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Small seromas that are not bothersome to the patient usually resolve on their own digoxin 0.25 mg visa blood pressure numbers for seniors. Hand and Arm Care After Axillary Lymph Node Dissection Avoid blood pressures purchase digoxin 0.25mg mastercard blood pressure zoloft, injections cheap digoxin 0.25mg fast delivery can blood pressure medication kill you, and blood draws in affected extremity generic digoxin 0.25 mg with mastercard heart attack iglesias. This risk may be higher in patients with accompanying conditions such as diabetes, immune disorders, and advanced age, as well as in those with poor hygiene. Patients are taught to monitor for signs and symptoms of infection (redness, warmth around incision, tenderness, foul- smelling drainage, temperature greater than 100. Promoting Home and Community-Based Care Teaching Patients Self-Care Patients who undergo breast cancer surgery receive a tremendous amount of information preoperatively and postoperatively. It is often difficult for the patient to absorb all of the information, partly because of the emotional distress that often accompanies the diagnosis and treatment. Teaching may need to be reviewed and reinforced to ensure that the patient and family are prepared to manage the necessary home care. The nurse reiterates symptoms the patient should report, such as infection, seroma, hematoma, or arm swelling. Initially, the drainage fluid appears bloody, but it gradually changes to a serosanguineous and then a serous fluid over the next several days. If the patient lives alone and drainage management is difficult for her, a referral for a home care nurse should be made. The drains are usually removed when the output is less than 30 mL in a 24-hour period (approximately 7 to 10 days). Generally, the patient may shower on the second postoperative day and wash the incision and drain site with soap and water to prevent infection. If immediate reconstruction has been performed, showering may be contraindicated until the drain is removed. The patient should know that sensation may be decreased in the operative area because the nerves were disrupted during surgery, and gentle care is needed to avoid injury. After the incision has completely healed (usually after 4 to 6 weeks), lotions or creams may be applied to the area to increase skin elasticity. The patient can begin to use deodorant on the affected side, although many women note that they no longer perspire as much as before the surgery. Range of motion exercises are initiated on the second postoperative day, although instruction often occurs on the first postoperative day. The goals of the exercise regimen are to increase circulation and muscle strength, prevent joint stiffness and contractures, and restore full range of motion. The patient is instructed to perform range of motion exercises at home 3 times a day for 20 minutes at a time until full range of motion is restored (generally 4 to 6 weeks). Most patients find that after the drain is removed, range of motion returns quickly if they have adhered to their exercise program. With elbows slightly bent, place the palms of the hand on the wall at shoulder level. With the rope-holding arm extended and held away from the body (nearly parallel with the floor), turn the rope, making as wide swings as possible. Reverse maneuver, raising the rod above the head, then return to the starting position. Pull the left arm up by tugging down with the right arm, then the right arm up and the left down in a see-sawing motion. If the patient is having any discomfort, taking an analgesic 30 minutes before beginning the exercises can be helpful. Taking a warm shower before exercising can also loosen stiff muscles and provide comfort. When exercising, the patient is encouraged to use the muscles in both arms and to maintain proper posture. Specific exercises may need to be prescribed and introduced gradually if the patient has had skin grafts; has a tense, tight surgical incision; or has had immediate reconstruction. Self-care activities, such as brushing the teeth, washing the face, and brushing the hair, are physically and 231 emotionally therapeutic because they aid in restoring arm function and provide a sense of normalcy for the patient. Generally, heavy lifting (more than 5 to 10 lbs) is avoided for about 4 to 6 weeks, although normal household and work-related activities are promoted to maintain muscle tone. Brisk walking, use of stationary bikes and stepping machines, and stretching exercises may begin as soon as the patient feels comfortable. Once the drain is removed, the patient may begin to drive if she has full arm range of motion and is no longer taking opioid analgesics. General guidelines for activity focus on the gradual introduction of previous activities (e. Continuing Care Patients who have difficulty managing their postoperative care at home may benefit from a home health care referral. The frequency of follow-up visits after surgery may vary but generally should occur every 3 to 6 months for the first several years. The patient may alternate visits with the surgeon, medical oncologist, or radiation oncologist, depending on the treatment regimen. The ambulatory care nurse can also be a great source of comfort and security for the patient and family and should encourage them to telephone if they have any questions or concerns. It is common for people to ignore routine health care when a major health issue arises, so women who have been treated for breast cancer should be reminded of the importance of participating in routine health screening. Evaluation Expected Preoperative Patient Outcomes Expected preoperative patient outcomes may include: Exhibits knowledge about diagnosis and surgical treatment options o Asks relevant questions about diagnosis and available surgical treatments o States rationale for surgery o Describes advantages and disadvantages of treatment options Verbalizes willingness to deal with anxiety and fears related to the diagnosis and the effects of surgery on self-image and sexual functioning Demonstrates ability to cope with diagnosis and treatment o Verbalizes feelings appropriately and recognizes normalcy of mood lability o Proceeds with treatment in timely fashion o Discusses impact of diagnosis and treatment on family and work Demonstrates ability to make decisions regarding treatment options in timely fashion Expected Postoperative Patient Outcomes Expected postoperative patient outcomes may include: Reports that pain has decreased and states pain and discomfort management strategies are effective 232 Identifies postoperative sensations and recognizes that they are a normal part of healing Exhibits clean, dry, and intact surgical incisions without signs of inflammation or infection Lists the signs and symptoms of infection to be reported to the nurse or surgeon Verbalizes feelings regarding change in body image Discusses meaning of the diagnosis, surgical treatment, and fears appropriately Participates actively in self-care activities o Performs exercises as prescribed o Participates in self-care activities as prescribed Discusses issues of sexuality and resumption of sexual relations Demonstrates knowledge of postdischarge recommendations and restrictions o Describes follow-up care and activities o Demonstrates appropriate care of incisions and drainage system o Demonstrates arm exercises and describes exercise regimen and activity limitations during postoperative period o Describes care of affected arm and hand and lists indications to contact the surgeon or nurse Experiences no complications o Identifies signs and symptoms of reportable complications (eg, redness, heat, pain, edema) o Explains how to contact appropriate health care providers in case of complications 233 Chapter 49 Assessment and Management of Problems Related to Male Reproductive Processes Anatomy and Physiology The scrotum (two parts; each contains a testis, an epididymis, and a portion of the spermatic cord, otherwise known as vas deferens). The prostate (an encapsulated gland that encircles the proximal portion of the urethra). The testes have a dual function: spermatogenesis (production of sperm) and secretion of the male sex hormone testosterone, which induces and preserves the male sex characteristics. The prostate gland produces a secretion that is chemically and physiologically suitable to the needs of the spermatozoa in their passage from the testes. Symptoms include unilateral pain and soreness in the inguinal canal, sudden, severe pain in the scrotum, scrotal swelling, fever, pyuria, bacteriuria, dysuria, and pyuria. Epididymitis/ treatment If it is caused by a chlamydial infection, the patient and his wife must be treated with antibiotics. Observe for abscess formation Epididymectomy (excision of the epididymis from the testis) may be performed for patients who have chronic, painful conditions Nursing Management Bed rest and scrotal support to prevent traction on the spermatic cord and to relieve pain. He needs to know that it may take 4 weeks or longer for the epididymis to return to normal. Inflammatory Diseases: Orchitis An inflammation of the testes that most often occurs as a complication of a bloodborne infection originating in the epididymis. Causes include gonorrhea, trauma, surgical manipulation, and tuberculosis and mumps that occur after puberty. Symptoms include sudden scrotal pain, scrotal edema, chills, fever, nausea, and vomiting. Inflammatory Diseases: Prostatitis An inflammation of the prostate which is a common complication of urethritis caused by chlamydia or gonorrhea. More than 50% of men over the age of 50 and 80% of men ≥ 80 demonstrate some increase in the size of the prostate gland. Suprapubic resection – lower abdomen – incision through the bladder – urethrotomy C. Risk factors include: advancing age (over 55, more than 70% of cases diagnoses at age ≥ 65 ); first-degree relative with prostate cancer; African-American heritage; high level of serum testosterone. Management same as prostate cancer Risk Factors Undescended testicles (cryptorchidism), A family history of testicular cancer, Cancer of one testicle, Ethnicity: more common in white Caucasian Assessment Subjective data Heaviness in scrotum Weight loss Scrotal pain Anxiety or depression Objective data Palpation of abdomen and scrotum – enlarged Mass or lump on the testicle and usually painless Medical Management The testis is removed by orchiectomy Cryptorchidism 243 Hydrocele •Collection of amber fluid within the testes, tunica vaginalis, and spermatic cord •Painful •Swelling •Discomfort in sitting and walking •Treatment: aspiration (usually in children) •Hydrocelectomy – removal of the sac Nursing Interventions: •Preoperative and postoperative management •Scrotal support (elevation) •Supportive to parents/patient 244 Varicocele -Vein- dilation -Spermatic cord = Vas deferens -Occurs when incompetent or absent valves in the spermatic venous system permits blood to accumulate and increase hydrostatic pressure -Hyperthermia – decrease spermatogenesis = fertility -Bluish discoloration -Wormlike mass Treatment: High Ligation 245 Plan of Nursing Care: The Patient with Prostate Cancer Nursing Diagnosis: Anxiety related to concern and lack of knowledge about the diagnosis, treatment plan, and prognosis Goal: Reduced stress and improved ability to cope Nursing Interventions Rationale Expected Outcomes 1. Helping the patient to relieved understanding of his understand the diagnostic Demonstrates health problem tests and treatment plan will understanding of c.

I am satisfied that I have seen patients die from deprivation of common salt during a protracted illness discount digoxin 0.25 mg blood pressure in the morning. It is a common impression that the food for the sick should not be seasoned purchase digoxin 0.25mg otc blood pressure symptoms, and whatever slop may be given proven digoxin 0.25mg blood pressure medication met, it is almost innocent of this essential of life discount 0.25 mg digoxin mastercard blood pressure chart uk nhs. In the milk diet that I recommend in sickness, common salt is used freely, the milk being boiled and given hot. And if the patient cannot take the usual quantity in his food, I have it given in his drink. This matter is so important that it can not be repeated too often, or dwelt upon to long. Without a supply of salt the tongue would become broad, pallid, puffy, with a tenacious pasty coat, the effusion at the point of injury serous, with an unpleasant watery pus, which at last became a mere sanies or ichor. A few days of a free allowance of salt would change all this, and the patient would get along well. A salt of potash is indicated where there is feebleness of the muscles to a greater extent than can be accounted for by the disease. Occasionally such want is expressed in a marked manner by feebleness of the heart. Ammonia will, occasionally, prove the best salt for temporary use, especially where there is great debility. But when so used, it should be followed by the free use of common salt, or some salt of soda. It deserves thorough examination, which I hope some of our readers will give it and report. We may employ the Alnus in infusion, or in the form of tincture with dilute alcohol; the first being preferable if we wish its greatest influence. It exerts a specific influence upon the processes of waste and nutrition, increasing the one and stimulating the other. It is thus a fair example of the ideal alterative, and is one of the most valuable of our indigenous remedies. Its special use seems to be in those cases in which there is superficial disease of the skin or mucous membranes, taking the form of eczema or pustular eruption. In these cases I have employed it as a general remedy, and as a local application with the best results. It does not seem to make much difference whether it is a phlyctenular conjunctivitis, an ulcerated sore mouth or throat, chronic eczema or secondary syphilis presenting these characteristics, it is equally beneficial. I believe that in small quantity and in combination with other agents that act upon the upper intestinal canal, it proves a good cathartic, as in the following: ℞ Podophyllin, grs. One of them at night will prove an excellent laxative, and those who employ cathartics freely will like the formula. But it is not for this purpose that I would recommend Aloes, but for one that may seem very singular. In small doses it exerts a direct influence upon the waste and nutrition of the nervous system. In cases of feeble innervation, especially in persons of gross habit, it will be one of our best agents. I have usually prescribed it with tincture of nux vomica or with tincture of belladonna. In some cases it will prove serviceable when associated with the bitter tonics, as in this: ℞ Extract of nux vomica, grs. Brought to this country in 1876, it was exhibited at the Centennial with the Australian exhibit, but attracted very little attention. A friend of mine procured a piece of the bark, and gave it a pretty thorough test, with such marked results in the cure of ague, that he resolved to import it and sell it as an “ague cure. Whilst it may not be as certain in its action as quinine, especially in recent agues, it seems to produce more permanent results. So that an ague cured with Alstonia is likely to remain cured, and is not simply “broken. Agues not curable with quinine, and cases of chronic ague, will give a very good field for its use. Those who have used it most claim that it will be found a most excellent tonic and restorative, especially where the secretions are defective as above. As an antiperiodic the dose will be somewhat less than quinine, say ten grains in divided doses: as a tonic it may be given in grain doses. The Alstonia Scholaris is likely to prove an excellent remedy in disease of the bowels, with imperfect digestion and diarrhœa, especially in malarial regions. It has been claimed to have antiperiodic properties, but these are feeble, as compared with the Alstonia Constricta. The Bromide of Ammonium is a stimulant to the nerve centers; increasing waste and improving nutrition. I have employed it principally in epilepsy, in some cases of which it is undoubtedly a specific. I do not think I can point out the exact cases in which it is likely to prove curative, as the evidences of pathological states in this disease are very obscure. I have used it now for some twenty years, and it has given excellent satisfaction. But whilst it has effected permanent cures in a large number of cases, it has only proven of temporary benefit in some, and has wholly failed in others. We not unfrequently meet with disease, in which there is disordered innervation, manifesting itself as epileptiform, partially spasmodic, or in other ways, but in which there is undoubtedly the same enfeeblement of the cerebro- spinal centers. In diseases of children, I have been accustomed to employ this remedy in convulsions, following the first influence obtained by Lobelia or Gelseminum, and with marked success. When a child is subject to repeated attacks of convulsions from slight causes, the Bromide of Ammonium may be used to remove the predisposition. In some cases of whooping cough it exerts a direct action, as it does in many cases of nervous cough in both child and adult. Iodide of Ammonium increases retrograde metamorphosis at the same time that it exerts a stimulant influence upon the nervous system, especially the sympathetic system. Thus it can be employed with less risk than Iodide of Potassium, when the nutritive powers are feeble, as is the case occasionally in secondary syphilis. They are those in which the eye is dull, the face expressionless, the circulation feeble, the patient being of a full habit. The best indication for it is a dusky flush of the skin, the redness effaced by pressure returning slowly. A dusky redness of mucous membranes, not indicative of blood poisoning, will sometimes call for this remedy. It is also a good remedy when there is oppressed respiration, with bronchial sounds on auscultation, neither dry or moist. We also employ a bath of Muriate of Ammonia as a stimulant to the skin, especially in the eruptive fevers when the eruption is tardy in appearing. It would be well to have it thoroughly tested, and for this purpose I would suggest a tincture of the fresh bark, in doses of from one-fourth to one teaspoonful. The first will be found preferable in cases of acute gastric irritation; but for ordinary office use, I would suggest the following: Take of the green bark of the young limbs (suckers), a sufficient quantity, and cover with alcohol 50 per cent. The infusion or tincture, as above prepared, has a direct influence in quieting irritation of the stomach and upper intestinal canal. It also exerts an influence upon the circulation, and upon the nervous system, which deserves investigation.

In the middle column of Worksheet 3-14 cheap 0.25mg digoxin overnight delivery hypertension teaching for patients, write down any thought or action from that day that you feel limits your efforts at overcoming your anxiety or depression digoxin 0.25 mg generic hypertension vs pulmonary hypertension. In the right-hand column discount digoxin 0.25mg overnight delivery blood pressure medication ear ringing, write down how helpful (if at all) you think the self- sabotage may have been as well as any arguments you can find against it digoxin 0.25 mg line heart attack left arm. Maintain this diary for at least one week; keep it up much longer if you continue to see lots of self-sabotage. Criticizing yourself for the sabotage you notice yourself committing only leads to more sab- otage. Chapter 3: Overcoming Obstacles to Change 41 Worksheet 3-14 My Self-Sabotage Diary Day Self-Sabotage Response to Self-Sabotage Sunday Monday Tuesday Wednesday Thursday Friday Saturday You can download extra copies of this form at www. Rewriting your self-sabotaging scripts Our minds create stories — about ourselves, our lives, and our worlds. For example, you may have a long- running play in your mind that has you as its central character. Try creating a new story about you and your life that allows you to ultimately succeed. But remember, in addition to success, the new story needs to contain realistic struggle and difficulty. Part I: Analyzing Angst and Preparing a Plan 42 Worksheet 3-15 Molly’s Current Life-Script I might have money and a little prestige, but I deserve none of it. Although it takes her a while to start believing it, gradually she begins to see her life in a new light. Worksheet 3-16 Molly’s New Life-Script I have a good job, and I worked very hard to get it. Besides, I’m capable of learning new behaviors, and I’m working on my irritability. This will be a struggle for me, but I see myself cutting back a little on my work and making new friends. In Worksheet 3-17, write your current life-script, including how you see yourself today and in the future. Be sure to include your thoughts on hope, change, possibilities, as well as struggle. Worksheet 3-17 My Current Life-Script Worksheet 3-18 My New Life-Script Chapter 4 Minding Your Moods In This Chapter Listening to your body Figuring out your feelings Connecting events and feelings Tracking thoughts, events, and feelings ou can’t overcome anxiety and depression by running on autopilot. In this chapter, we provide instructions for observing the relationships among your feelings, your thoughts, and the happenings in your life. This information helps you become more aware of the physical components of depression and anxiety. Some people aren’t very good at identifying their feelings, so we help you by providing a list of feeling words. Finally, we show you how to become aware of how thoughts link up with feelings, events, and bodily sensations. Deciphering Body Signals Your heart may race or your hands may sweat when you feel anxious. Monitoring your bodily sensations gives you an early warning that a storm of emotional distress is brewing. Tyler begins to understand his body’s signals by monitoring phys- ical sensations on a daily basis. He jots down any time that he feels something uncomfortable in his body and includes information about what was going on at the time. Worksheet 4-1 Tyler’s Body Responses Tracking Sheet Body Response How did my body feel? Breathing/ I could tell my Tuesday evening while talking with Increased heart breathing was rapid my ex-wife. Headaches None this week Posture I noticed I’m walking I notice this mostly after lunch on around stooped Thursday and Friday. Other: Dizziness, Spacey and Saturday morning before paying sweating, lightness, light-headed bills. Worksheet 4-2 Tyler’s Reflections I noticed that my body seems to react to what’s going on in my life. These sensations aren’t very pleasant, and maybe the doc is right that I’m depressed. I realize that talking with my ex-wife and my boss both make me feel pretty weird and stressed. Now that I know all this, I really want to do something to get myself to a better place. Now fill out your own Body Responses Tracking Sheet (see Worksheet 4-3) and record your reflections on the exercise (see Worksheet 4-4). If you experienced a reaction in a given category, elaborate and specify how your body reacted (in the middle column). Chapter 4: Minding Your Moods 45 Worksheet 4-3 My Body Responses Tracking Sheet Body Response How did my body feel? Muscle tightness Breathing Stomach symptoms Fatigue Headaches Posture Other: Dizziness, lightness, tingling, constriction in throat or chest, or feeling spacey and disoriented Visit www. We recommend stashing a couple of them in your purse or briefcase so they’re handy whenever you experi- ence unpleasant physical sensations. Part I: Analyzing Angst and Preparing a Plan 46 Worksheet 4-4 My Reflections Connecting the Mind and Body After you become more observant of your body’s signals, it’s time to connect your mental and physical states. If you’re unac- customed to describing your feelings, spend some time looking over the list of words in the following chart and ponder whether they apply to you. Track your feelings every day for a week using the Daily Unpleasant Emotions Checklist in Worksheet 4-5. At the end of the week, look back over your checklist and tally the most prevalent feelings. Worksheet 4-5 Daily Unpleasant Emotions Checklist Day Sadness Fear Shame Anger Sunday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Monday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Tuesday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Chapter 4: Minding Your Moods 47 Day Sadness Fear Shame Anger Wednesday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Thursday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Friday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Saturday Despondent, Panicked, nervous, Guilty, regretful, Outraged, bitter, miserable, tense, afraid, timid, remorseful, furious, resentful, hopeless, gloomy, terrified, embarrassed, mad, annoyed, grief, joyless, apprehensive, disgraced, irritable, dispirited, worried dishonored indignant dejected, sad Worksheet 4-6 My Reflections Putting Events, Feelings, and Sensations Together As you work through this chapter, you should become more aware of how your body reacts to events in your life. And thanks to the Daily Unpleasant Emotions Checklist in the previous section, you have feeling words to label your mental and physical states. It’s time to connect these body sensations and feeling words to the events that trigger them. Part I: Analyzing Angst and Preparing a Plan 48 Jasmine suffers from constant worry and anxiety. She thinks that her worries mainly center on her children, but at times she has no idea where her anxiety comes from. She pays special attention to her body’s signals and writes them down when- ever she feels something unpleasant. She rates the emotions and sensations on a scale of 1 (almost undetectable) to 100 (maximal). Worksheet 4-7 is a sample of Jasmine’s Mood Diary; specifically, it’s a record of four days on which Jasmine noticed undesirable moods. Worksheet 4-7 Jasmine’s Mood Diary Day Feelings and Sensations (Rated 1–100) Corresponding Events Sunday Apprehension, tightness in my I was thinking about going to chest (70) work tomorrow morning. Thursday Worry, tightness in my chest My middle child has a cold, and (60) I’m worried she’ll have an asthma attack. Saturday Nervous, tension in my I have a party to go to, and I shoulders (55) won’t know many people there. After studying her complete Mood Diary, she comes to a few conclusions (see Worksheet 4-8).

Implementation of an integrated drug information system for inpatients to reduce medication errors in administering stage buy generic digoxin 0.25mg how is pulse pressure used as a diagnostic tool. Impact of computerized physician order entry prescribing on medication errors in the outpatient setting cheap digoxin 0.25mg with mastercard hypertension 140 90. Evaluation of access discrepancies associated with an automated storage and distribution cabinet cheap digoxin 0.25 mg with amex blood pressure chart morning. Reasons for declining computerized insulin protocol recommendations: application of a framework generic digoxin 0.25mg overnight delivery arrhythmia statistics. Improving investigational drug service operations through development of an innovative computer system. Dispensing errors in community pharmacy: perceived influence of sociotechnical factors. Improving influenza vaccination rates in children with asthma: A test of a computerized reminder system and an analysis of factors predicting vaccination compliance. Countering imbalanced datasets to improve adverse drug event predictive models in labor and delivery. Benefits and risks of electronic patient records on the works of the Pharmaceutical Department in the National Hospital Organization, Kyoto Medical Center. Development of an inspection-supporting system using drug images for unit dose packages. Yakugaku Zasshi - Journal of the Pharmaceutical Society of Japan 2001;121(11):821-8. Impact of computerized drug profiles and consulting pharmacist on outpatient prescribing patterns: Clinical trial. Improving patient safety through computerized drug management: the devil is in the details. The Office of the Future Project: the integration of new technology into office practice. Improving patient safety in hospitals: Contributions of high- reliability theory and normal accident theory. Quality improvement: experience of a sexually transmitted infection clinic in Singapore. Automating the drug scheduling of cancer chemotherapy via evolutionary computation. Active Guidelines: integrating Web-based guidelines with computer- based patient records. Electronic interface for emergency department management of asthma: A randomized control trial of clinician performance. Quantifying value for physician order-entry systems: a balance of cost and quality. Development and validation of criteria to identify patients requiring clinical pharmacist intervention. Electronic prescribing in the ambulatory care environment: Promise, progress, barriers, solutions. The Annual Symposium on Computer Applications in Medical Care 1995;Proceedings:459-63. Clinical decision support in electronic prescribing: recommendations and an action plan: report of the joint clinical decision support workgroup. Clinical decision support for electronic prescribing: Recommendations and an action plan. Cost savings from computerization and addition of bar coding capability to a pharmacy puchasing and inventory management system. Personal digital assistants: A review of current and potential utilization among medical residents. Implementation and evaluation of carousel dispensing technology in a university medical center pharmacy. Linking laboratory and medication data: new opportunities for pharmacoepidemiological research. Development of an electronic prescription processing option: an aid for general practice. Computerized prescriber order entry associated with pharmacist participation in physician round in a French teaching hospital: assessment of pharmacist’s interventions. Implementation of a tight glycaemic control protocol using a web-based insulin dose calculator. Computerised decision support to achieve tight glycaemic control in critical illness. Computerised Patient-specific Guidelines for Management of Common Mental Disorders in Primary Care: a Randomised Controlled Trial. Evaluating E&M coding accuracy of GoCode as compared to internal medicine physicians and auditors. The characteristics of personal order sets in a computerized physician order entry system at a community hospital. Computerized physician order entry, a factor in medication errors: Descriptive analysis of events in the Intensive Care Unit Safety Reporting System. A computerised guidance tree (decision aid) for hypertension, based on decision analysis: development and preliminary evaluation. Development and description of a decision analysis based decision support tool for stroke prevention in atrial fibrillation. A patient decision aid to support shared decision- making on anti-thrombotic treatment of patients with atrial fibrillation: randomised controlled trial. Development of a computerized pharmacy therapeutic recommendation tracking program. Approach to computer-based medication planning and coordination support in intensive care units. User-centered design techniques for a computerised antibiotic decision support system in an intensive care unit. Prevention of potential adverse drug events in a computerized physician ordering system. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. A comment on White and Du Mont’s ‘Visualizing sexual assault: An exploration of the use of optical technologies in the medico-legal contact’. The construction of a checking system for drug­ contraindicant disease in order entry system. Support system with a composition analysis for prescription order of injection agents. Structured conversion from thrice weekly to weekly erythropoietic regimens using a computerized decision-support system: a randomized clinical study. Health information technology in primary health care in developing countries: a literature review. Effects of novel infection control system using electronic medical records of Showa University Northern Yokohama Hospital. A systematic review of strategies to improve prophylaxis for venous thromboembolism in hospitals. In my opinion: Hospital pharmacists are needed in the development of data systems in Finland. Morbidity reduction in critically ill trauma patients through use of a computerized insulin infusion protocol: a preliminary study. How technology is helping children’s medical center of Dallas reach zero-error tolerance.

The skin over the pressure points is assessed for redness or breaks; the perineum is checked for soilage discount 0.25mg digoxin visa blood pressure 4020, and the catheter is observed for adequate drainage generic 0.25mg digoxin mastercard blood pressure medications list. Special attention should be given to pressure areas in contact with the transfer board purchase digoxin 0.25mg otc blood pressure medication and st john's wort. Pressure-sensitive areas should be kept well lubricated and soft with hand cream or lotion order digoxin 0.25mg amex arteria thyroidea ima. To increase understanding of the reasons for preventive measures, the patient is educated about the danger of pressure ulcers and is encouraged to take control and make decisions about appropriate skin care (Kinder, 2005). Because the patient has no sensation of bladder distention, overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder function. At an early stage, family members are shown how to carry out intermittent catheterization and are encouraged to participate in this facet of care, because they will be involved in long- term follow-up and must be able to recognize complications so that treatment can be instituted. The patient is taught to record fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics of urine, and any unusual sensations that may occur. The management of a neurogenic bladder (bladder dysfunction that results from a disorder or dysfunction of the nervous system) is discussed in detail in Chapter 11. As soon as bowel sounds are heard on auscultation, the patient is given a high-calorie, high-protein, high-fiber diet, with the amount of food gradually increased. The nurse administers prescribed stool softeners to counteract the effects of immobility and analgesic agents. Providing Comfort Measures A patient who has had pins, tongs, or calipers placed for cervical stabilization may have a slight headache or discomfort for several days after the pins are inserted. Patients initially may be bothered by the rather startling appearance of these devices, but usually they readily adapt to it because the device provides comfort for the unstable neck. The patient may complain of being caged in and of noise created by any object coming in contact with the steel frame of a halo device, but he or she can be reassured that adaptation to such annoyances will occur. The Patient in Halo Traction The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. A torque screwdriver should be readily available in case the screws on the frame need tightening. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The liner of the vest should not become wet, because dampness causes skin excoriation. Powder is not used inside the vest, because it may contribute to the development of pressure ulcers. If the patient is to be discharged with the vest, detailed instructions must be given to the family, with time allowed for them to return demonstrate the necessary skills of halo vest care (Chart 63-9). The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies are performed if a significant increase is noted. Patients remain at high risk for thrombophlebitis for several months after the initial injury. Patients with paraplegia or tetraplegia are at increased risk for the rest of their lives. Anticoagulation is initiated once head injury and other systemic injuries have been ruled out. Low-dose fractionated or unfractionated heparin may be followed by long- term oral anticoagulation (ie, warfarin) or subcutaneous fractionated heparin injections. Additional measures such as range-of-motion exercises, thigh-high elastic compression stockings, and adequate hydration are important preventive measures. Pneumatic compression devices may also be used to reduce venous pooling and promote venous 421 return. It is also important to avoid exter-nal pressure on the lower extremities that may result from flexion of the knees while the patient is in bed. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Interruption in the reflex arcs that normally produce vasoconstriction in the upright position, coupled with vasodilation and pooling in abdominal and lower extremity vessels, can result in blood pressure readings of 40 mm Hg systolic and 0 mm Hg diastolic. Orthostatic hypotension is a particularly common problem for patients with lesions above T7. In some patients with tetraplegia, even slight elevations of the head can result in dramatic changes in blood pressure. A number of techniques can be used to reduce the frequency of hypotensive episodes. Thigh-high elastic compression stockings should be applied to improve venous return from the lower extremities. Abdominal binders may also be used to encourage venous return and provide diaphragmatic support when the patient is upright. Activity should be planned in advance, and adequate time should be allowed for a slow progression of position changes from recumbent to sitting and upright. Autonomic Dysreflexia Autonomic dysreflexia (autonomic hyperreflexia) is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). Because this is an emergency situation, the objectives are to remove the triggering stimulus and to avoid the possibly serious complications. The following measures are carried out: The patient is placed immediately in a sitting position to lower blood pressure. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. If one is present, a topical anesthetic is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. The process begins during hospitalization, as acute symptoms begin to subside or come under better control and the overall deficits and long-term effects of the injury become clear. Patient teaching may initially focus on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the injury and the resulting disability, the focus of teaching broadens to address issues necessary for carrying out the tasks of daily living and taking charge of their lives (Kinder, 2005). They will require dedicated nursing support to gradually assume full care of the patient. Although maintaining function and preventing complications will remain important, goals regarding self-care and preparation for discharge will assist in a smooth transition to rehabilitation and eventually to the community. The nurse becomes a support to both the patient and the family, assisting them to assume responsibility for increasing aspects of patient care and management. The nurse often serves as coordinator of the management team and as a liaison with rehabilitation centers and home care agencies. The patient and family often require assistance in dealing with the psychological impact of the injury and its consequences; referral to a psychiatric clinical nurse specialist or other mental health care professional often is helpful. Preconception assessment and counseling are strongly recommended to ensure that the woman is in optimal health and to increase the likelihood of an uneventful pregnancy and healthy outcomes. Therefore, teaching in the home and community focuses on health promotion and addresses the need to minimize risk factors (eg, smoking, alcohol and drug abuse, obesity) (Mastrogiovanni, Phillips & Fine, 2003). Assisting patients to identify accessible health care providers, clinical facilities, and imaging centers may increase the likelihood that they will participate in health screening. Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness. Management • Medical –Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder.

Administer Rh immune globulin (RhIg) transfusion reaction and/or evoke an even stronger D cheap digoxin 0.25 mg line blood pressure chart male. Adsorb the antibody onto antigen-positive cells antibody response digoxin 0.25mg line blood pressure medication can you stop, possibly causing more harm to the fetus digoxin 0.25mg amex heart attack jarren benton lyrics. Blood bank/Apply knowledge of standard operating procedures/Hemolytic disease of the newborn/Antibody 5 digoxin 0.25 mg visa blood pressure pump. A If the cord cells contain excessive Wharton’s jelly, testing/2 then further washing or obtaining another cord sample will not solve the problem. Early induction of labor Blood bank/Apply knowledge of standard operating procedures/Hemolytic disease of the newborn/Clinical interventions/2 158 4. O-negative mother; A-positive baby; second fetus pregnancy; no anti-D in mother D. Yes, if the baby’s type is Rh negative anti-K, she will be monitored to determine if the C. Yes, if the baby’s type is Rh positive antibody level and signs of fetal distress necessitate D. C RhIg is immune anti-D and is given to Rh-negative Blood bank/Correlate clinical and laboratory data/ mothers who give birth to Rh-positive babies and Hemolytic disease of the newborn/RhIg/3 who do not have anti-D already formed from 8. Should an A-negative woman who has just had a previous pregnancies or transfusion. Yes, but only if she does not have evidence of the fetus is unknown, termination of a pregnancy active Anti-D from any cause presents a situation in which an B. Yes, but only a minidose regardless of trimester is used if the pregnancy is terminated in the first D. The on a woman who is 6 weeks pregnant with woman is weak D positive, and, therefore, is not a vaginal bleeding as O negative. Typically, a test for weak D is not tells the emergency department physician she is done as part of the obstetric workup. Is A-positive baby and has no anti-D formed from a this woman a candidate for RhIg? Yes, based upon the Provue results immunization typically has a titer >4, compared with passive administration of anti-D, which has a Blood bank/Correlate clinical and laboratory results/ titer <4. All of the following are routinely performed on a 40 fetal cells in 2,000 maternal red cells. Divide this number by 30 to arrive at the Blood bank/Apply knowledge of biological principles/ number of doses. When the number to the right of Hemolytic disease of the newborn/1 the decimal point is less than 5, round down and add one dose of RhIg. Anti-E is detected in the serum of a woman in the right of the decimal point is 5 or greater, round the first trimester of pregnancy. Perform plasmapheresis to remove anti-E from cross into the central nervous system, causing brain the mother damage to the infant. Perform an intrauterine transfusion using mother and provides a temporary solution to the E-negative cells problem until the fetus is mature enough to be Blood bank/Correlate clinical and laboratory data/ delivered. The procedure may need to be performed Hemolytic disease of the newborn/3 several times, depending upon how quickly and how 14. Administration of RhIg when the mother’s serum contains an would not contribute to solving this problem caused alloantibody? Crossmatch and antibody screen performed before week 20, and would be considered B. A crossmatch is necessary as long procedures/Hemolytic disease of the newborn/ as maternal antibody persists in the infant’s blood. O negative only Blood bank/Select course of action/Hemolytic disease of the newborn/Hemotherapy/2 4. Why do Rh-negative women tend to have a Answers to Questions 17–19 positive antibody screen compared to Rh-positive women of childbearing age? It is known as a single entity Blood bank/Apply knowledge of biological principles/ as opposed to separate antibodies. Anti-D would Hemolytic disease of the newborn/3 not be the cause because this is the first pregnancy. Anti-D from the mother coating the infant red physician can communicate with the pathologist cells once he or she receives this information from the B. Maternal anti-A, B coating the infant cells Blood bank/Correlate clinical and laboratory data/ Hemolytic disease of the newborn/3 19. Te nurse then requests to take 50 mcg from the 300 mcg syringe to satisfy the physician’s orders. Instruct the nurse that the blood bank does not stock minidoses of RhIg and manipulating the full dose will compromise the purity of the product D. Instruct the nurse that the blood bank does not stock minidoses of RhIg, and relay this information to the patient’s physician Blood bank/Select course of action/Hemolytic disease of the newborn/RhIg/3 4. Pools of up to 16 donors are tested; if pool is Blood bank/Apply knowledge of standard operating reactive, individual samples are screened procedures/Processing/1 D. All donors are screened individually; if samples are reactive, blood is discarded Answers to Questions 1–5 Blood bank/Standard operating procedures/Processing/3 1. Told to come back in 6 months Blood bank/Select best course of action/Processing/3 6. B The recipient’s physician should be notified by the positive, then the unit may be used medical director to ascertain the current health C. Cellular components may be prepared but must what treatment, if any, the recipient should receive. However, testing may be done on procedures/Processing/2 units intended for transfusion to low birth weight 8. Red blood cells made from the used for intrauterine transfusion; units intended whole blood were transfused to a recipient of a for immunocompromised patients who are community hospital in June with no apparent seronegative; prospective transplant recipients who complications. Te blood supplier notified the are seronegative; or transplant recipients who have medical director of the hospital that the donor received a seronegative organ. Repeat the reverse grouping using A1 cells that inconclusive are negative for M antigen D. Repeat the reverse grouping using A1 cells that nonsecretor are positive for M antigen Blood bank/Evaluate laboratory data to make D. A The blood typing result demonstrates A antigen on Mixed field 0 1+ 4+ the red cells and anti-B in the serum. Type patient cells with anti-A1 lectin and type agglutination when A1 cells were added. Retype patient cells; type with anti-H and H antigen; therefore, the H antigen in the saliva anti-A,B; use screen cells or A2 cells on patient would be bound by anti-H reagent. No agglutination serum; run patient autocontrol would occur when the O cells are added. A positive reaction with anti-A,B would help to differentiate an A subgroup from group O. If A2 cells are not agglutinated by patient serum, the result would indicate the presence of anti-A1. If the patient’s serum agglutinates A2 cells, then an alloantibody or autoantibody should be considered. B The scenario showed an antibody in the patient serum directed toward the M antigen, and the M antigen happened to be on the A1 cells in reverse grouping. An Rh phenotyping shows the following results: department of a community hospital complaining Anti-D Anti-C Anti-E Anti-c Anti-e of dizziness and fatigue. History included no 4+ 2+ 0 0 3+ transfusions and a positive rheumatoid factor 1 year ago. Fearing the sample would clog the ProVue, testing was performed Blood bank/Apply knowledge of fundamental using the tube method.

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