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By L. Mamuk. Thomas Cooley Law School. 2019.

Evidence was insufficient to conclude that either comparator is favored to avoid headache order 25 mg benadryl with visa allergy wipes for cats. To avoid insomnia purchase benadryl 25 mg with visa allergy symptoms blurry vision, there is moderate strength evidence favoring oral selective antihistamine rather than oral decongestant buy benadryl 25mg free shipping allergy forecast dc. Fifty-four percent of the patient sample for 101 cheap 25mg benadryl visa allergy testing louisville ky, 103 this adverse event was in good quality trials that actively ascertained adverse events. Seventy-two percent of the patient sample for this 101, 105 adverse event was in trials that reported statistically nonsignificant risk differences. Evidence was insufficient to conclude that either comparator is favored to avoid anxiety. Oral Selective Antihistamine Versus Oral Leukotriene Receptor Antagonist (Montelukast) Key Points 108, 110-112 Four of nine trials reporting efficacy outcomes also reported adverse events. Evidence was insufficient to support the use of either selective oral antihistamine or oral leukotriene receptor antagonist to avoid headache as an adverse outcome. Although the body of evidence included less than half of the trials identified for efficacy, the finding is 97, 109, 113, 114 indirectly supported by the assertions of four other trials that adverse events were similar in frequency between trial arms. Synthesis and Evidence Assessment 108, 110-112 Four of nine trials reporting efficacy outcomes also reported adverse events. Four 97, 109, 113, 114 other trials did not report specific events, but included statements suggesting that there were no differences between groups with regard to adverse events. Table 62 displays the risk differences and elements for the synthesis of evidence for this comparison. Evidence was insufficient to conclude that either comparator is favored to avoid 97, 109, 113, 114 headache. This finding is consistent with four trials that did not report group level incidences of adverse events but reported no between-group differences. Evidence was insufficient to support the use of either intranasal corticosteroid or nasal antihistamine to avoid any of the following adverse events reported in eight trials: sedation, headache, nasal discomfort, bitter aftertaste, and nosebleeds. Synthesis and Evidence Assessment 115-119, 121 Eight of nine trials that reported efficacy outcomes also reported adverse events. Table 63 displays the risk differences and elements for the synthesis of evidence for this comparison. These trials were included in the synthesis of evidence only to assess 116 consistency of effect. Only one trial reported burning or dryness (risk differences 2 percent, favoring nasal antihistamine to avoid dryness, and 4 percent, favoring intranasal corticosteroids to avoid burning). Sixty-seven percent of the 115 patient sample for this adverse event was in a good quality trial that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid sedation. Eighty-five percent of the 115 patient sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Sixty- 115 nine percent of the patient sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid nasal discomfort. Seventy-eight percent of the patient sample for this adverse event was in good quality 115 trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid a bitter aftertaste. Eighty percent of the patient 115 sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid nosebleeds. Intranasal Corticosteroid Versus Nasal Cromolyn Key Points 122, 125 Data for synthesis was available from two small trials with three direct 122 125 comparisons. Both trials were rated poor quality; one had both passive ascertainment of harms and inadequate patient blinding. Evidence was insufficient to support the use of either intranasal corticosteroid or nasal cromolyn to avoid any of the following adverse events: headache, dryness, burning, nasal discomfort, and nosebleeds. Synthesis and Evidence Assessment 122-125 Four trials (five direct comparisons) that reported efficacy outcomes also reported adverse events. Table 64 displays the risk differences and elements for the synthesis of evidence for this comparison. These trials were included in the synthesis of evidence only to assess consistency of effect. The risk of bias was considered high; both trials 125 125 were rated poor quality and one had inadequate patient blinding and ascertained adverse events in a passive fashion. Evidence was insufficient to conclude that either comparator is favored to avoid headache. The risk of bias was considered high; both trials 125 125 were rated poor quality and one had inadequate patient blinding and ascertained adverse events in a passive fashion. Evidence was insufficient to conclude that either comparator is favored to avoid dryness. The risk of bias was 125 considered high; the trial was rated poor quality, had inadequate patient blinding, and ascertained adverse events in a passive fashion. Evidence was insufficient to conclude that either comparator is favored to avoid burning. Evidence was insufficient to conclude that either comparator is favored to avoid nasal discomfort. The risk of bias was considered high; both trials 125 125 were rated poor quality and one had inadequate patient blinding and ascertained adverse events in a passive fashion. Evidence was insufficient to conclude that either comparator is favored to avoid nasal discomfort. Intranasal Corticosteroid Versus Oral Leukotriene Receptor Antagonist (Montelukast) Key Points 126, 127, 129 Evidence from three high quality trials was insufficient to support the use of either intranasal corticosteroid or oral leukotriene receptor antagonist to avoid headache 126, 129 127 or nosebleed. Synthesis and Evidence Assessment 126, 127, 129 Three of five trials that reported efficacy outcomes also reported adverse events. Both of these trials were rated poor quality; the three that reported adverse events were rated good quality. Table 65 displays the risk differences and elements for the synthesis of evidence for this comparison. Sixty- 127, 129 three percent of the patient sample for this adverse event was in good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid headache. Sixty-three percent of the patient sample for this adverse event was in 127, 129 good quality trials that actively ascertained adverse events. Evidence was insufficient to conclude that either comparator is favored to avoid nosebleed. Synthesis and Evidence Assessment 90, 98, 130 90, Of three trials that reported efficacy outcomes, adverse events were assessed in two. The other reported risk differences of 2 percent and 3 percent favoring oral antihistamine monotherapy to avoid burning and nosebleeds, respectively. A risk difference of 4 percent favored combination therapy to avoid headache, and a risk difference of zero was observed for sedation.

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For example cheap 25mg benadryl otc allergy treatment new, 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 generic benadryl 25 mg line allergy symptoms 6 year molars. This may occur buy generic benadryl 25 mg on-line allergy symptoms august, for example cheap benadryl 25 mg without a prescription allergy forecast napa ca, 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. The patient then holds the wrist over the heart while the device measures blood flow and records pressure. Variables Affecting Blood Flow and Blood Pressure Five variables influence blood flow and blood pressure: • Cardiac output • Compliance • Volume of the blood • Viscosity of the blood • Blood vessel length and diameter Recall that blood moves from higher pressure to lower pressure. If you increase pressure in the arteries (afterload), and cardiac function does not compensate, blood flow will actually decrease. Increased pressure in the veins does not decrease flow as it does in arteries, but actually increases flow. Since pressure in the veins is normally relatively low, for blood to flow back into the heart, the pressure in the atria during atrial diastole must be even lower. Any factor that causes cardiac output to increase, by elevating heart rate or stroke volume or both, will elevate blood pressure and promote blood flow. These factors include sympathetic stimulation, the catecholamines epinephrine and norepinephrine, thyroid hormones, and increased calcium ion levels. Conversely, any factor that decreases cardiac output, by decreasing heart rate or stroke volume or both, will decrease arterial pressure and blood flow. These factors include parasympathetic stimulation, elevated or decreased potassium ion levels, decreased calcium levels, anoxia, and acidosis. The greater the compliance of an artery, the more effectively it is able to expand to accommodate surges in blood flow without increased resistance or blood pressure. When vascular disease causes stiffening of arteries, compliance is reduced and resistance to blood flow is increased. A Mathematical Approach to Factors Affecting Blood Flow Jean Louis Marie Poiseuille was a French physician and physiologist who devised a mathematical equation describing blood flow and its relationship to known parameters. Although understanding the math behind the relationships among the factors affecting blood flow is not necessary to understand blood flow, it can help solidify an understanding of their relationships. Please note that even if the equation looks intimidating, breaking it down into its components and following the relationships will make these relationships clearer, even if you are weak in math. Poiseuille’s equation: 4 Blood fl w = π ΔP r 8ηλ • π is the Greek letter pi, used to represent the mathematical constant that is the ratio of a circle’s circumference to its diameter. One of several things this equation allows us to do is calculate the resistance in the vascular system. Normally this value is extremely difficult to measure, but it can be calculated from this known relationship: Blood fl w = ΔP Resistance If we rearrange this slightly, Resistance = ΔP Blood fl w Then by substituting Pouseille’s equation for blood flow: 8ηλ Resistance = 4 πr By examining this equation, you can see that there are only three variables: viscosity, vessel length, and radius, since 8 and π are both constants. The important thing to remember is this: Two of these variables, viscosity and vessel length, will change slowly in the body. Only one of these factors, the radius, can be changed rapidly by vasoconstriction and vasodilation, thus dramatically impacting resistance and flow. Further, small changes in the radius will greatly affect flow, since it is raised to the fourth power in the equation. We have briefly considered how cardiac output and blood volume impact blood flow and pressure; the next step is to see how the other variables (contraction, vessel length, and viscosity) articulate with Pouseille’s equation and what they can teach us about the impact on blood flow. Water may merely trickle along a creek bed in a dry season, but rush quickly and under great pressure after a heavy rain. Low blood volume, called hypovolemia, may be caused by bleeding, dehydration, vomiting, severe burns, or some medications used to treat hypertension. It is important to recognize that other regulatory mechanisms in the body are so effective at maintaining blood pressure that an individual may be asymptomatic until 10–20 percent of the blood volume has been lost. Hypervolemia, excessive fluid volume, may be caused by retention of water and sodium, as seen in patients with heart failure, liver cirrhosis, some forms of kidney disease, hyperaldosteronism, and some glucocorticoid steroid treatments. Restoring homeostasis in these patients depends upon reversing the condition that triggered the hypervolemia. The viscosity of blood is directly proportional to resistance and inversely proportional to flow; therefore, any condition that causes viscosity to increase will also increase resistance and decrease flow. Conversely, any condition that causes viscosity to decrease (such as when the milkshake melts) will decrease resistance and increase flow. Since the vast majority of formed elements are erythrocytes, any condition affecting erythropoiesis, such as polycythemia or anemia, can alter viscosity. Since most plasma proteins are produced by the liver, any condition affecting liver function can also change the viscosity slightly and therefore alter blood flow. Liver abnormalities such as hepatitis, cirrhosis, alcohol damage, and drug toxicities result in decreased levels of plasma proteins, which decrease blood viscosity.

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Explain procedure to patient cheap 25mg benadryl amex allergy treatment at home in hindi, in order to gain her/his co-operation Basic Nursing Art 94 2 purchase benadryl 25mg without prescription allergy symptoms of cats. Insert the tube as directed in nasal feeding and ask the patient to swallow as the tube goes down discount benadryl 25 mg with amex allergy index st louis. Instruct patient to open her or his mouth to make sure the tube is in the stomach 7 generic benadryl 25mg without prescription allergy medicine that starts with a z. Always measure the amount withdrawn accurately noting color, contents and small 3. Enema Enema: is the introduction of fluid into rectum and sigmoid colon for cleansing, therapeutic or diagnostic purposes. Purpose: • For emptying – soap solution enema the cloth • For diagnostic purpose Barium enema Basic Nursing Art 95 • For introducing drug/substance (retention enema) Mechanisms of some solutions used in enema 1. Soap solution: increases peristalsis due to irritating effect of soap to the lumenal mucosa of the colon. Classified into: ƒ Cleansing (evacuation) ƒ Retention ƒ Carminative ƒ Return flow enema Cleansing enema is of two kinds: 1. High enema ƒ Is given to clean as much of the colon as possible ƒ The solution container should be 30-45 cm about the rectum 2. Low enema ƒ Is administered to clean the rectum and sigmoid colon only Guidelines o o Enema for adults are usually given at 40-43 c and for children at 37. Colonoscopy ƒ To remove feces prior to a surgical procedure or a delivery ƒ For incontinent patients to keep the colon empty ƒ For diagnostic test E. Epsum salt 15 gm – 120 gm in 1,000 ml of H2O Cleansing Enema Procedure ƒ Inform the patient about the procedure ƒ Put bed side screen for privacy ƒ Attach rubber tube with enema can with nozzle and stop cock or clamp ƒ Place the patient in the lateral position with the Rt. Procedure Similar with the cleansing enema but the enema should be administered very slowly and always be preceded by passing a flatus tube Note 1. Kinds of solution used to supply body with fluid are plain H2O, normal saline, glucose 5% sodabicarbonate 2-5% 6. Olive oil 100-200 cc to be retained for 6-8 hrs is given for server constipation Retention Enema ƒ Are enemas meant for various purpose in which the fluid usually medicine is retained in rectum for short or long period – for local or general effects E. Principles: • Is given slowly by means of a rectal tube • The amount of fluid is usually 150-200 cc • Cleansing enema is given after the retention time is over • Temperature of enema fluid is 37. Asafetida in 1:1000 to relieve distention Amount of solution • 5-6 liters or until the wash out rectum fluid becomes clear Procedure • Insert the tube like the cleansing enema • The client lies on the bed with hips close to the side of the bed (client assumes a right side lying position for siphoning) • Open the clamp and allow to run about 1,000 cc of fluid in the bowel, then siphon back into the bucket • Carry on the procedure until the fluid return is clear Note: • The procedure should not take > 2 hrs • Should be finished 1 hr before exam or x-ray – to give time for the large intestine to absorb the rest of the fluid • Give cleansing enema ½ hr before the rectal wash out • Allow the fluid to pass slowly Passing a Flatus Tube Purpose • To decrease flatulence (sever abdominal distention) • Before giving a retention enema Procedure • Place the patient in lt. Lateral position Basic Nursing Art 101 • Lubricate the tube about 15 cm • Separate the rectum and insert 12-15 cm in to the rectum and tape it • Connect the free end to extra tubing by the glass connector • The end of the tube should reach the (tape H2O) solution in the bowel • The amount of air passed can be seen bubbling through the solution (a funnel may be connected to free end of tube and placed in an antiseptic solution in bowel) • Teach client to avoid substances that cause flatulent • Leave the rectal tube in place for a period or no longer than 20 – can affect the ability to voluntarily control the sphincter if placement is prolonged • Reinsert the rectal tube Q 2-3 hrs if the distention has been unrelieved or reaccumulates – allows gas to move in the direction of the rectum. Urinary Catheterization Definition of catheterization: Is the introduction of a tube (catheter) through the urethra into the urinary bladder • Is performed only when absolutely necessary • Fear of infection and trauma Note. Select the type of material in accordance with the estimated length of the catheterization period: - Are sized by diameters of the lumen Basic Nursing Art 103 - Graded on French scale or numbers 2. Determine appropriate catheter size • Catheter size depends on the size of the urethral canal ⇐ # 8-10 Fr – children ⇐ # 14-16 Fr – female adults ⇐ # 18 Fr – adult male 3. Determine appropriate catheter length by the clients gender • For adult male – 40 cm catheter • For adult females – 22 cm catheter 4. Select appropriate balloon size • 5 ml – for adults • 3 ml – for children Types of Catheter 1. Retention (Foleys, indwelling) Catheterization Using a straight catheter Purpose • To relieve discomfort due to bladder distention • To assess the anti of residual urine • To obtain a urine specimen • To empty the bladder prior to surgery Procedure • Prepare the client and equipment for perennial wash • Position the patient – dorsal recumbent (pillows can be used to elevate the buttocks in females). Dorsal Recumbent Female - for a better view of the urinary meatus and reduce the risk of catheter contaminate. Male- allows greater relaxation of the abdominal and perennial muscles and permits easier insertion of the tube. Ask the client to take deep breaths - relaxes the external sphincter (slight resistance is normal) Inserting a Retention (Indwelling) Catheter Purpose • To manage incontinence • To provide for intermittent or continuous bladder drainage and irrigation • To prevent urine from contacting an incision after perineal surgery (prevent information) • To measure urine out put needs to be monitored hourly Procedure • Explain the procedure to the patient • Prepare the equipment like the straight catheterization and retention catheter ⇐ Syringe ⇐ Sterile water ⇐ Tape ⇐ Urine collection bag and tubing Retention (Foley) Catheter • Contains a second, smaller tube through out its length on the inside – this tube is connected to a balloon near the insertion tip. Basic Nursing Art 106 • The balloons are sized by the volume of fluid or air used to inflate them 5 ml – 30 ml (15 commonly) indicated with the catheter size 18 Fr – 5 ml. From the balloon using a syringe • And remove gently Basic Nursing Art 107 Study Questions 1. Oral Administration Definition: Oral medication is drug administered by mouth Purpose a. When prolonged systemic action is desired Disadvantages and Contra- indications 1. When there is inadequate absorption of the drug, which leads to inaccurate determination of the drug absorbed. Lozenges (troches) - sweet medicinal tablet containing sugar that dissolve in the mouth so that the medication is applied to the mouth and throat 2. Tablets - a small disc or flat round piece of dry drug containing one or more drugs made by compressing a powdered form of drug(s) 3. Capsules - small hollow digestible case usually made of gelatin, filled with a drug to be swallowed by the patient. Pills and gargle - a small ball of variable size, shape and color some times coated with sugar that contains one or more medicinal substances in solid form taken in mouth. Powder - a medicinal preparation consisting of a mixture of two or more drugs in the form of fine particles. Give your undivided attention to your work while preparing and giving medications. Intradermal Injection Definition: It is an injection given into the dermal layer of the skin (corneum) Purpose For diagnostic purpose a. Intradermal injection may also be given for therapeutic purpose Site of Injection • The inner part of the forearm (midway between the wrist and elbow. Sub - Cutaneous Injection Definition: Injecting of drug under the skin in the sub- cutaneous tissue, (under the dermis) Purpose: • To obtain quicker absorption than oral administration • When it is impossible to give medication orally Equipment • Tray • Sterile syringe & needle • Forceps in a container • Alcohol swabs • Medication • File • Medication chart Basic Nursing Art 115 • Receiver • Water in a bowel • Disposing box Site of Injection • Outer part of the upper arm • The abdomen below the costal margin to the iliac crest. If repeated injections are given, the nurse should rotate the site of injection so that each succeeding injection is about 5 cm away from the previous one. Purpose • To obtain quick action next to the intra- venous route • To avoid an irritation from the drug if given through other route. Equipment • Tray • Ordered drug (ampoule, vial) • Sterile syringes and needle in a container • Alcohol swab • Receiver • A bowl of water for used syringes and needle • File • Sterile jar with sterile forceps • Chart Sites for I. Clean the upper outer quadrant with alcohol swab: • Stretch the skin and inject the medicine • Draw back the piston (plunger) to check whether or not you are in the blood vessel ( if blood returns, withdraw and get a new needle & reinject in a different spot) • Push the drug slowly into the muscle • When completed, withdraw the needle and massage the area with swab gently to and absorption. M Injection is the deltoid muscle and the outer part of the thigh (quadriceps muscle) 3. Purpose • When the given drug is irritating to the body tissue if given through other routes. Basic Nursing Art 118 • When it is particularly desirable to eliminate the variability of absorption. Give very slowly unless there is an order to give it fast (Normally 40-60 drops is given in 1 minute). Intravenous Therapy Definition: It is the administration of a large amount of fluid into the system through a vein. Purpose • To maintain fluid & electrolyte balance • To introduce medication particularly antibiotics. V pole • Adhesive tape • Medication chart Preparation of the Patient Since an infusion therapy takes several hours to complete, the patient should first be made conformable. Basic Nursing Art 121 • Support needle with sterile gauss or sterile cotton balls • If necessary to keep it in proper position in the vein • Anchor the I. Infusion bottle should be labeled with the date, time infusion is started, drops per minute, and any added medications.

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