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By Z. Ayitos. Concordia University, Portland Oregon. 2018.

Fowler’s Position: Off all the positions prescribed for a patient diovan 80 mg low price, perhaps the most common order diovan 40 mg overnight delivery, as well as the most difficult to maintain is the Fowler’s position purchase 80 mg diovan amex. The patient’s with abdominal drainage usually are put in Fowler’s position as soon as they have recovered conciousness 160 mg diovan with mastercard, but great caution must be observed in raising the bed buy 160 mg diovan mastercard. Hand washing is a vigorous, brief rubbing together of all surfaces of hands lathered in soap, followed by rinsing under a stream of water. The purpose is to remove soil and transient organisms from the hands to reduce to microbial counts over time. Situation for hand washing: Garnerand Favero recommend that nurses wash hands in the following situations. Medical Hand Washing Equipments: 1) Easy to reach sink with warm running water 2) Antimicrobial soap / Regular soap. Use circular movements to wash palms, back of hands, wrists, forearms and interdigital spaces for 20­25 Seconds. Ask the assisting nurse to bring the gown over shoulders 3) The assisting nurse fastens the ties at the neck. Assess the patients for following: § Muscle strength § Joint mobility and contracture formation(arthritis) § Paralysis or paresis § Orthostatic hypotension(risk of fainting) § Activity tolerance § Level of comfort(pain) § Vital signs 2. Assess the patients sensory status § Adequacy of central and peripheral vision § Adequacy of hearing § Loss of peripheral sensation § Cognitive status 3. Assess for any contra indications to lift or transfer § Check for the doctors order § Assess patients level of motivation § Patients eagerness § Whether patient avoids activity § Assess previous mode of transfer § Assess patients specific risk for falling when transferred § Assess special equipments needed to transfer § Assess for safety hazards § Perform hand hygiene § Explain procedure to patient § Transfer the patient After care: § Following each transfer assess the patients body alignment, tolerance, fatigue, comfort § If the patient is transferred to bed after transfer, side rails are raised 41 § If the patient is transferred to wheel chair the brakes are released before moving the patient § Record the procedure accurately. The patients performance is also recorded § Any difficulty of disruption occurred during the transfer is also recorded with date and time § The patients comfort, vital signs are all recorded Procedure: § Transferring a patient from a bed to stretcher § An immobilized patient who must be transferred from a bed to a stretcher requires a three person carry or two person carry § Another method is using a sheet to lift Transferring a patient from a bed to stretcher: § Three of you should stand side by side facing of patients bed § Each person assumes responsibility for one of three areas a) Head and Shoulders b) Hips and thighs c) Ankles § Perform three­person carry from bed to stretcher(Bed at Stretcher level) § Three persons stand side by side facing side of patients bed 1. Each person assumes responsibility for one of three areas: head and shoulders, hips and thighs, and ankles 2. Each person assumes wide base of support with foot closer to stretcher in front and knees slightly flexed 3. Arms of lifters are placed under clients head and shoulders, hips and thighs, and ankles with fingers securely around other side of clients body(see illustration) 4. Have the wheel chair(lock the brakes at its 45° angle to bed § Apply transfer belt(if present) § Ensure that the patient has stable non skid shoes. For a man who has not been able to reach the toilet facilities he may stand at the bedside and void into a plastic of metal receptacle for urine. If he is unconscious or unable to stand at bedside the assistant needs to assist him to use the urinal. Purpose: § Provide a container for collection of urine § To measure the urine output § For observation of color and consistency of urine Indications: For patient with impair mobility due to surgery, fracture, injury Elderly man (aging impairs micturation) may require urinal more frequently to avoid urinary incontinence For mobile person who is able to go to bathroom, does not require urinal. The pan is approximately 5cm deep Fracture pan Designed for patients with body or leg casts, the shallow upper end approximately 1­3cm deep that slips easily under the patient Offering bedpan A bedpan for patients confined to bed provides a means to collect stool Female bedpan to pass urine and feces, For male bedpans only for defecation Sitting on a bedpan can be extremely uncomfortable. Purposes The nursing assistance paces and removes the bedpan to bed to bed ridden patients For bowel elimination when the patient is not permitted to go out of bed Obtain a stool specimen During bowel training, it facilitates bowel incontinence Indication: For the patients restricted to bed must use bedpan for defecation. To make a ‘reef knot’ take the ends of the bandage one in each hand cross the end in the right hand under and then over the end in the left hand thus making a turn. Then cross the end now in the right hand over and then under the end in the left hand thus making a second turn. Preparation of the Patient § Explain the sequence of the procedure to the patient and explain how the patient can assist you. Rules For Application Of Roller Bandage § Face the patient § When bandaging left limb, hold the head of the bandage in the right hand and vice versa. The usual practice of tearing the final end into two long tails and tying them up is quite satisfactory. With the back of the patient’s hand towards you, take a fixing turn round the wrist and carry the next turn upwards at an angle of 45°, turn the bandage over to cross itself at a right angle, and bring it round the limb ready for the next turn. It can be used to apply pressure over an extended joint or to bandage a leg, foot, hand or arm if movement is allowed. To use it on the leg, take a fixing turn, then carry the bandage upwards across the front of the limb at 45° round behind it at the same level and downwards over the front to cross the first turn at a right angle. Succeeding turns pass alternately above and below these turns, forming a pattern at each side of the joint. Elbow bandage Roller bandages can be used at these joints to hold dressings in place, or to support soft tissue injuries such as strains (or) sprains.

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We review aspects such as the definition of drugs and addictive behavior purchase diovan 160mg overnight delivery, consumption patterns and the current status of the problem diovan 160mg on-line. Also presented are the criteria used to determine whether consumption or abuse of a substance is taking place buy 80mg diovan with visa. Finally order 160mg diovan, we review the main individual risk factors that favor substance consumption and integrate them into a comprehensive model cheap diovan 80 mg with amex. To understand the magnitude of the phenomenon it is necessary to know the basic physiological correlates of drug consumption. In this first unit general concepts on the pharmacodynamics and pharmacokinetics of drug consumption are addressed. The characteristics of the main psychoactive substances and their psychoactive effects and mechanisms are also presented. Others are the result of chemical processes carried out using natural products, like what occurs with alcoholic beverages, which are obtained from the fermentation or distillation of grain or fruit juice. There has also been a differentiation between soft and hard drugs, although currently that distinction is rarely used because of its scant utility and the fact that it can give rise to the erroneous interpretation that so-called soft drugs are not quite detrimental to health. The first group includes alcohol, opiates and psychotropic drugs such as hypnotics, anxiolytics and antipsychotics. In the third group, consisting of psychedelic drugs, are hallucinogens, cannabis, synthetic drugs and solvents (e. Central Nervous System Depressants a) Alcohol b) Hypnotics: Barbiturates and non-barbiturates c) Anxiolytics: diazepam d) Narcotic analgesics: i. Drug consumption becomes abusive at the appearance of dependence, which is defined as the set of physiological, behavioral and cognitive manifestations in which the use of a drug is a priority for the individual. This term is usually linked to tolerance, or the need to consume more of a substance to achieve the effects of previous consumption. It is a cluster of symptoms that affect an individual who is suddenly deprived of any toxin or drug on which he/she is physically dependent and which previously had been consumed on a regular basis. The quantity of symptoms, as well as their intensity and duration will depend on the type of drug, the length of time the person has consumed the substance and his/her physical and psychological state at the time of withdrawal. Physical dependence is a state of adaptation of the organism to the presence of the drug and is manifested by the appearance of intense physical discomfort (tremors, chills, insomnia, vomiting, pain in the muscles and bones, etc. This same physical discomfort occurs when the substance´s action on the organism is influenced by drugs designed to block its effects. Psychological dependence refers to the situation in which a person feels an emotional need and urge to consume a drug on a regular basis in order to feel good, be satisfied (obtain pleasure or avoid discomfort) although he/she does not need the substance physiologically. There are the so-called non-toxic addictions which involve dependency behavior with an evident syndrome of psychological withdrawal. There is, for example, addiction to gambling or pathological gambling and others such as technological addictions (internet, mobile, and video games), addiction to shopping, exercise or sex. These addictive behaviors share, if not all, some of the characteristics mentioned so far, with the peculiarity that there is not a mediating substance that produces physical changes in the subject. Effects of Drugs 4 José Pedro Espada and Daniel Lloret Irles As already mentioned, drugs act on the central nervous system (i. The physiological correlates and effects vary according to each substance; there are specific mechanisms that involve precise receptors for each substance type. When a substance enters the body it first affects the neuronal receptors, which are structures located within a neuron or in its membrane and are characterized by selective binding to a substance and the physiological effect that accompanies the union. The presence of a drug in the body affects the presynapse, altering the production/ release of neurotransmitters. During the next step, the drug affects the synapses, by increasing the presence of neurotransmitters in the synaptic space. The activity of the drug in the body over a period of time comprises the processes of absorption, distribution, localization in tissues, biotransformation and excretion. Central Nervous System Depressants Alcohol The two main types of alcohol based on their chemical composition are: methyl alcohol (methanol), which is the simplest of the alcohols and is used as a solvent, antifreeze and in industrial applications; and ethyl alcohol (ethanol), which is what alcoholic beverages contain. After the distillation process, the amount of alcohol can be concentrated and significantly increased. From a physical standpoint, the short term effects of alcoholic beverage intake are impaired balance, movement, speech and vision, hurried and unintelligible expression, decreased ability to concentrate, drowsiness, and despondency, irritability, nausea, vomiting and/or headaches.

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The withdrawal or modification of oral intake when trying to prevent aspiration pneumonia is a contentious issue amongst healthcare professionals and the insufficient evidence highlights the need by the group for a research recommendation in these areas cheap 80 mg diovan mastercard. There was a consensus that an important reason for giving patients water would be to enable them to maintain adequate oral hygiene and to reduce patient distress diovan 80 mg line. The consensus of the group was that there was insufficient evidence on which a recommendation could be made discount diovan 160 mg online. Although the incidence of intracerebral haemorrhage has fallen overall in the last 20 years generic diovan 40mg, largely due to improved identification and treatment of hypertension buy 80 mg diovan fast delivery, there has not been an equivalent fall in incidence in elderly patients. As the population ages, the absolute number of haemorrhages in the elderly might increase in future. The commonest cause of intracerebral haemorrhage is hypertension, but other causes should be considered including underlying structural abnormalities (e. The 30-day mortality is higher in deep haemorrhages than lobar, and increases with increasing volume of bleed. Patients with cerebellar haematoma are at particular risk of deterioration, specifically direct compression of the brain stem and cerebellum, and hydrocephalus. The surgical evacuation of haematoma has been used in selected patients and recently subjected to randomised controlled trial. The clinical question is which patients with primary intracerebral haemorrhage should be referred for surgical evacuation. Patients were admitted to the trial if the neurosurgeon felt there was equipoise regarding the benefits of either treatment. Patients were eligible if the haematoma was greater than 10 cu cm and the interval between stroke and start of treatment was less than 48 hours. Only univariate analyses were reported and this combined with the small sample size limits the generalisability of these results. None of the endoscopically treated patients were reported to have died from a surgically related complication. At 6 months, the mortality rate was significantly lower in the surgically treated patients compared with those treated medically (42 vs 70%; p<0. In this study, 25% of the patients who were randomised for conservative therapy later went on to have surgery. There were no papers identified in the evidence review which specifically addressed hydrocephalus in association with intracerebral haemorrhage. There was no strong evidence on which to set an age threshold above which surgery should not be considered. The consensus of the group was that previously fit patients with a lobar haemorrhage with hydrocephalus, or those who are deteriorating neurologically where draining of the haematoma might improve outcome should be referred for surgery. However, the consensus was that patients with cerebellar haematoma should be carefully and regularly monitored for changes in neurological status that might indicate the development of coning or hydrocephalus by specialists in neurosurgical or stroke care. R58 People with intracranial haemorrhage should be monitored by specialists in neurosurgical or stroke care for deterioration in function and referred immediately for brain imaging when necessary. R59 Previously fit people should be considered for surgical intervention following primary intracranial haemorrhage if they have hydrocephalus. It has a mortality rate of 80%192 and usually presents within 2–5 days of stroke onset. There have been a number of reports of benefit from decompressive hemicraniectomy, but concerns remain as to the benefits in terms of both survival and good clinical outcome. Neurosurgeons in many centres have been reluctant to operate partly because of their experiences of hemicraniectomy in other conditions. Poor outcomes may be related to late referral of patients when surgery is performed after brain damage has become irreversible. Timely referral is vital to ensure that intervention takes place before damage is irreversible.

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The latter contains horizontal ridges of musclea • On the septal surface a depression marks the fossa ovalis discount diovan 160 mg amex. The thick wall is necessary to septum secundum gives rise to a patent foramen ovale (atrial septal pump oxygenated blood at high pressure through the systemic circula- defect) but as long as the two septa still overlap purchase diovan 80 mg without a prescription, there will be no func- tion buy 160mg diovan visa. During ventricular • The wall of the right ventricle is thicker than that of the atria but not systole the free edges of the cusps come into contact and eversion is as thick as that of the left ventricle quality 40mg diovan. During ventricular diastole back-pressure of blood above the cusps forces them to fill and hence close discount diovan 80mg visa. Times are in msec 22 Thorax The grooves between the four heart chambers represent the sites that right atrium via the coronary sinus. The coronary sinus drains into the offer the least stretch during systole and, for this reason, are where most right atrium to the left of and superior to the opening of the inferior vena of the vessels supplying the heart are situated. The great cardiac vein follows the anterior interventricular branch of the left coronary and then sweeps backwards to the left in the The arterial supply of the heart (Fig. The middle cardiac vein follows the posterior The coronary arteries are responsible for supplying the heart itself with interventricular artery and, along with the small cardiac vein which fol- oxygenated blood. The coronary The coronary arteries are functional end-arteries and hence follow- sinus drains the vast majority of the heart’s venous blood. Under these conditions the increased demand placed on the myocardium cannot be met by the diminished arterial supply. It is situated dilating (angioplasty), or surgically bypassing (coronary artery bypass near the top of the crista terminalis, below the superior vena caval grafting), the arterial stenosis. Ischaemic heart disease is the leading cause of death in the tion pathway can lead to dangerous interruption of heart rhythm. For example, in some people the posterior interven- position of the Purkinje fibres accounts for the almost synchronous tricular branch of the right coronary artery is large and supplies a large contraction of the ventricles. The nerve supply of the heart Similarly, the sinu-atrial node is usually supplied by a nodal branch The heart receives both a sympathetic and a parasympathetic nerve of the right coronary artery but in 30–40% of the population it receives supply so that heart rate can be controlled to demand. Pulmonary trunk They are all covered with Left auricle Posterior pulmonary plexus the mediastinal pleura Sympathetic trunk Phrenic nerve Descending aorta Left ventricle Greater splanchnic nerve Oesophageal plexus on oesophagus Subclavian artery Oesophagus Subclavian vein Trachea Left brachiocephalic Vagus nerve vein Superior vena cava Pulmonary artery Acending aorta Fig. Here the right phrenic enters the caval opening and immediately penetrates the The thoracic sympathetic trunk (Figs 9. It descends in the thorax behind the pleura immediately lateral to costal vein to descend in front of the left lung root onto the pericardium the vertebral bodies and passes under the medial arcuate ligament of the overlying the left ventricle. Note: the phrenic nerves do not pass • The thoracic chain bears a ganglion for each spinal nerve; the first beyond the undersurface of the diaphragm. However, they also transmit fibres which are sensory preganglionic fibres from its corresponding spinal nerve and sends to the fibrous pericardium, mediastinal pleura and peritoneum as well back a grey ramus, bearing postganglionic fibres. Upper limb sympathectomy is used for the treatment of hyperhidro- Irritation of the diaphragmatic peritoneum is usually referred to the sis and Raynaud syndrome. Hence, upper abdominal pathology such as a perfor- of part of the thoracic sympathetic chain (usually for two interspaces) ated duodenal ulcer often results in pain felt at the shoulder tip. It finally reaches the lower oesophagus where it visceraathe heart and great vessels, the lungs and the oesophagus. From this plexus, • Mainly preganglionic fibres from T5–12 form the splanchnic nerves, anterior and posterior vagal trunks descend (carrying fibres from both which pierce the crura of the diaphragm and pass to the coeliac and left and right vagi) on the oesophagus to pass into the abdomen through renal ganglia from which they are relayed as postganglionic fibres to the oesophageal opening in the diaphragm at the level of T10. It is itself crossed here by the left superior intercostal (T5–10), lesser splanchnic (T10–11) and lowest splanchnic (T12). Below, it descends behind the lung root to reach the oesophagus They lie medial to the sympathetic trunk on the bodies of the thoracic where it contributes to the oesophageal plexus mentioned above (see vertebrae and are quite easily visible through the parietal pleura. The cardiac plexus Vagal branches This plexus is for descriptive purposes divided into superficial and deep • The left recurrent laryngeal nerve arises from the left vagus below parts. The nerves of the thorax 25 10 Surface anatomy of the thorax Cervical plexus 2 2 4 4 Cardiac notch of lung Transverse fissure 6 6 Oblique fissure Costodiaphragmatic recess 8 8 10 10 Apex of lower lung Oblique fissure 6 Beginning of transverse fissure 8 Costodiaphragmatic recess Fig. The areas of auscultation for the aortic, pulmonary, mitral and tricuspid valves are indicated by letters 26 Thorax The anterior thorax pleura passes laterally for a small distance at the 4th costal cartilage and Landmarks of the anterior thorax include: descends vertically lateral to the sternal border to the 6th costal cartil- • The angle of Louis (sternal angle): formed by the joint between the age. It is an important landmark as the cross the 8th rib in the mid-clavicular line, the 10th rib in the mid- 2nd costal cartilages articulate on either side and by following this line axillary line and finally reach the level of the 12th rib posteriorly.

Diovan
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