Directorate of Technical Education
KERALA (Government of Kerala)



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By: Q. Tempeck, M.B. B.A.O., M.B.B.Ch., Ph.D.

Assistant Professor, Lewis Katz School of Medicine, Temple University

Vasodilating agents are recommended for the treatment of patients with severe (3–4+/4+) aortic regurgitation under one of three circum stances (9): (i) short-term administration in preparation for aortic valve replacement in patients with severe heart failure symptoms antibiotics headache buy cheap zyvox 600mg on line, or significant left ventricular systolic dysfunction; (ii) long-term adminis tration in patients with symptoms or left ventricular systolic dysfunc tion who are not considered candidates for valve replacement surgery because of medical comorbidities or patient preference; (iii) long term administration in asymptomatic patients with normal left ven tricular systolic function to extend the compensated phase of aortic regurgitation prior to the need for valve replacement surgery infection merca discount zyvox line. Vasodi lator therapy is generally not recommended for asymptomatic patients with mild-to-moderate aortic regurgitation unless systemic hypertension is also present antimicrobial on air filters studies about zyvox 600 mg amex, as these patients generally do well for years without medical intervention. The goal of long-term therapy in appropriate candidates is to reduce the systolic pressure (afterload), though it is usually difficult to achieve low-to-normal values owing to the augmented stroke volume and preserved contractile function at this stage. Several small studies have demonstrated haemodynamically benefi cial effects with a variety of vasodilators, including nitroprusside, hydralazine, nifedipine, enalapril and quinapril (27). These agents generally reduce left ventricular volumes and regurgitant fraction, with or without a concomitant increase in ejection fraction. Only one study, which compared long-acting nifedipine (60mg bid) with digoxin in 143 patients followed for six years, has demonstrated that vasodilator therapy can favorably influence the natural history of asymptomatic severe aortic regurgitation (35). The use of nifedipine in this study was associated with a reduction in the need for aortic valve surgery from 34% to 15% over six years. Whether angiotensin converting enzyme inhibitors can provide similar long-term effects has not been conclusively demonstrated in large numbers of patients. Finally, it is important to note that vasodilator therapy is not a substi tute for surgery once symptoms and/or left ventricular systolic func tion intervene, unless there are independent reasons not to pursue aortic valve replacement. Diuretics are recommended to relieve symptoms of pulmonary congestion (dyspnea, orthopnea). Extrapo lating from studies of patients with dilated cardiomyopathy, digoxin and spironolactone may be of symptomatic and survival benefit when added to diuretics and angiotensin converting enzyme inhibitors, al though data from prospective studies in patients with valvular heart 63 disease are lacking. As noted previously for patients with acute severe aortic regurgitation, beta-blockers, which can slow the heart rate and thus allow greater time for diastolic regurgitation, are contra indicated. The loss of the atrial contribution to ventricular filling with the onset of fibrillation, as well as a rapid ventricular rate, can result in sudden and significant haemodynamic deterioration. Cardiover sion is advised whenever feasible, with the same caveats regarding anticoagulation for thromboembolic prophylaxis, as reviewed above. Mixed aortic stenosis/regurgitation Management of patients with mixed aortic valve disease can be quite challenging and depends, in part, on the dominant lesion. Clinical assessment requires integration of both physical examination and echocardiographic data. Symptoms may develop and indications for surgery may be met before the traditional anatomic (valve area) and haemodynamic (ejection fraction) thresholds are reached. The nondominant lesion may exacerbate the pathophysiology im posed by the dominant lesion. Diuretic and/or vasodilator therapies may alter loading conditions in favorable or unfavorable ways, though the former is usually well tolerated in patients with pulmonary con gestion. Beta-blockers should be avoided; digoxin may be of benefit once left ventricular systolic function has declined, though its use remains largely empirical. In general, management should be predicated on the identification of the dominant valve lesion and location, though it is recognized that the proximal valve lesion(s) may mask the presence and significance of the more distal valve lesion(s). Thus, the signs of left ventricular volume overload with aortic regurgitation may be attenuated by the presence of significant mitral stenosis, as obstruction to left ventricu lar inflow restricts filling. Other common combinations include mitral stenosis with tricuspid regurgitation (usually secondary to pulmonary hypertension and right ventricular dilatation), and aortic stenosis with mitral regurgitation. Intermittent or chronic diuretic use to treat symptoms of pulmonary or systemic venous congestion is usually well tolerated. The use of vasodilators must be individualized and depends on the dominant valve lesion, as well as on the expected contribution of the nondominant lesion(s). Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis.

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Gestational diabetes develops in 2 percent to 5 percent of all pregnancies but usually disappears when a pregnancy is over infection specialist doctor order zyvox with visa. Gestational diabetes occurs more frequently in African Americans virus blocking internet generic 600mg zyvox amex, Hispanic/Latino Americans treatment for uti antibiotics used discount zyvox 600mg overnight delivery, American Indians, and people with a family history of diabetes than in other groups. Women who have had gestational diabetes are at increased risk for later developing Type 2 diabetes. In some studies, nearly 40 percent of women with a history of gestational diabetes developed diabetes in the future. Such types of diabetes may account for 1 percent to 2 percent of all diagnosed cases of diabetes. Treatment for Type 2 diabetes Treatment typically includes diet control, exercise, home blood glucose testing, and in some cases, oral medication and/or insulin. Approximately 40 percent of people with type 2 diabetes require insulin injections. A number of studies have shown that regular physical activity can significantly reduce the risk of developing type 2 diabetes. In response to the growing health burden of diabetes mellitus (diabetes), the diabetes community has three choices: prevent diabetes; cure diabetes; and take better care of people with diabetes to prevent devastating complications. Normal Blood Glucose Control In people without diabetes, glucose stays in a healthy range because Insulin is released at the right times and in the right Insulin helps amounts glucose enter cells High Blood Glucose (Hyperglycemia) In diabetes, blood glucose builds up for several possible reasons… Liver releases Too little too much insulin is glucose made Cells can’t use insulin well Symptoms of Hyperglycemia •Increased thirst •Increased urination •Blurry vision •Feeling tired •Slow healing of cuts or wounds •More frequent infections •Weight loss •Nausea and vomiting Hyperglycemia Can Cause Serious Long-Term Problems Chronic complications of diabetes •Blindness •Kidney disease •Nerve damage •Amputation •Heart attack •Stroke Two Main Types of Diabetes Type 1 diabetes Pancreas makes too little or no insulin Type 2 diabetes •Cells do not use insulin well (insulin resistance) •Ability for pancreas to make insulin decreases over time Type 1 Diabetes •1 in 20 people with diabetes have type 1 •Most people are under age 20 when diagnosed •Body can no longer make insulin •Insulin is always needed for treatment Symptoms of Type 1 Diabetes Symptoms usually start suddenly •Weight loss •Loss of energy •Increased thirst •Frequent urination •Diabetic ketoacidosis (emergency condition of nausea, vomiting, dehydration. Can lead to coma) Managing Type 1 Diabetes •Blood glucose monitoring •Education •Healthy food choices •Physical activity •Insulin Before and After Insulin Treatment Discovery of 7-year-old child insulin in 1921 before and 3 changed type 1 months after from a death insulin therapy sentence to a chronic disease Type 2 Diabetes •Most people with diabetes have type 2 •Most people are over age 40 when diagnosed, but type 2 is becoming more common younger adults, children and teens •Type 2 is more likely in people who: •Are overweight •Are non-Caucasian •Have a family history of type 2 Symptoms of Type 2 Diabetes •Usually subtle or no symptoms in early stages: •Increased thirst •Increased urination •Feeling tired •Blurred vision •More frequent infections •Symptoms may be mistaken for other situations or problems •1 in 4 with type 2 aren’t aware they have it Treatment for Type 2 Diabetes May Change Over a Lifetime Always Includes: •Education •Healthy eating •Blood glucose monitoring •Physical Activity May Include: •Medications, including insulin Risk Factors for Type 2 Diabetes •Being overweight •Sedentary lifestyle •Family history of diabetes •History of gestational diabetes •Age •Ethnic/racial background: •African American •Hispanic/Latino •Native American •Asian American Obesity Prevalence in Adults 1994 2000 2010 No Data <14. Examples of some carbohydrates are: bread, rice, pasta, potatoes, corn, fruit, and milk products. In order for glucose to be transferred from the blood into the cells, the hormone insulin is needed. Insulin is produced by the beta cells in the pancreas (the organ that produces insulin). Diabetes develops when the pancreas fails to produce suffcient quantities of insulin – Type 1 diabetes or the insulin produced is defective and cannot move glucose into the cells – Type 2 diabetes. Either insulin is not produced in suffcient quantities or the insulin produced is defective and cannot move the glucose into the cells. There are two main types of diabetes: Type 1 diabetes occurs most frequently in children and young adults, although it can occur at any age. There does appear to be a genetic component to Type 1 diabetes, but the cause has yet to be identifed. Type 2 diabetes primarily affects adults, however recently Type 2 has begun developing in children. There is a strong correlation between Type 2 diabetes, physical inactivity and obesity. Normal DiabeTes Fasting blood sugar 80-99 mg/dl 126 mg/dl and above Random blood sugar 80-139 mg/dl 200 mg/dl and above 2 hour glucose tolerance test 80-139 mg/dl 200 mg/dl and above What are the symptoms of diabetes? If you have more than one of these symptoms you may want to ask your doctor to test your blood sugar. The diagnosis of diabetes is made by a simple blood test measuring your blood glucose level. A diagnosis of diabetes is a frightening and bewildering experience because there is so much information to take in and the diagnosis may come as a shock.

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Female Perineum • Is made up of the vulva (external genitalia) treatment for gardnerella uti zyvox 600 mg generic, including the mons pubis antibiotics for acne safe for pregnancy buy cheap zyvox, prepuce antibiotics to treat kidney infection purchase zyvox, clitoris, urethral and vaginal orifices, and labia majora and minora • the skin of the vaginal orifice is normally moist • the secretion has a slight odor due to the cells and normal vaginal florae • the clitoris consists of erectile tissues and many nerves fibers. Sterile cotton balls • the operative site and perineal area may be washed with an antiseptic solution – apply by squirting them on the perineum from a squeeze bottle Male Perineum • the penis contains pathways for urination and ejaculation through the urethral orifice (meatus) • At the end of the penis is the glans covered by a skin flap (fore skin or prepuce) • the urethral orifice is located in the center of the penis and opens at the tip 144 Basic Clinical Nursing Skills • the shaft of the penis consists of erectile tissue bound by the foreskin’s dense fibrous tissue Care • Hold the shaft of the penis firmly with one hand and the wash cloth with the other – to prevent erection – embarrassment • Use a circular motion, cleaning from the center to the periphery • Use a separate section of the wash cloth Position • Lying in bed with knee flexed to clean the perineal part and side lying cleaning the perineal area N. Hair care includes combing (brushing of hair), washing/shampooing of hair and pediculosis treatment. Equipments • Comb (which is large with open and long toothed) • Hand mirror • Towel • Lubricant/oils (if required) Procedure 1. Comb the hair by dividing the hair 146 Basic Clinical Nursing Skills • Hold a section of hair 2-3 inches from the end and comb the end until it is free from tangles. Shampooing/Washing the Hair of Patient Confined to Bed Purpose • Stimulate blood circulation to the scalp through massaging • Clean the patients hair so it increase a sense of well-being to the pt • To treat hair disorders like dandruft Equipments • Comb and brush • Shampoo/soap in a dish 147 Basic Clinical Nursing Skills • Shampoo basin • Plastic sheet • Two wash towels • Cotton balls • Water in basin and pitcher • Receptacle (bucket) to receive the used water • Lubricants/oil as required Procedure 1. Prepare the patient • Assist patient to move to the working side of the bed • Remove any hair accessories (e. Shampooing/washing the hair • Wet the hair thoroughly with water • Apply shampoo (soap) to the scalp. Documentation and reporting Pediculosis Treatment Definition Pediculosis: infestation with lice Purpose • To prevent transmission of some arthropod born diseases • To make patient comfortable Equipment Lindane 1% permethrine cream rinse Clean linen Fine-tooth “nit” comb Disinfectant for comb Clean gloves Towel Lice: • Are small, grayish white, parasitic insects that infest mammals • Are of three common kinds: 150 Basic Clinical Nursing Skills ¾ Pediculose capitis: is found on the scalp and tends to stay hidden in the hairs ¾ Pediculose pubis: stay in pubic hair ¾ Pediculose corporis: tends to cling to clothing, suck blood from the person and lay their eggs the clothing suspect their presence in the cloth and the body: a. There are hemorrhagic spots in the skin where the lice have sucked blood Head and body lice lay their eggs on the hairs then eggs look like oval particles, similar to dandruff, clinging to the hair. Kerosene Oil mixed with equal parts of sweet oil • Destroys both adult lice and eggs of nits • From aesthetic point of view, kerosene causes foul smell and create discomfort to patient and the attendant 151 Basic Clinical Nursing Skills Guidelines for Applying Pediculicides Hair: • Apply pediculicide shampoo to dry hair until hair is thoroughly saturated and work shampoo in to a lather • Allow product to remain on hair for stated period (varies with products) • Pin hair and allow to dry • Use a fine toothed comb to remove death lice and nits (comb should not be shared by other family members) • Repeat it in 8-10 days to remove any hatched nits • Apply pediculious lotion (or cream) to affected areas • Bath after 12 hrs and put on clean clothes 7. Oil of Sassafras • Is a kind of scented bark oil • Only destroy lice not nits • For complete elimination, the oil should be massaged again after 10 days when the nits hatch • Is used daily for a week with equal parts of Luke warm H2O then it should be repeated after a week 8. Gammaxine (Gamma Bengenhexa Chloride) • Emphasize the need for treatment of sexual partner • After complete bathing wash linen available as a cream, lotion, and a shampoo 152 Basic Clinical Nursing Skills • 1. Feeding a Helpless Patient During illness, trauma or wound healing, the body needs more nutrients than usual. However, many peoples, because of weakness, immobility and/or one or both upper extremities are unable to feed themselves all or parts of the meal. Therefore, the nurse must be knowledgeable, sensitive and skillful in carrying out feeding procedures. Purpose • To be sure the pt receives adequate nutrition • To promote the pt well-beings Procedure 1. Prepare pt units 153 Basic Clinical Nursing Skills • Remove all unsightly equipments; remove solid linens and arranging bedside tables. Lab, radiologic examination or surgery) • Assess any cultural or religious limitations, specific likes or dislikes. Feed the patient • Place the food tray in such a way that the patient can see the food. Comfort patient • Assist hand washing and oral care • Offer bedpan and commodes, of indicated • Comfort patient, provide quite environment so that the pt may relax after meal, which also promote good digestion. Morning, Afternoon, and Evening Care • Morning, afternoon, and evening care are used to describe the type of hygienic care given at different times of the day Early Morning Care • Is provided to clients as they awaken in the morning • In a hospital it is provided by nurses on the night shift • Helps clients ready themselves for breakfast or for early diagnostic tests 155 Basic Clinical Nursing Skills Consists of: • Providing a urinal or bed pan if client is confined to bed • Washing the face and hands and • Giving oral care Late Morning Care • Is provided after clients have breakfast Includes: • the provision of a urinal or bed pan • A bath or shower • Perineal care • Back massage and • Oral, nail and hair care • Making clients bed Afternoon Care • When clients return from physiotherapy or diagnostic tests • Includes: ¾ Providing bed pan or urinal ¾ Washing the hands and face ¾ Assisting with oral care refresh clients Evening Care • Is provided to clients before they retire for the night 156 Basic Clinical Nursing Skills • Involves: ¾ Providing for elimination needs ¾ Washing hands ¾ Giving oral care ¾ Back massage care as required Study questions: 1. To relieve pain and muscles spasm – by relaxing muscles Increase blood flow to the area 2. To relieve swelling (facilitate wound healing) To relieve inflammation and congestion Heat • Increases the action of phagocytic cells that ingest moisture and other foreign material • Increases the removal of waste products or infection metabolic process 3. Dry Purpose: (Indication) • To reduce body to during high fever and hyper pyrexia or sun stroke • To relieve local pain • To reduce subcutaneous bleeding e.

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