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By A. Grok. Xavier University, Cincinnati, OH. 2018.

Evaluate and treat possible complications: hyperthermia generic rumalaya liniment 60 ml, glucose abnormalities cheap rumalaya liniment 60 ml otc, seizures 7. Intracranial pressure monitoring (intraventricular drain, intraparenchymal catheter (Camino), subarachnoid bolt). Mechanical ventilation: sats >95%, avoid hypercapnia, consider short- term hyperventilation 12. Mannitol- decreases blood viscosity by lowering hematocrit, may reduce brain water content in the uninjured portion) Æ give rapidly, “chronic” dose is 0. Other: barbiturates-controversial, steroids- will help reduce vasogenic edema (around tumors), no effect on cytotoxic brain edema or in the management of head trauma 15. Reversible, diffuse lower-airway obstruction caused by airway inflammation and edema, bronchial smooth muscle spasm and mucous plugging 2. Exam: level of consciousness, breath sounds (distant or absent is ominous),central cyanosis, accessory muscle use 2. Arterial blood gas: - Early phase Æ hypoxemia, hypocarbia - Impending respiratory failure Æ hypercabia Treatment: 1. High flow supplemental oxygen (Non-rebreather if necessary, use blender if possible to avoid 100 % FiO2) 5. Mechanical ventilation is also difficult and should be managed by an experienced pediatric intensivist. Support modes of ventilation (pressure support and volume support) are used frequently. Beta agonists- tachycardia, arrhythmia, hypertension or hypotension, agitation/tremulousness, hyperactivity 5. Magnesium- hypotension, respiratory depression, heart block, flushing, nausea, somnolence 7. Acute Respiratory Distress Syndrome Definition: Acute respiratory distress characterized by acute lung injury, noncardiogenic pulmonary edema and severe hypoxia. The clinical and pathological features closely resembled those seen in infants with respiratory distress and to conditions in congestive atelectasis and postperfusion lung. Pulmonary artery wedge pressure < or = to 18mm or absence of evidence of left atrial hypertension 4. Pao2/Fio2 ratio < or = to 200 *[Pao2/Fio2 ratio < or = to 300 is defined as Acute Lung Injury] -American-European Consensus Conference Statement, 1994 Risk Factors: Pulmonary Extra-pulmonary Bacterial pneumonia Sepsis Viral pneumonia Trauma Aspiration Multiple transfusion Inhalation injury Cardiopulmonary bypass Fat emboli Pancreatitis Near Drowning Peritonitis Anything really bad - 21 - Pathophysiology: 1. Endothelial and epithelial cell damage leads to increased permeability and the influx of fluid into the alveolar space. Ventilatory support- ensures “adequate” oxygenation/ventilation while minimizing ventilator induced lung injury. Drugs sometimes used include steroids (late phase), NitricOxide (no proven survival benefit), 4. If on <60%, Sat goal should be ~92, if not able to maintain 92 on <60%, tolerate 85%. Monitor trends closely—absolute numbers are not usually important, trends in numbers are often extremely important. Remember that cardio-pulmonary interactions occur, and ventilator maneuvers may affect hemodynamics. Inflammation of the membranes surrounding the brain and spinal cord including the dura, arachnoid and pia mater 2. May present in combination with inflammation of the cerebral cortex, then called meningoencephalitis 3. Most commonly caused by viral or bacterial infection, but must consider infection with fungus, mycobacterium and cryptococcus and anaerobes. Prognosis depends on age, etiology, time of onset to therapy, and complications 2. Case fatality rate range from 3-5 % for meningococcal meningitis to 10% for pneumococcal meningitis and 15-20% in neonatal cases 3. The common etiologic agents of meningitis can be divided by age group as follows: <1 Month 1-3 Months 3 Months through Immunocompromised School Age Group B Strep Group B Strep N. Further inflammatory response occurs following antibiotic administration due to rapid bacterial lysis and release of cell wall/fragments Evaluation: 1. History- fever, headache, neck pain or stiffness, nausea, vomiting, photophobia and irritability; young infants may only exhibit irritability, somnolence and fever; seizures also possible 2.

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Moving a Patient Purpose: o To increase muscle strength and social mobility o To prevent some potential problems of immobility o To stimulate circulation o To increase the patient sense of independence and self-esteem o To assist a patient who is unable and move by himself o To prevent fatigue and injury o To maintain good body alignment Ensure that the client is appropriately dressed to walk and wears shoes or slippers with non-skid buy rumalaya liniment 60 ml with mastercard. Facilitates blood flow to the brain ⇒ If a chair is not close by assist the client to a horizontal position on the floor before fainting occurs Controlling Postural Hypo tension o Sleep with the head of the bed elevated (8-12 inches) purchase rumalaya liniment 60 ml with amex. Mention some of the nursing responsibilities during admission and discharge of the patient. In most instances beds are made after the client receives certain care and when beds are unoccupied. Closed bed: is a smooth, comfortable and clean bed, which is prepared for a new patient • In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and under the pillows. Open bed: is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier of a client to get in. Occupied bed: is a bed prepared for a weak patient who is unable to get out of bed. To conserve patient’s energy and maintain current health status Basic Nursing Art 22 Anesthetic bed: is a bed prepared for a patient recovering from anesthesia ⇒ Purpose: to facilitate easy transfer of the patient from stretcher to bed Amputation bed: a regular bed with a bed cradle and sand bags ⇒ Purpose: to leave the amputated part easy for observation Fracture bed: a bed board under normal bed and cradle ⇒ Purpose: to provide a flat, unyielding surface to support a fracture part Cardiac bed: is one prepared for a patient with heart problem ⇒ Purpose: to ease difficulty in breathing General Instructions 1. Linen for one client is never (even momentarily) placed on another client’s bed 5. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered for disposal 6. Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain Basic Nursing Art 23 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on the other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the clients feet. Vertical - make a fold in the sheet 5-10 cm 1 to the foot Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot 10. While tucking bedding under the mattress the palm of the hand should face down to protect your nails. Bed spread Note • Pillow should not be used for babies • The mattress should be turned as often as necessary to prevent sagging, which will cause discomfort to the patient. Closed Bed • It is a smooth, comfortable, and clean bed that is prepared for a new patient Basic Nursing Art 24 Essential Equipment: • Two large sheets • Rubber draw sheet • Draw sheet • Blankets • Pillow cases • Bed spread Procedure: • Wash hands and collect necessary materials • Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed • Tuck sheet under mattress at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck sheet on the sides and foot of bed, mitering the corners • Tuck sheets smoothly under the mattress, there should be no wrinkles • Place rubber draw at the center of the bed and tuck smoothly and tightly • Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely • Place top sheet with wrong side up, center fold of sheet on center of bed and wide hem at head of bed • Tuck sheet of foot of bed, mitering the corner • Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the corner • Fold top sheet over blanket Basic Nursing Art 25 • Place bed spread with right side up and tuck it • Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothening out all wrinkles, put pillow case on pillow and place on bed • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands B. Occupied Bed Purpose: to provide comfort, cleanliness and facilitate position of the patients Essential equipment: • Two large sheets • Draw sheet • Pillow case • Pajamas or gown, if necessary Procedure: • If a full bath is not given at this time, the patient’s back should be washed and cared for • Wash hands and collect equipment • Explain procedure to the patient • Carry all equipment to the bed and arrange in the order it is to be used • Make sure the windows and doors are closed • Make the bed flat, if possible • Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow cases on the chair for receiving dirty linen Basic Nursing Art 26 • Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder and the shoulder hand over the patient’s knees, turn the patient towards you • Never turn a helpless patient away from you, as this may cause him/her to fall out bed • When you have made the patient comfortable and secure as near to the edge of the bed as possible, to go the other side carrying your equipment with you • Loosen the bedding on that side • Fold, the bed spread half way down from the head • Fold the bedding neatly up over patient • Roll dirty bottom sheet close to patient • Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half close to the patient, tucking top and bottom ends tightly and mitering the corner • Put on rubber sheet and draw sheet if needed • Turn patient towards you on to the clean sheets and make comfortable on the edge of bed • Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back care • Remove dirty sheet gently and place in dirty pillow case, but not on the floor • Remove dirty bottom sheet and unroll clean linen • Tuck in tightly at ends and miter corners • Turn patient and make position comfortable • Back rub should be given before the patient is turned on his /her back • Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious Basic Nursing Art 27 • Go to foot of bed and pull the dirty top sheet out • Replace the blanket and bed spread • Miter the corners • Tuck in along sides for low beds • Leave sides hanging on high beds • Turn the top of the bed spread under the blanket • Turn top sheet back over the blanket and bed spread • Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s toes and chest • Be sure the patient is comfortable • Clean bedside table • Remove dirty linen, leaving room in order • Wash hands Study Questions 1. Bath (Bathing and Skin Care) It is a bath given to a patient in the bed who is unable to care for himself/herself. Cleansing bath: Is given chiefly for cleansing or hygiene purposes and includes: • Complete bed bath: the nurse washes the entire body of a dependent patient in bed • Self-help bed bath: clients confined to bed are able to bath themselves with help from the nurse for washing the back and perhaps the face • Partial bath (abbreviated bath): only the parts of the client’s body that might cause discomfort or odor, if neglected are washed the face, hands, axilla, perineum and back (the Basic Nursing Art 29 nurse can assist by washing the back) omitted are the arms, chest, abdomen. Also used for therapeutic baths • Shower: many ambulatory clients are able to use shower • The water should feel comfortably warm for the client • People vary in their sensitivity to heat generally it should be o o 43-46 c (110-115 f) • The water for a bed bath should be changed at least once Before bathing a patient, determine a. The bed linen required Note: when bathing a client with infection, the caregiver should wear gloves in the presence of body fluids or open lesion. Principles • Close doors and windows: air current increases loss of heat from the body by convection • Provide privacy – hygiene is a personal matter & the patient will be more comfortable • The client will be more comfortable after voiding and voiding before cleansing the perineum is advisable • Place the bed in the high position: avoids undue strain on the nurses back Basic Nursing Art 30 • Assist the client to move near you – facilitates access which avoids undue reaching and straining • Make a bath mitt with the washcloth. It retains water and heat better than a cloth loosely held • Clean the eye from the inner canthus to the outer using separate corners of the wash cloth – prevents transmitting micro organisms, prevents secretions from entering the nasolacrmal duct • Firm strokes from distal to proximal parts of the extremities increases venous blood return Purpose: o To remove transient moist, body secretions and excretions, and dead skin cell o To stimulate circulation o To produce a sense of well being o To promote relaxation, comfort and cleanliness o To prevent or eliminate unpleasant body odors o To give an opportunity for the nurse to assess ill clients o To prevent pressure sores Two categories of baths given to clients o Cleansing o Therapeutic A.

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Over a five-year period buy discount rumalaya liniment 60 ml line, 40 of 600 strains generic 60 ml rumalaya liniment, or approximately 7% of strains included in annual panels, have been excluded. The study on borderline strains has been useful in confirming that the most important factor explaining the variation of the results of panel testing is strain selection. Currently, there is no established gold standard to replace the judicial 80 system. One possible solution would be a definition of “intermediary” resistant results; however, this would require testing at two concentrations. Many high- income countries will test drugs (at least isoniazid) at two concentrations. To date, no study has systematically evaluated all available methods for testing, established critical concentrations for all available second-line drugs, or evaluated a large number of clinical isolates for microbiological and clinical end-points. In July 2007, guidance was developed for the selection of and testing for second-line drugs. Based on evidence or expert consensus (where no evidence was available), a hierarchy was developed recommending drug-susceptibility testing based on both clinical relevance and reliability of the test available. Rifampicin and isoniazid were prioritized, followed by ethambutol, streptomycin and pyrazinamide, and then the second-line injectables (amikacin, kanamycin and capreomycin) and fluroquinolones. The policy guidance is available, and full technical guidelines for the drug-susceptibility testing of second-line drugs became available in 2008. Tests for rapid identification of second-line drug resistance are not yet available. The variation in resistance among countries within the region is relatively narrow; however, roughly half of the data points used to look at the distribution are at least five years old. Only Botswana, Côte d’Ivoire, Sierra Leone and Mpumalanga Province, South Africa, have carried out repeat surveys. Detection of this outbreak was only possible because of the extensive laboratory infrastructure available in the country. It is likely that similar outbreaks of drug resistance with associated high mortality are taking place in other countries, but are not being detected due to insufficient laboratory capacity. Botswana, Mauritania and Mozambique have nationwide surveys under way, and Angola, Burundi, Lesotho, Malawi, Namibia, South Africa, Uganda and Zambia have plans to initiate nationwide surveys over the next year. Nigeria and the Congo plan to begin a survey covering selected districts in their respective countries in 2008. Currently, Botswana and Swaziland are surveying high-risk populations to examine the extent of first and second-line drug resistance; results should be available in early 2008. Malawi, Mozambique, Zambia and Zimbabwe all have plans to conduct similar studies. South Africa has recently conducted a review of the country’s laboratory database and found that 996 (5. Selection and testing practices varied across the country and with time; however, all isolates correspond to individual cases29. Data from this project will be available in early 2008 and, if shown to be comparable with phenotypic testing, may be a useful tool in the expansion of survey coverage in the region as well as in trend analysis. The most critical factor in addressing drug resistance in African countries is the lack of laboratory infrastructure and transport networks that can provide rapid diagnosis. However, if laboratories are to scale up rapidly, coordination of funding and technical agencies will be critical, as will concerted efforts to address the widespread constraints in human-resource capacity in the region. In the last report — though in the same reporting period (2002) — Ecuador showed 4. In North America, Canada has shown low proportions of resistance and relatively steady trends in resistance among both new and previously treated cases. Uruguay showed a decrease in resistance to any drug, but this was not significant. Many countries plan to upgrade laboratory networks because there is increased demand for development of second-line testing capacity. Jordan, Lebanon and Oman reported high proportions of resistance among re-treated cases, though sample sizes were small and confidence levels were wide.

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It is usually given on most days of the week for 5-7 weeks in an outpatient setting order 60 ml rumalaya liniment overnight delivery, but this may differ between patients buy rumalaya liniment 60 ml free shipping. Side effects  Skin colour changes  Itching, burning, blistering, peeling, irritation/discomfort/pain over radiation site  Chest pain  Fatigue  Low white blood cell count  Cardiac complications  Pulmonary complications (especially pulmonary fibrosis)  Although now considered very rare, brachial plexopathies have historically been shown to develop up to 20 years post radiotherapy (Hayes et al, 2012). Psychological Impact Patients can have high levels of anxiety prior to starting radiotherapy. The most common source of anxiety for women is the effects of radiation on their future health (Halkett et al 2012). Patients tend to have a better experience of radiotherapy than they expect and so their anxiety decreases once treatment is over (Halkett et al, 2012; Rahn et al, 1998) Hormone Therapy Background/ Indications Cancer cells can be similar to or very dissimilar from normal cells in appearance and structure. When these hormones, particularly oestrogen, connect to the receptors, breast cells are stimulated to grow and divide. Some breast cancer cells will still have oestrogen and/or progesterone receptors on their surface. If the receptors are present, the cancer is said to be “receptor positive” for that hormone. Therefore, the growth of oestrogen-receptor positive tumours will be stimulated by oestrogen. Hormone therapy for Breast Cancer, also called Anti-Oestrogen therapy, works in two ways: to lower the amount of oestrogen in the body, and/or to block the action of oestrogen at the breast tissue by blocking the hormone receptors. Therefore, hormone therapy will only work on cancers which are hormone receptor positive. Pre-menopause: Before menopause the body’s oestrogen is made primarily in the ovaries. The amount of oestrogen in the body, therefore can be lowered by shutting down the ovaries. This can be temporarily induced by drugs which are given as injections every few months, or permanently by surgical removal of the ovaries (ophorectomy). Women who are at high risk of developing breast cancer may choose to have a prophylactic ophorectomy to reduce the risk of hormone-receptor positive breast cancer. In women with early-stage hormone- receptor-positive breast cancer, ophorectomy plus 5 years of tamoxifen can increase the chances of 10 year disease-free survival from 47-66% and 10 year overall survival from 49- 82% compared with surgery alone (Love et al, 2008). Post-menopause: After menopause, the ovaries stop producing oestrogen, but it is still made by aromatase. Hormone therapy in these women therefore focuses on stopping this process from occurring by use of aromatase inhibitors, and by blocking the action of oestrogen at the breast tissue. Hormone Therapy and Obesity Ewertz et al (2010) in a large, retrospective study found hormone therapy was less effective in obese women than lean women who had breast cancer. Since oestrogen is synthesized in adipose tissue after menopause, there is an excess of oestrogen in obese post-menopausal women (Ket et al, 2003). Obesity is also correlated with decreased plasma levels of sex- hormone-binding globulin, which naturally restricts the biologic activity of oestrogen (Siniscrope & Dannenberg 2010). Side effects of Hormone Therapy Tamox Arimidex Aromasin Femara Evista Fareston Faslodex ifen Bone/joint yes yes yes yes yes pain Osteoporosis yes yes yes Bone yes yes yes thinning Nausea yes yes yes yes yes Vomiting yes yes yes Hot flashes yes yes yes yes yes yes yes Weakness yes yes Fatigue yes yes yes yes Headache yes yes yes Insomnia yes yes 40 Tamox Arimidex Aromasin Femara Evista Fareston Faslodex ifen Sweating yes yes Dizziness yes yes Drowsiness yes High yes cholesterol Weight gain yes Blood clots yes yes Stroke yes yes Endometrial yes yes cancer Increased yes yes bone / tumour pain Mood swings yes yes Depression yes Hair yes thinning Constipation yes yes Dry skin yes yes yes Loss of yes libido Leg cramps yes 41 Tamox Arimidex Aromasin Femara Evista Fareston Faslodex ifen Swelling yes yes Flu-like yes symptoms Hypercalce yes mia Rash yes Vaginal yes discharge / bleeding Vision yes problems Dry eyes yes Diarrhoea yes Sore throat yes Back pain yes Abdominal yes pain Injection site yes pain Psychological Impact  Premature menopause induced by adjuvant therapy is associated with poorer quality of life, decreased sexual functioning, menopausal symptom distress, psychosocial distress related to fertility concerns in premenopausal breast cancer patients 42  Psychosocial distress is common in women who experience loss of fertility; loss of choice to have more children, or any children. Multi-disciplinary team members involved in breast cancer care 44 Oncologist: There are three main types of oncologists in breast cancer care:  Medical oncologist: specializes in cancer drugs e. Healthy eating can reduce cancer risk, recurrence and help reduce lymphoedema volume (McNeely et al, 2011). Dieticians devise diet plans that aim to  Ensure patients are as lean as possible within the normal range of body weight  Avoid weight gain and increase in waist circumference This is achieved through:  Limiting consumption of energy-dense foods  Consuming ‘fast foods’ sparingly 45  Eating mostly foods of plant origin  Eating at least 5 portions of various non-starchy vegetables and fruit a day  Eating relatively unprocessed cereals(grains) and/or pulses(legumes) with every meal  Limiting refined starchy foods  Limiting intake of red meat and avoiding processed meat  Limiting consumption of salt (World Cancer Research Fund/American Institute for Cancer Research, 2007) Dieticians also treat and provide advice on side effects of breast cancer treatments: nausea, mouth soreness, taste changes, constipation, diarrhoea, weight gain/loss, bone health and other specific dietary considerations due to co morbidities (Breast Cancer Care 2009) Occupational Therapist: Role: To facilitate patients to achieve maximum functional performance, both physically and psychologically, in everyday living regardless of their life expectancy (Penfold 1996). Mentioned how this is treated with analgesics or in more severe cases referral to a specialist is required. Sinead Cobbe (Senior physiotherapist in palliative care in Milford Hospice) • Demonstrated how to perform lymphoedema bandaging on breast cancer patients. Lymph vessels: (Absorption) A network of thin vessels that transport lymph and lymphocytes (white blood cells that Figureht infection and the growth of tumours) throughout the body. Lymph nodes: (Filtration) Small, bean-shaped structures located along the lymph vessels. Lymph is filtered through several lymph nodes where it is inspected for foreign substances. Lymphatic Ducts: (Drainage) Eventually, the lymph vessels empty into the lymphatic ducts which drain into one of the two subclavian veins. The lymphatic vessels of the left arm drain into the left subclavian lymphatic trunk and lymph channels of the right arm drain into the right subclavian lymphatic trunk.

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