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Pull it cup a short distance while using gentle rotation and cut off the tip of the drain with sterile scissors (the length to be cut order red viagra 200 mg overnight delivery, depends on the instruction purchase red viagra 200mg without prescription. Equipment • Sterile galipot or kidney dish • Sterile cotton balls • Sterile gauze • 3 Sterile forceps • Sterile catheter • Sterile syringe 20 cc • 2 receiver • Rubber sheet and its cover • Rubber sheet and its cover • Solutions (H2O2 or normal sullen are commonly used) • Adhesive tape or bandage • Bandage scissors • Receiver for soiled dressings Procedure Explain the procedure to the patient and organize the needed items. Suturing Definition: The application of stitch on body tissues with the surgical needle & thread. Purpose • To approximate wound edges until healing occurs • To speed up healing of wound • To minimize the chance of infection • For esthetic purpose Equipment • Tray or trolley covered with a sterile towel • Sterile needle holder 145 • Sterile round needle (2) • Sterile cutting needle (2) • Sterile silk • Sterile cat- gut • Sterile tissue forceps • Sterile suture scissors • Sterile cotton swabs in a galipot • Sterile solution for cleaning • Sterile dressing forceps • Sterile receiver • Sterile gauze • Sterile plaster • Dressing scissors • Local anesthesia • Sterile needle & syringes • Sterile gloves • Sterile hole- towel (Fenestrated towel) Procedure • Explain procedure to patient • Adjust light • Wash your hands • Clean the wound thoroughly • Wash your hands again • Put on sterile gloves • Drape the Wound with the hold- sheet • Infiltrate the edges of the wound to be sutured with local anesthesia. How ever, such wounds have to be seen by a doctor since excision of all dead & devitalized tissue and eventual suturing may be required. Removal of the Stitch Technique: Use aseptic technique Principles • Sutures may be removed all at a time or may be removed alternatively. Remove – gum with benzene or ether and discard the forceps 147 • Place sterile gauze to receive pleases or sutures. Clips Definition: Metal suture used to stitch the skin Purpose Some as suturing with stitch Equipment • Michel clip applier • Tissue forceps (toothed dissecting forceps • Cleaning material- same as stuttering with stitch. Procedure The first part of procedure is the same as for suturing with stitch Except that instead of suturing the skin with thread and needle you would apply clips with the applier. Removal of Clips Technique Use aseptic technique 148 Equipment • Sterile gauze • Sterile cotton balls • Sterile kidney dish • Sterile forceps 3 • Sterile clip removal forceps • Antiseptic solution (Savalon 1% and iodine) • Receiver • Benzene or ether • Adhesive tape or bandage Procedure Explain procedure to the patient and organize the needed equipment • Drape and position patient • Protect bedding with rubber sheet and its cover • Remove old dressing and discard. Pre-operative Purpose • To prepare the patient emotionally, mentally and physically for surgery. Equipment As necessary • It is important that the patient be in a good state of physical health before he has surgery. Try to relieve his fears about the operation and any fear of death: explain to him what will be done and that every measure will be taken for his safety. If the surgery is on the face, neck, shoulders or upper chest, the hair should be the roughly washed, combed and tied up to keep it from touching the operative area. Any thing abnormal such as pain, fever cough rapid pulse or elevated blood pressure must be reported immediately. Just before surgery • Just before it is time to take the patient void, if he is unable to void inform the doctor. The patient may be very sleepy or dizzy from the preoperative medications and may hurt himself. Shaving Purpose To minimize the danger of infection by decreasing the number of bacteria on the skin. Specific Area to be Shaved: Head Operations • Explain the reason for having the head to the patient 154 • If the hair is long, it must be cut short • Wash the head and hair well • Shave the area of the operation as directed. Face Operation • Shave the side of the face there the operation will be • If the patient is a man, make sure that the face is completely free from beard. Anterior Neck Operations: • Wash the patient’s head and neck • If the patient is a woman, tie her hair, and keep it away from her neck, or cut it short. Breast Operations • Shave the anterior and posterior chest from neck to the waist line on the side where the surgery will be • Shave the axilla on that side and the arm as far down as the elbow. Abdominal operations • Shave the whole abdomen from the end of the sternum down to the pubes. Equipment • Anesthetic bed • Oxygen • Sphygmomanometer • Stereoscope • Suction machine (as needed) • Extra rubber sheet (as needed) • I. V stand • Emergency drugs (to be ready in wards) • Bed blocks (as needed) for shock Procedure • Prepare anesthetic bed (see section on bed making) • Assist operating room nurse or health assistance in planning patient in bed. An unconscious patient may be placed on either his right or left side unless his right or left side unless specifically o Orders. Charting • Time of return • General condition and appearance ⇐ State of consciousness ⇐ Color of skin ⇐ Temperature of skin to touch ⇐ Skin- moist or dry ⇐ Blood pressure, plus and respiration ⇐ Any unusual condition such as bleeding drainage, Vomiting etc. Generals Instructions • If patient shows any signs of shock immediate action should be taken and then be reported to the doctor. The head of the bed should be lowered (If no gatches on bed, bed blocks may be used) • Do not leave unconscious patient alone. Breast Surgery • Encourage deep breathing often, because of danger of pneumonia • Special arm exercises should be given Abdominal Surgery • Encourage deep breathing • Turn from side to side often st • Sit patient on edge of bed 1 day postoperatively and • Start walking second day post operatively (unless contra-indicated) • Intake and output should be recorded • If gastric suction is present make sure it is working properly • Frequent mouth care for patients who are not allowed to drink. Eye Surgery • Must lie very still because the incision and sutures can be damaged by pulling on the eye muscles. Spinal Surgery • Must lie on abdomen of back with bed flat, and supported by fracture board mattress. This will make it easier to breathe since the pressure of dressing and swelling may give choking feeling. Tonsillectomy Child • Lie on abdomen or side to prevent blood drainage into throat, lunge or stomach. Adult • If conscious, he may sit in semi- fowler’s positron in order to spit the blood more easily. List some important equipment to provide care for immediate postoperative patients. Legal death is the total absence of brain activities as assessed and pronounced by the physician. If the dying patient is in a ward, move him to a room where there are no other patients, if possible, if this is impossible, put screen around his bed. To show kindness to the family Equipment • Basin for water, wash cloth and towel • Cotton • Gauze • Dressings and tape if necessary • Clean sheet • Stretcher • Forceps • Name tag • Gloves, if necessary Procedure • Note the exact time of death and chart it • If the doctor is present call him to pronounce death • If the family members are not present, send for them • Wash hands and wear clean gloves according to agency policy • Close doors to room or pull curtain • Raise bed to comfortable working level (when necessary) • Arrange for privacy and prevent other patients from seeing in to room. Autoclave Equipment that decontaminates materials by exposing them to steam under pressure.
Less dramatic than the vasoconstriction seen in smaller arteries and arterioles discount red viagra 200mg with visa, venoconstriction may be likened to a “stiffening” of the vessel wall purchase 200 mg red viagra amex. Through venoconstriction, this “reserve” volume of blood can get back to the heart more quickly for redistribution to other parts of the circulation. This includes repair and replacement of diseased or damaged vessels, removal of plaque from vessels, minimally invasive procedures including the insertion of venous catheters, and traditional surgery. Following completion of medical school, the physician generally completes a 5-year surgical residency followed by an additional 1 to 2 years of vascular specialty training. Vascular technicians are specialists in imaging technologies that provide information on the health of the vascular system. This profession often overlaps with cardiovascular technology, which would also include treatments involving the heart. Although recognized by the American Medical Association, there are currently no licensing requirements for vascular technicians, and licensing is voluntary. Vascular technicians typically have an Associate’s degree or certificate, involving 18 months to 2 years of training. Ventricular contraction ejects blood into the major arteries, resulting in flow from regions of higher pressure to regions of lower pressure, as blood encounters smaller arteries and arterioles, then capillaries, then the venules and veins of the venous system. This section discusses a number of critical variables that contribute to blood flow throughout the body. As noted earlier, hydrostatic pressure is the force exerted by a fluid due to gravitational pull, usually against the wall of the container in which it is located. One form of hydrostatic pressure is blood pressure, the force exerted by blood upon the walls of the blood vessels or the chambers of the heart. Blood pressure may be measured in capillaries and veins, as well as the vessels of the pulmonary circulation; however, the term blood pressure without any specific descriptors typically refers to systemic arterial blood pressure—that is, the pressure of blood flowing in the arteries of the systemic circulation. In clinical practice, this pressure is measured in mm Hg and is usually obtained using the brachial artery of the arm. Components of Arterial Blood Pressure Arterial blood pressure in the larger vessels consists of several distinct components (Figure 20. Systolic and Diastolic Pressures When systemic arterial blood pressure is measured, it is recorded as a ratio of two numbers (e. The systolic pressure is the higher value (typically around 120 mm Hg) and reflects the arterial pressure resulting from the ejection of blood during ventricular contraction, or systole. The diastolic pressure is the lower value (usually about 80 mm Hg) and represents the arterial pressure of blood during ventricular relaxation, or diastole. For example, an individual with a systolic pressure of 120 mm Hg and a diastolic pressure of 80 mm Hg would have a pulse pressure of 40 mmHg. This may occur, for example, in patients with a low stroke volume, which may be seen in congestive heart failure, stenosis of the aortic valve, or significant blood loss following trauma. In contrast, a high or wide pulse pressure is common in healthy people following strenuous exercise, when their resting pulse pressure of 30–40 mm Hg may increase temporarily to 100 mm Hg as stroke volume increases. A persistently high pulse pressure at or above 100 mm Hg may indicate excessive resistance in the arteries and can be caused by a variety of disorders. Chronic high resting pulse pressures can degrade the heart, brain, and kidneys, and warrant medical treatment. Mean is a statistical concept and is calculated by taking the sum of the values divided by the number of values. If the value falls below 60 mm Hg for an extended time, blood pressure will not be high enough to ensure circulation to and through the tissues, which results in ischemia, or insufficient blood flow. Neurons are especially sensitive to hypoxia and may die or be damaged if blood flow and oxygen supplies are not quickly restored. Pulse After blood is ejected from the heart, elastic fibers in the arteries help maintain a high-pressure gradient as they expand to 902 Chapter 20 | The Cardiovascular System: Blood Vessels and Circulation accommodate the blood, then recoil. This expansion and recoiling effect, known as the pulse, can be palpated manually or measured electronically. Although the effect diminishes over distance from the heart, elements of the systolic and diastolic components of the pulse are still evident down to the level of the arterioles. Because pulse indicates heart rate, it is measured clinically to provide clues to a patient’s state of health. A high or irregular pulse rate can be caused by physical activity or other temporary factors, but it may also indicate a heart condition. Pulse can be palpated manually by placing the tips of the fingers across an artery that runs close to the body surface and pressing lightly. While this procedure is normally performed using the radial artery in the wrist or the common carotid artery in the neck, any superficial artery that can be palpated may be used (Figure 20. Common sites to find a pulse include temporal and facial arteries in the head, brachial arteries in the upper arm, femoral arteries in the thigh, popliteal arteries behind the knees, posterior tibial arteries near the medial tarsal regions, and dorsalis pedis arteries in the feet. Measurement of Blood Pressure Blood pressure is one of the critical parameters measured on virtually every patient in every healthcare setting. Turbulent blood flow through the vessels can be heard as a soft ticking while measuring blood pressure; these sounds are known as Korotkoff sounds. The technique of measuring blood pressure requires the use of a sphygmomanometer (a This OpenStax book is available for free at http://cnx. The technique is as follows: • The clinician wraps an inflatable cuff tightly around the patient’s arm at about the level of the heart. Initially, no sounds are heard since there is no blood flow through the vessels, but as air pressure drops, the cuff relaxes, and blood flow returns to the arm. As more air is released from the cuff, blood is able to flow freely through the brachial artery and all sounds disappear. In this graph, a blood pressure tracing is aligned to a measurement of systolic and diastolic pressures. The majority of hospitals and clinics have automated equipment for measuring blood pressure that work on the same principles.
As regards the features most emphasized by the review studies on school- based prevention discount red viagra 200mg line, the specialized literature indicates that: 34 Mónica Gázquez Pertusa order 200 mg red viagra with visa, José Antonio García del Castillo, Diana Serban and Diana Bolanu a) the optimal number of sessions is 15. In reference to the prior training of the teaching staff responsible for implementing the programs: a) it should include the application of the sessions, use of videos and role playing, and be followed up with booster sessions. The Moderator-Mediator Variable Distinction in Social Psychological Research: Conceptual, Strategic and Statistical Considerations. Adolescent tobacco, alcohol and drug abuse: prevention strategies, empirical findings and assessment issues. Prevention in the Classroom: Drug Education and Gambling Workshops for Educators Influences on Substance Use: Risk and Protective Factors. Listado de indicadores elaborados para el Curso: Calidad en Prevención: Avances Teóricos e Instrumentos Prácticos (Unpublished document). Scotland: University of Strathclyde, Scottish Executive Effective Interventions Unit, Scottish Executive Drug Misuse Research Programme. Testing the generalizability of intervening mechanism theories: understanding the effects of adolescent drug use prevention interventions. The long-term prevention of tobacco use among junior high school students: classroom and telephone intervention. Social and personal factors in marijuana use and intentions to use drugs among inner city minority youth. Deterring the onset of smoking in children: Knowledge of immediate psychological effects and coping with peer pressure, media pressure, and parent modeling. The Seattle Social Development Project: Effects of the first four years on protective factors and problem behaviors. Changing teaching practices in mainstream classrooms to reduce discipline problems among low achievers. La prevención del consumo de drogas y la conducta antisocial en la escuela: análisis y evaluación de un programa. The effectiveness of supportive refutational defences in immunizing and restoring beliefs against persuasion. Mediating mechanisms in a school-based drug prevention program: first year effects of the Midwestern Prevention Project. Preventing Drug Abuse Among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders, Second Edition. Primary prevention of chronic diseases in adolescence: effects of the Midwestern prevention project on tobacco use. Project Northland: Outcomes of a Comunitywide Alcohol use prevention program during early adolescence. Long term follow-up of a high school Alcohol Misuse Prevention Programm’s effect on 43 School-based Drug Use Prevention students subsequent driving. Meta-analysis of 143 adolescent drug prevention programs: quantitative outcome results of program participants compared to a control or comparison group. The development of new an- sity supported the project in small but key ways; gratitude is ex- esthetic agents (both inhaled and intravenous), regional tech- tended to Joanna Rieber, Alena Skrinskas, James Paul, Nayer niques, sophisticated anesthetic machines, monitoring equipment Youssef and Eugenia Poon. Brown, who was instrumental throughout the duration of the project, contributing to both the arduous work of formatting as well as creative visioning and problem-solving. Crawford Long administered the ﬁrst anesthetic using an ether-saturated towel applied to his patient’s face on March 30, 1842, in the American state of Georgia. As well, you will develop an understanding of the ﬂuid compartments of the body from which an approach to ﬂuid management is developed. The airway is innervated by both sensory and • The Difﬁcult Airway motor ﬁbres (Table 1,Figure 1, Figure 2). The pur- Airway Anatomy pose of the sensory ﬁbres is to allow detection of The upper airway refers to the nasal passages, foreign matter in the airway and to trigger the nu- oral cavity (teeth, tongue), pharynx (tonsils, merous protective responses designed to prevent uvula, epiglottis) and larynx. The swallowing mechanism is an ex- ynx is the narrowest structure in the adult airway ample of such a response whereby the larynx and a common site of obstruction, the upper air- moves up and under the epiglottis to ensure that way can also become obstructed by the tongue, the bolus of food does not enter the laryngeal in- tonsils and epiglottis. The cough reﬂex is an attempt to clear the up- The lower airway begins below the level of the per or lower airway of foreign matter and is also larynx. The most prominent of these is the thyroid cartilage (Adam’s apple) which acts as a shield for the delicate laryngeal structures behind it. Below the larynx, at the level of the sixth cervical vertebra (C6), the cri- coid cartilage forms the only complete circumfer- ential ring in the airway. The cricothyroid muscle, an adductor muscle, is sup- This ﬁgure was plied by the external branch of the superior laryngeal nerve. The purpose of the assessment is to identify potential difﬁculties with airway management and to determine the most ap- propriate approach. Examples include arthritis, infection, tu- mors, trauma, morbid obesity, burns, congenital anomalies and pre- vious head and neck surgery. As well, the anesthesiologist asks about symptoms suggestive of an airway disorder: dyspnea, hoarseness, stridor, sleep apnea. Finally, it is important to elicit a history of previous difﬁcult intubation by reviewing previous anes- thetic history and records. The physical exam is focused towards the identiﬁcation of anatomi- cal features which may predict airway management difﬁculties. Traditional teaching main- tains that exposure of the vocal cords and glottic opening by direct laryngoscopy requires the alignment of the oral, pharyngeal and laryngeal axes (Figure 3). The “snifﬁng position” optimizes the alignment of these axes and optimizes the anesthesiologist’s chance of achieving a laryngeal view. An easy intubation can be anticipated if the patient is able to open his mouth widely, ﬂex the lower cervical spine, extend the head at the atlanto-occipital joint and if the patient has enough anatomical space to allow a clear view. Class 4 corresponds well with a difﬁcult intuba- the anesthesiologist also observes the teeth for over- tion.
Es una enfermedad inflamatoria red viagra 200mg on line, en la cual generic 200mg red viagra visa, mecanismos de inmunidad interactúan, sobre una base genética, con “factores de riesgo” ambientales y metabólicos para iniciar, propagar y activar lesiones en el endotelio de las principales arterias. Este depósito comienza como una pequeña elevación del endotelio hacia el interior de la luz, que crece al tiempo que la pared se inflama, de manera que disminuye al principio y obstruye después, la luz arterial. El ateroma mientras crece se puede romper, fragmentar, partir, agrietar, ulcerar, desprender, embolizar, calcificar y otras. No todas las arterias se enferman de ateroesclerosis, se enferman las grandes arterias, de los grandes trabajos y de los grandes esfuerzos. Grandes arterias Las grandes arterias son aquellas desde la salida del corazón hasta las de los miembros inferiores: aorta, ilíacas, femorales, y otras. En este caso la enfermedad se evidencia por claudicación intermitente durante la marcha: detención por dolor en los músculos. En los estadios finales, dolor constante en reposo y gangrena de los miembros inferiores. Grandes trabajos Las que realizan grandes trabajos: carótidas, vertebrales, del polígono de Willis, intracerebrales. El cuadro clínico varía desde la isquemia cerebral transitoria hasta el accidente vascular encefálico oclusivo. La manifestación clínica transcurre entre la angina de pecho y el infarto cardíaco. Miembros inferiores 91 En realidad el enfermo tiene las tres localizaciones preferentes de la enfermedad, pero su mayor probabilidad de evidencia es en este orden. El paciente que claudica durante su marcha es un fuerte candidato al infarto cardíaco y a la trombosis cerebral. El que hereda la predisposición familiar o étnica comienza desde muy temprano y de forma muy acelerada. Existen familias en las que muchos de sus integrantes mueren por infarto cardíaco, trombosis cerebral o amputados. El que no tiene tanta carga genética puede desarrollarla por el hecho de ser del sexo masculino o de envejecer, pero fundamentalmente porque tenga otros factores de riesgo, los que están íntimamente relacionados con sus hábitos y estilos de vida, con su cultura. Para esto necesita de dos productos: una enzima y vitaminas del complejo B, en particular folatos. Se estima que 15 % de la población de Norteamérica sufre de hiperhomocisteinemia, al no ingerir folatos en su habitual comida “chatarra”. Al quemar cigarros su humo contiene unas 200 sustancias nocivas, todas con acciones deletéreas sobre las arterias. La peor de estas funestas acciones en el sistema circulatorio es la constricción de arterias pequeñas: colaterales, vasa vasorum, entre otras. También afectan numerosos órganos: pulmón, colon, estómago, vejiga, y otros, a los que predispone al cáncer. Quien suprime el hábito, mejora este estilo de vida, desacelera de forma importante el desarrollo funesto de la ateroesclerosis en cualquier localización. El mejor, el de oliva, pues es poliinsaturado, aunque resulta muy caro en nuestro medio. La “dieta mediterránea” incluye, además del aceite de oliva, los vegetales y frutas, el pescado y el vino tinto. Los fabricantes adicionan a los aceites comerciales algunos componentes atractivos para vender más: antioxidantes, vitamina E, ácidos omega 3. Se ha comenzado a divulgar la necesidad de ingerir unos 15 gramos dos o tres veces a la semana. Suministran vitaminas, minerales, fibras vegetales, antioxidantes y los poco conocidos y muy necesarios microelementos. Hacerlo de acuerdo con as posibilidades de cada paciente, que tienen otras limitaciones: osteoarticulares, del equilibrio, visuales, auditivas. Si por sus limitaciones sólo puede hacerlo en casa: cuidado con las mascotas, juguetes en el piso y barreras arquitectónicas. Mantener toda la actividad física y psíquica posible - Participar en los círculos de abuelos - Practicar el campismo - Ir a la playa - Hacer ejercicios de forma controlada - Oír radio - Ver televisión - Leer libros, revistas y periódicos - Recordar recados Hasta aquí, lo más difícil fue cambiar hábitos y estilos de vida, los cuales debemos recomendar a toda la población, desde la cuna, seguir en la escuela y prolongarse durante toda la vida. La dosis no depende del peso corporal, sino de circunstancias mucho menos evidentes como sería el número de plaquetas del paciente, su agregabilidad, el estado físico químico de la sangre, entre otros. Cada día se sustituye entre 10 y 12 % de las plaquetas, de manera que cada día hay que tomar la dosis mínima. Reduce de peso a algunos pacientes, lo que es conveniente cuando se trata de obesos. De igual manera es un energizante y el enfermo se muestra más dispuesto en su actividad diaria. Sin embargo, el mundo gira en la actualidad alrededor de las estatinas, entre las cuales ya se produce en Cuba, la simvastatina. Ellas tienen bien establecidas sus acciones beneficiosas, a las que cada día se le añaden más. Su acción más importante es que estabilizan el ateroma Necesitan de control hepático periódico, son caras y están menos disponibles. Más que ácido fólico en tabletas específicas, indicamos complejos vitamínicos de cualquier tipo, que siempre lo contienen: polivitamínicas, nutriforte, entre otros, y resultan un suplemento más completo. Se conoce muy poco que el ácido fólico pertenece al complejo B con los números B9, B10 y B11. Tratar la hipertensión arterial Desde la olvidada reserpina, hasta los inhibidores de la enzima de conversión, de sus receptores, o de la renina, según el enfermo. Tratar la diabetes mellitus Desde la dieta, hipoglicemiantes orales, hasta las insulinas clásicas, humanas y los análogos de la insulina: Lispro, Aspart o Glargine.
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