaining the female reproductive organs and the secondary sex characteristics associated with the adult female. Estrogens play an important role in breast development and in monthly cyclic changes in the uterus. Progesterone is also important in regulating the changes that occur in the uterus during the menstrual cycle. It is secreted by the corpus luteum, which is the ovarian follicle after the ovum has been released. Progesterone is the most important hormone for conditioning the endometrium (the mucous membrane lining the uterus) in preparation for implantation of a fertilized ovum. If pregnancy occurs, the progesterone secretion becomes largely a function of the placenta and is essential for maintaining a normal pregnancy. In addition, progesterone, working with estrogen, prepares the breast for producing and secreting milk. These hormones are involved in the early development of the follicle and also affect the female libido. The secretion of ovarian hormones follows a cyclic pattern that results in changes in the uterine endometrium and in menstruation. This cycle is typically 28 days in length, but there are many normal variations (21 to 42 days). Under the combined stimulus of estrogen and progesterone, the endometrium reaches the peak of its thickening and vascularization. The luteal phase begins after ovulation and is characterized by the secretion of progesterone from the corpus luteum. If the ovum is fertilized, estrogen and progesterone levels remain high and the complex hormonal changes of pregnancy follow. The product consisting of old blood, mucus, and endometrial tissue is discharged through the cervix and into the vagina. After the menstrual flow stops, the cycle begins again; the endometrium proliferates and thickens from estrogenic stimulation, and ovulation recurs. Menstruation ceases, and because the ovaries are no longer active, the reproductive organs become smaller. These changes include neuroendocrinologic, biochemical, and metabolic alterations related to normal maturation or aging (Table 46-2). Topics that are relevant would include fitness, nutrition, cardiovascular risks, health screening, sexuality, abuse, health risk behaviors, and immunizations. If allowed to go untreated, however, they may result in anxiety and health problems. It usually occurs between the ages of 45 and 52 years but may occur as early as age 42 or as late as age 55; the median age is 51. Health and sexual histories, physical examination findings, and laboratory results are all part of the database. The sexual history may enable the patient to discuss sexual matters openly and to discuss sexual concerns with an informed health professional. This information can be obtained with the health history after the gynecologic-obstetric or genitourinary history is completed. By incorporating the sexual history into the general health history, the nurse can move from areas of lesser sensitivity to areas of greater sensitivity after establishing initial rapport. Taking the sexual history becomes a dynamic process reflecting an exchange of information between the patient and the nurse and provides the opportunity to clarify myths and explore areas of concern that the patient may not have felt comfortable discussing in the past. When asking about sexual health, the nurse also cannot assume that the patient is married or unmarried. Asking a woman to label herself as single, married, widowed, or divorced may be seen as an inappropriate inquiry by the patient. Asking about a partner or about current meaningful relationships may be a less offensive way to initiate a sexual history. The assessment begins by introducing the topic and asking the woman for permission to discuss issues of sexual functioning with her. The nurse can begin by explaining the purpose of obtaining a sexual history (eg, "I ask all my patients about their sexual health.