By H. Jerek. Missouri Baptist College.
This chapter aims to provide some of the basic information required in the general approach of poisoned victims order 100 mg kamagra with mastercard impotence 25. When acute poisoning is suspected discount kamagra 100 mg otc impotence age 60, the clinician needs to ask a number of questions in order to establish a diagnosis (history of present illness) kamagra 50 mg online erectile dysfunction doctor michigan. In the case of an unconscious (comatose) victim buy 100 mg kamagra with mastercard impotence male, the circumstances in which the victim was found and whether any tablet, bottles or other containers (scene residues) were present can be important. If the victim is awake, he or she should be questioned about the presence of poisons in the home or workplace. Physical examination of the victim may indicate The poison or class of poison involved. For example, the combination of pin-point pupils, hyper salivation, incontinence and respiratory depression suggests poisoning with a cholinesterase inhibitor such as an organophosphorus pesticide. However, the value of this approach is limited 21 Toxicology if a number of poisons with different actions have been absorbed. Moreover, many drugs have similar effects on the body, while some clinical features may be the result of secondary effects such as anoxia. Thus, if a victim is admitted with depressed respiration and pin-point pupils, this strongly suggests poisoning with an opioid. For example, coma can be caused by a cerebrovascular accident, uncontrolled diabetes infections as well as poisoning. The availability of the results of urgent biochemical and hematological tests is obviously important in these circumstances. Examples include: cardiorespiratory arrest (cyanide), hepatitis (paracetamol) and so on. B Generally Physical examination should include – Vital signs – Evaluation of specific parts of the body Investigations a) General laboratory tests Hematological Biochemical b) Toxicological studies c) Electrocardiogram d) X-ray findings 22 Toxicology Principles of management of poisoning The initial management of a patient with altered mental status follows the follow the same approach regardless of the poison involved. After this, one can begin in a more detailed evaluation to make a specific diagnosis. Therefore, in principle, during poisoning, one should treat the victim first followed by treating the poison itself. Supportive measures The first priority is to establish & maintain vital functions. Subsequently, most victims can be treated successfully using supportive care alone. Principles of toxin eliminations - If the poison has been inhaled, the victim should first be removed from the contaminated environment. However, repeated oral administration of activated charcoal appears to be effective in enhancing elimination of certain poisons. The results of either a qualitative or a quantitative toxicological analysis may be required before some treatments are commenced because they are not without risk to the victim. In general, specific therapy is only started when the nature and/or the amount of the poison(s) involved are known. Antidotes or protective agents are only available for a limited number of poisons. In summery there are four main methods of enhancing elimination of the poison from the systemic circulation: 1. Some antidotes &protective agents used to treat acute poisoning Antidote Indication • Acetylcysteine Paracetamol 24 Toxicology • Atropine Organophosphate • Deferoxamine Iron • Methylene blue Nitrates • Physiostigmine Atropine • Naloxone Opioids • Pyridoxine Isoniazid Exercise 1. Discuss about collection, transportation, storage, characteristics, physical examination &analytical tests of laboratory specimens. Describe about apparatus, reference compounds & reagents used in clinical toxicology laboratory 6. Introduction Clinical toxicology involves the detection and treatment of poisonings caused by a wide variety of substances, including household and industrial products, animal poisons and venoms, environmental agents, pharmaceuticals, and illegal drugs. The toxicology laboratory must provide appropriate testing in three general areas: Identification of agents responsible for acute or chronic poisoning; Detection of drugs of abuse; and therapeutic drug monitoring. Increasingly sophisticated analytic methods are available to accomplish these tasks, but it is imperative that they be used judiciously. The numbers of compounds for which true emergency laboratory results are needed to guide therapy are still relatively few. For most potentially lethal intoxications the victim must be treated empirically before the laboratory results are known. A wide held misconception is that the laboratory can routinely detect 27 Toxicology any of the thousands of potential drugs or toxins that may be present in a sample. Because the financial and personnel resources required for such complete “screens” would be prohibitive, clinical laboratories must employ selective procedures suitable for the victim population in question. Therefore in most cases in clinical or hospital-based settings, tests are done for only a finite number of compounds, generally the more common drugs of abuse. Ideally, a diagnosis of poisoning would be made clinically, with the laboratory playing a confirmatory role. This short chapter is meant to discuss the basic structures which are said to be vital in clinical toxicology laboratory. The role of clinical toxicology laboratory Most poisoned victims can be treated successfully without any contribution from the laboratory other than routine clinical biochemistry and hematology. This is particularly true for those cases where there is no doubt about the poison involved and when the results of a quantitative analysis would not affect therapy. However, toxicological analyses can play a useful role If the diagnosis is in doubt, The administration of antidotes or protective agents is contemplated, or The use of active elimination therapy is being considered. Basic information necessary for toxicology laboratory 28 Toxicology Close communication between clinical and laboratory personnel is essential. Although a standard screen may not include the suspected agent, if alerted beforehand the laboratory may be able to modify procedures as needed in order to search for the suspected agents. Suspected dose Analytic sensitivities vary among laboratories, and some facilities may not be able to detect therapeutic concentrations of certain drugs in their routine screens. Knowledge of the approximate dose ingested is important because in certain cases the use of analytic methods designed for therapeutic monitoring, not screening may be necessary. Time of ingestion and sampling Knowledge of both ingestion and sampling time is necessary to determine the degree of drug absorption; with serial determinations, knowledge of sampling times is critical, as a single quantitative level may be misleading and must be correlated with the time of ingestion. Serial levels, timed appropriately with respect to the pharmacokinetics of the agent, document that the concentration has peaked, which helps guide further therapy. Clinical presentation Knowledge of the clinical presentation helps the laboratory select the most appropriate screening procedures. The 29 Toxicology screening procedure for a victim with a depressed level of consciousness is entirely different from conscious victim. Location of the victim Location of the victim to the clinical laboratory determines the type of the test that is going to be done (e. Post-analytical phase •Interpret the results and discuss them with the clinician looking after the victim. Laboratory specimens 30 Toxicology Before starting an analysis it is important to obtain as much information about the victim as possible (medical, social and occupational history, treatment given, and the results of laboratory or other investigations). It is also important to be aware of the time that elapsed between ingestion or exposure and the collection of specimens, since this may influence the interpretation of results. No single specimen type is universally appropriate for identification of toxic agents. The selection of specimen type is based on both the toxicokinetics of the suspected agent and laboratory methodology. In general, quantitative tests are performed on serum or whole blood, and qualitative tests are performed on urine and gastric contents. When in doubt, obtain as many specimen types as possible and forward to the laboratory, where the most appropriate specimens can be selected.
B) Pediculosis corporis or vestimenti (Body louse) –Refer Antiseptic Bath in procedure “Applying Hot Applications” purchase kamagra 50mg otc impotence thesaurus. C) Pediculosis pubis (Crab louse) · A tray containing a) Protective sheet and towel b) Bowl of warm water c) Razor and blade d) Soap and brush e) Antiseptic lotion in a kidney tray and paper bag buy kamagra 50 mg online erectile dysfunction wiki. Guidelines 1) Combing: Hair are combed and arranged in the style the patient prefers at least twice a day cheap kamagra 50 mg without prescription erectile dysfunction treatment herbal. B) Rash a) Neck and behind ears in head louse b) All over the body in body louse c) On and around the part affected in crab louse cheap kamagra 100 mg on line erectile dysfunction pills images. C ) Sores a) Scalp in head louse b) Body in body louse c) On the part affected in crab louse The common parasiticides used are: a) Mediker. Wait for atleast 15 minutes § Before placing the thermometer in the mouth rinse the thermometer in cold water to remove all disinfectants § Do not use hot water for washing thermometer § Before placing thermometer in position wipe it from the bulb to stem to keep the bulb clean § After taking the thermometer wipe it from stem to bulb to avoid contaminating the fingers of the care giver with saliva and faeces. In auxiliary method leave the thermometer in position for 5 minutes 6) Count the pulse and respirations while the thermometer is still in place 7) Place the patients hand over his chest with the wrist extended and the palm downwards. Place the finger tips over the pulse point 8) Holding the watch in the left hand, start to count the pulse rate with zero then 1,2 etc. If the pulse is not regular, count the rate for one full minute 10) Continue palpation of the pulse to assess the rhythm, volume, tension and irregularity 11) With the right hand still on the pulse count respiration by watching the rise of the chest, with out the knowledge of the patient 12) If the respirations are normal count the number of respirations in the 30 seconds and multiply by 2. If the respirations are abnormal, count the rate for full one minute and note the pattern of breathing 13) Remove the thermometers after 2 minutes (after 5 minutes in case of auxillary method). Keep clients upper body and lower extremities covered with sheet or blanket 3) Apply disposable gloves 4) Hold end of glass thermometer with finger tips 5) Read mercury level while gently rotating thermometer at eye level. If mercury is above desired level, grasp tip of thermometer securely, stand away from soiled objects and sharply flick wrist downward. Ask the client to deep breath slowly and relax 9) Gently insert thermometer into anus in the direction of umbilicus 3. Don’t force the thermometer 10) If resistance is felt during inserting, withdraw the thermometer immediately. Never force the thermometer 11) Hold thermometer in place for 2 seconds or according to agency policy 12) Carefully remove thermometer, discard plastic sleeve cover in appropriate container, and wipe off any remaining secretions with clean tissue. Gently rotate until scale appears 14) Wipe client’s anal area with soft tissue to remove lubricant or feces and discard tissue. It is believed that when the patient is flat in bed, respiration often is more free and turning is easier, advantages that are important in the prevention of respiratory complications. Prone Position: In the prone position, the client lies on the abdomen with the head turned to one side. Both children and adults often sleep in this position, sometimes with one or both arms flexed over their heads (Figure 3416). When used periodically, the prone position helps to prevent flexion contractures of the hips and knees, thereby counteracting a problem caused by all other bed positions. The prone position also promotes drainage from the mouth and is especially useful for unconscious clients or those clients recovering from surgery of the mouth or throat. Fowler’s Position: Off all the positions prescribed for a patient, perhaps the most common, as well as the most difficult to maintain is the Fowler’s position. The patient’s with abdominal drainage usually are put in Fowler’s position as soon as they have recovered conciousness, but great caution must be observed in raising the bed. Hand washing is a vigorous, brief rubbing together of all surfaces of hands lathered in soap, followed by rinsing under a stream of water. The purpose is to remove soil and transient organisms from the hands to reduce to microbial counts over time. Situation for hand washing: Garnerand Favero recommend that nurses wash hands in the following situations. Medical Hand Washing Equipments: 1) Easy to reach sink with warm running water 2) Antimicrobial soap / Regular soap. Use circular movements to wash palms, back of hands, wrists, forearms and interdigital spaces for 2025 Seconds. Ask the assisting nurse to bring the gown over shoulders 3) The assisting nurse fastens the ties at the neck. Assess the patients for following: § Muscle strength § Joint mobility and contracture formation(arthritis) § Paralysis or paresis § Orthostatic hypotension(risk of fainting) § Activity tolerance § Level of comfort(pain) § Vital signs 2. Assess the patients sensory status § Adequacy of central and peripheral vision § Adequacy of hearing § Loss of peripheral sensation § Cognitive status 3. Assess for any contra indications to lift or transfer § Check for the doctors order § Assess patients level of motivation § Patients eagerness § Whether patient avoids activity § Assess previous mode of transfer § Assess patients specific risk for falling when transferred § Assess special equipments needed to transfer § Assess for safety hazards § Perform hand hygiene § Explain procedure to patient § Transfer the patient After care: § Following each transfer assess the patients body alignment, tolerance, fatigue, comfort § If the patient is transferred to bed after transfer, side rails are raised 41 § If the patient is transferred to wheel chair the brakes are released before moving the patient § Record the procedure accurately. The patients performance is also recorded § Any difficulty of disruption occurred during the transfer is also recorded with date and time § The patients comfort, vital signs are all recorded Procedure: § Transferring a patient from a bed to stretcher § An immobilized patient who must be transferred from a bed to a stretcher requires a three person carry or two person carry § Another method is using a sheet to lift Transferring a patient from a bed to stretcher: § Three of you should stand side by side facing of patients bed § Each person assumes responsibility for one of three areas a) Head and Shoulders b) Hips and thighs c) Ankles § Perform threeperson carry from bed to stretcher(Bed at Stretcher level) § Three persons stand side by side facing side of patients bed 1. Each person assumes responsibility for one of three areas: head and shoulders, hips and thighs, and ankles 2. Each person assumes wide base of support with foot closer to stretcher in front and knees slightly flexed 3. Arms of lifters are placed under clients head and shoulders, hips and thighs, and ankles with fingers securely around other side of clients body(see illustration) 4. Have the wheel chair(lock the brakes at its 45° angle to bed § Apply transfer belt(if present) § Ensure that the patient has stable non skid shoes. For a man who has not been able to reach the toilet facilities he may stand at the bedside and void into a plastic of metal receptacle for urine. If he is unconscious or unable to stand at bedside the assistant needs to assist him to use the urinal. Purpose: § Provide a container for collection of urine § To measure the urine output § For observation of color and consistency of urine Indications: For patient with impair mobility due to surgery, fracture, injury Elderly man (aging impairs micturation) may require urinal more frequently to avoid urinary incontinence For mobile person who is able to go to bathroom, does not require urinal. The pan is approximately 5cm deep Fracture pan Designed for patients with body or leg casts, the shallow upper end approximately 13cm deep that slips easily under the patient Offering bedpan A bedpan for patients confined to bed provides a means to collect stool Female bedpan to pass urine and feces, For male bedpans only for defecation Sitting on a bedpan can be extremely uncomfortable. Purposes The nursing assistance paces and removes the bedpan to bed to bed ridden patients For bowel elimination when the patient is not permitted to go out of bed Obtain a stool specimen During bowel training, it facilitates bowel incontinence Indication: For the patients restricted to bed must use bedpan for defecation. To make a ‘reef knot’ take the ends of the bandage one in each hand cross the end in the right hand under and then over the end in the left hand thus making a turn. Then cross the end now in the right hand over and then under the end in the left hand thus making a second turn. Preparation of the Patient § Explain the sequence of the procedure to the patient and explain how the patient can assist you. Rules For Application Of Roller Bandage § Face the patient § When bandaging left limb, hold the head of the bandage in the right hand and vice versa. The usual practice of tearing the final end into two long tails and tying them up is quite satisfactory. With the back of the patient’s hand towards you, take a fixing turn round the wrist and carry the next turn upwards at an angle of 45°, turn the bandage over to cross itself at a right angle, and bring it round the limb ready for the next turn. It can be used to apply pressure over an extended joint or to bandage a leg, foot, hand or arm if movement is allowed. To use it on the leg, take a fixing turn, then carry the bandage upwards across the front of the limb at 45° round behind it at the same level and downwards over the front to cross the first turn at a right angle. Succeeding turns pass alternately above and below these turns, forming a pattern at each side of the joint. Elbow bandage Roller bandages can be used at these joints to hold dressings in place, or to support soft tissue injuries such as strains (or) sprains. Spread the bandage over the chest, with one end going over the shoulder on the uninjured side, and the other hanging over the abdomen; the point should be beneath the elbow.
Deﬁbrillation Deﬁbrillation (and cardioversion) depolarizes a critical mass of the myocardium cheap kamagra 50mg with visa erectile dysfunction jacksonville doctor, allowing the nat- Figure 4 quality kamagra 50 mg erectile dysfunction treatment in mumbai. Deﬁbrillators have a power source discount 100mg kamagra with mastercard erectile dysfunction pump infomercial, either mains or battery buy cheap kamagra 50mg line erectile dysfunction hiv medications, which charges a capacitor to a predetermined level. A manual de- diameter, placed on the patient’s chest wall (see ﬁbrillator must only be charged when the paddles below). Success depends on the current ﬂow are on the patient’s chest and must not be moved through the myocardium and therefore to reduce between deﬁbrillator and patient whilst charged. This is often referred to as with the patient or trolley, directly or indirectly ‘manual deﬁbrillation’. Increasingly, ‘hands free’ (via spilt electrolyte solution), when the deﬁbrilla- systems consisting of two large, self-adhesive tor is discharged. Any nitrate patches The paddles or self-adhesive electrodes are should be removed from the patient’s chest placed anterolateral: one to the right of the ster- along with any high-ﬂow oxygen to eliminate num, just below the clavicle; and the other over the risk of ﬁre. Al- ally a shout of ‘stand back’, and a visual check of though the paddles are marked positive and nega- the area are mandatory before discharging the tive, each can be placed in either position (Fig. An alternative is to place them anteroposterior to If further shocks are required, the paddles should the heart. A •Shout ‘stand back’ and make a visual check of precordial thump can be used under the same cri- the area. In general, the outcome from asystole is Epinephrine (adrenaline) poor unless there are ‘p’ waves present that may re- This is a naturally occurring catecholamine, ad- spond to cardiac pacing. This leads to an in- Atropine crease in the peripheral vascular resistance that tends to divert blood ﬂow to the vital organs An anticholinergic acting at muscarinic receptors, (heart, brain). It is the ﬁrst drug used in cardiac ar- causing block of the vagus nerve at both the sinoa- rest of any aetiology. Furthermore, if the optimum support is to be given, the techniques must be adjusted ac- • Hypoxia • Hypovolaemia cording to the size of the child. It is usually a result of conditions that • Head tilt plus chin lift A hand is placed on the mechanically restrict cardiac ﬁlling or outﬂow, or forehead, and the head is gently tilted back as for biochemically disrupt cardiac contractility. The best chance of survival is rapid identiﬁcation and ﬁngers of the other hand should then be placed treatment of the underlying cause. It may be necessary to use the thumb of the Open chest cardiac compression same hand to part the lips slightly. The output generated by direct compression of the • Jaw thrust This is achieved by placing two or heart is two to three times greater than closed chest three ﬁngers under the angle of the mandible bilat- compression and coronary and cerebral perfusion erally, and lifting the jaw upwards. The procedure is may be easier if the rescuer’s elbows are resting on performed via a left thoracotomy through the the same surface as the child is lying on. The It can also be considered in those patients in whom child’s soft palate is easily damaged, causing bleed- closed chest compression is less effective, namely ing, and foreign bodies may become impacted in severe emphysema, a rigid chest wall, severe valvu- the child’s cone-shaped airway and be even more lar heart disease or recent sternotomy. The technique of expired-air ventilation The airway is kept open using the techniques described above. If the mouth of the child alone is used, then the nose should be pinched closed using the thumb and index ﬁngers of the Figure 4. Since children vary in size, only general guid- The technique of external cardiac ance can be given regarding the volume and pres- compression in children sure of inﬂation (Table 4. Children vary in size, and the technique used must If the chest does not rise then the airway is not reﬂect this. In children over 8 years of age, the clear: method used in adults can be applied with appro- • readjust the head tilt/chin lift position; priate modiﬁcations for their size. The infant heart is lower compared to external landmarks; the area of compression is found by imagining a line running between the nipples and Circulation compressing over the sternum one ﬁnger’s breadth Because of the difﬁculties in identifying the pres- below this line. Two ﬁngers are used to compress ence of a pulse, lay persons should look for signs of the chest to a depth of approximately 1. Healthcare An alternative in infants is the hand-encircling professionals should check for a pulse; in children technique. The infant is held with both the res- the carotid artery can be palpated, but in infants cuer’s hands encircling the chest. The thumbs are the neck is generally short and fat, and it may be placed over the correct part of the sternum (see difﬁcult to identify; alternatives are the brachial above) and compression carried out. If a pulse cannot be detected or there are no The area of compression is one ﬁnger’s breadth signs of a circulation, or if in an infant the heart above the xiphisternum. The heel of one hand is rate is less than 60 beats/min, chest compressions used to compress the sternum to a depth of ap- will be required. One ventila- Larger children tion should be delivered for every ﬁve compres- The area of compression is two ﬁngers’ breadth sions. The heels of both hands re-establishing the correct position for compres- are used to compress the sternum to a depth of ap- sions will seriously decrease the total number of proximately 3–4cm, depending on the size of the compressions given per minute. Practice [The Association of Anaesthetists of Great Guidelines for Management of the Difﬁcult Britain & Ireland. Medical Treatment of Anaphylactic Reactions British Guidelines on the Management of for First Medical Responders and for Asthma. This pro- Recognition of patients at risk of becoming criti- poses a shift in emphasis away from deﬁning the cally ill is a key point and often the limiting step in needs of such patients in terms of hospital geogra- initiating appropriate management. How- training and education, a diverse range of courses ever, as stated previously, these judgements are is now available which aim to ‘short-circuit’ the often quite complex. Prospective evaluation of a modiﬁed Early Warning Score to aid earlier detection of patients developing critical illness on a surgical ward. With these systems, patients at risk of developing All of these are based on recording observations re- critical illness are highlighted at an earlier stage lating to the physiological and clinical status of the than perhaps they otherwise would be, and appro- patient and the allocation of ‘points’ according to priate treatment commenced. The other advantage the presence and severity of any derangement is that referral arrangements by nurses and inexpe- from a reference range. The variables used include rienced doctors for more senior help and advice heart rate, arterial blood pressure, respiratory rate, can be formalized into the protocol. Thus the ward body temperature, conscious level and urine out- nurse may be required to contact the house ofﬁcer put. Another subjective cate- timely improvement in the patient’s condition gory is sometimes added to include any patient based on an improving score. This leads ultimately about whom there are serious concerns, independ- to direct clinical input from either a senior doctor ent of the objective scoring assessment. The (consultant) or outreach team from critical care if importance of this latter point cannot be overem- the patient is still not improving. An example of one of these education of clinicians and there are several unre- scoring systems is shown in Table 5. As their intro- The main advantages of such scoring systems duction into clinical practice has been relatively are: recent, there is as yet insufﬁcient data available as •their simplicity, with the need for only the basic to which physiological parameters are most impor- monitoring equipment, normally present on acute tant, and the weighting of the variables to achieve hospital wards; the overall score has not been validated. A doctor • their reproducibility between different with experience in treating critically ill patients observers; will not need to formally score his or her patients 114 Recognition and management of the critically ill patient Chapter 5 Table 5. Clearly with actual or potential critical illness this is a less satisfactory approach and leads to a • Education and training of trainee doctors and more fragmented level of care. Multiple organ failure syndrome Nevertheless, it seems intuitive that scoring sys- tems will be useful in helping less-experienced per- Critical illness may be deﬁned as the failure of one sonnel identify patients at risk and in assessing the or more organ systems, the most immediately life- effects of their clinical intervention. The aims of outreach are summa- ness due initially to a primary failure of one organ rized in Table 5. The ischaemia produces damage to the mucosal integrity of the Initial assessment and gut, a breach of its normal barrier function management of critically and translocation of bacteria into the circulation ill patients (septicaemia).
Community mobilisation is looked at in more detail in the Health Education Module purchase kamagra 100 mg with amex impotence at 35. If they miss one of the appointments buy kamagra 100 mg erectile dysfunction in early age, they can then come on the subsequent Tuesday purchase 100mg kamagra visa erectile dysfunction non prescription drugs. This study session looked at the important steps you should take when managing a child with severe acute malnutrition discount kamagra 100mg otc erectile dysfunction doctor in karachi. You can see from the ﬂow chart the key steps that are necessary when managing severe uncomplicated malnutrition of a child during the different phases of treatment. The red arrows indicate referrals, while the green arrows indicate the children you had referred who have come back to you once their complication improves. The black arrows indicate the ﬂow of treatment as the child progresses over the course of treatment. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module. In this study session you will be introduced in more detail to the different ways you can help people to improve their own nutrition and that of their family. You will learn about behaviour change communication and essential nutrition actions, as well as useful ways of communicating information about these actions to people in your community. You will also learn about growth monitoring and the triple A cycle, which is a way of making sure that you can pass on your knowledge effectively to the people you are responsible for. Learning Outcomes for Study Session 11 When you have studied this session, you should be able to: 11. Systematic behaviour change approaches are a really important way of improving the nutritional status of the women and young children who are under your care. Audiences are carefully segmented (grouped), and communications can be made using mass media and through community leaders and elders to achieve deﬁned behavioural objectives. This helps prevent information overload for people, by ensuring they are not given unnecessary information. For instance, during pregnancy, it is better to focus on maternal nutrition and breastfeeding rather than talking to the mother and family about complementary feeding, which can be discussed at a later stage. It’s a way of ensuring that people get the information that is most relevant to them when they need it. Behaviour change communication There are eight stages in behaviour change that will help the people you are is more than just education, it working with change from being an uninformed person to becoming someone aims to change behaviour and who may even be able to teach or inﬂuence others about their behaviour. Step 1 Pre-awareness At this stage people are not even aware of the changes that they need to make. In order to help them become a person who has awareness, you need to give them information. Nutrition education would stop at this stage without making sure that the person being educated has changed their action, practice or behaviour. Before this stage the mother does not know about the importance of exclusive breastfeeding during the ﬁrst six months. Stage 2 Awareness At this stage, the person has heard about the need to change their behaviour, but needs extra help and persuasion to start to actually bring about the changes. At this stage the mother is aware about the need for exclusive breastfeeding during the ﬁrst six months, but has not thought of doing it for her baby. Stage 3 Contemplation This person is contemplating (thinking) about changing their behaviour, but needs more information and continued support and persuasion about the advantages and disadvantages of changing their behaviour. At this stage more information about the beneﬁts of exclusive breastfeeding compared to other forms of feeding is needed, as well as support that shows you understand the mother’s situation. Stage 4 Intention At this stage the person has understood the advantages and disadvantages of changing their behaviour but is not sure how they can bring about the new behaviour for themselves. The person needs encouragement to overcome obstacles of how to do the new behaviour. For example, the mother may be worried about not being able to maintain exclusive breastfeeding when she is away for work, or for other individual or personal reasons. In this situation you could show her how she can express breastmilk so the baby can be fed when she is away. Stage 5 Trial The person has tried the behaviour or action required, but has faced difﬁculties. For instance, the mother tried to exclusively breastfeed her baby, but she faced some difﬁculties. Reinforcing the 144 Study Session 11 Nutrition Education and Counselling ways of preventing the problem she faced during exclusive breastfeeding is also important. At this stage the mother may have inadequate breast milk output and think that her breast milk is not enough for the baby to feed on until six months old. Here, she needs to be assisted on proper positioning and attachment and be reassured about the capacity of the breastmilk to feed the baby for the ﬁrst six months. Your skills in negotiating the different options the mother can use will be important at this stage. For example, if persuade, encourage and support at this point the mother has not tried exclusive breastfeeding, there needs change. They now need discussion to reinforce their behaviour and sustain the change they have made. What she needs at this stage is further discussion on the beneﬁts of exclusive feeding to reinforce the behaviour and make sure that she continues exclusive breastfeeding for a few weeks. You can help her with this, by encouraging and praising her and emphasising the importance of exclusive breastfeeding for her baby’s health. Stage 7 Maintenance The person’s behaviour by this stage has changed and they understand the beneﬁts of the change. For example, the mother has changed her behaviour and is now used to exclusive breastfeeding and has understood its beneﬁts. It has become part of her behaviour and she thinks that she will exclusively breastfeed when she has another baby. Stage 8 Telling others The person has done the behaviour for a considerable length of time, it has become routine behaviour and now leads to the person convincing others about the beneﬁts of their health related behaviour. For example, the mother is encouraging other mothers to exclusively breastfeed their babies and describing the beneﬁts to the baby and mother. Using the techniques and approaches described in this study session you will be able to bring about practices that promote better health through optimal feeding practices and improved dietary habits. For such activities you will need to gain collaboration from the frontline agricultural workers in your community, as together you will have a greater impact. Of course the methods you are able to use in your work will depend on your own situation. As you read through the table you should think about the ways that you can bring about these stages of change in your own practice as a Health Extension Practitioner. Pre-aware (never having heard Build awareness and provide Drama, songs about the behaviour) information Community groups Radio Individual counselling Young child feeding support groups 2. Aware (having heard about the new Give more information, discuss Group discussions or talks behaviour and knowing what it is) beneﬁts and persuade Oral and printed word Counselling cards Feeding support groups 3 and 4. Contemplation and intention Persuasion and encouragement Group discussions or talks (thinking about new behaviour) Individual counselling Counselling cards Feeding support groups 5. Trial (trying new behaviour out) Negotiate the best ways of overcoming Home visits obstacles Use of visuals aids Groups of activities for family and the community Negotiate with the husband and mother-in-law (or inﬂuential family members) to support 6. Adoption (demonstrating the new Further discussion on the beneﬁts to Encouraging and praising behaviour) ensure the behaviour continues Emphasising the importance of the behaviour 7.
The presence of influenza virus can be ascertained using haemadsorption using guinea pig red blood cells (Weinberg 2005) or immunofluorescence on cultured cells 50 mg kamagra mastercard erectile dysfunction treatment jaipur. This is brought about by centrifugation of the inoculum onto the cell culture monolayer and the performance of immunofluoresence before a cytopathic effect can be observed 50 mg kamagra sale erectile dysfunction age 36. Laboratory animals Ferrets are often used in research facilities as a model of human influenza infection but have no role in routine diagnosis buy kamagra 100mg line erectile dysfunction pills in south africa. Serology Serology refers to the detection of influenza virus-specific antibodies in serum (or other body fluids) buy generic kamagra 100 mg on-line treatment of erectile dysfunction using platelet-rich plasma. In order to di- agnose acute infection, an at least four-fold rise in titre needs to be demonstrate, which necessitates both an acute and a convalescent specimen. Serology has greater clinical value in paediatric patients without previous exposure to influenza since previous exposure can lead to heterologous antibody responses (Steininger 2002). A viral hae- magglutinin preparation that produces visible haemagglutination (usually 4 hae- magglutination units) is then pre-incubated with two-fold dilutions of the serum specimen. These assays are labour intensive and necessitate controls for each procedure but reagents are cheap and widely available. Assays that detect IgG and IgA are more sensi- tive than IgM assays (Julkunen 1985) but are not indicative of acute infection. Indirect immunofluorescence Indirect immunofluorescence is not commonly used as a method to detect influenza virus antibodies. Rapid tests The clinical value of a diagnostic test for influenza is to a large extent dependent on the particular test’s turnaround time. The first diagnostic tests that were developed Laboratory Tests 155 for influenza diagnosis were virus isolation and serological assays. Although shell vial tests have reduced the turn-around time of isolation, they are not generally regarded as rapid tests. The development of direct tests such as immunofluorescence enabled the diagnosis within a few hours (1 to 2 incubation and wash steps). Immunofluorescence tests however necessitate skilled laboratory workers and the availability of immunofluo- rescence microscopes. Some of these tests are so easy to perform that even non-laboratory trained people can perform these tests in the clinic, which is referred to as bedside or point- of-care testing. Table 1 compares the characteristics of the different test methods available for in- fluenza diagnosis. During an epidemic the clinical symptoms of fever, cough, severe nasal symptoms and loss of appetite are highly predictive of influenza (Zambon 2001). These include viral, bacterial, mycoplasmal, chlamydial and fungal infections and also parasite infestations. Infections that could either be life-threatening also in the young and healthy, such as viral haemorrhagic fevers, or infections such as legionellosis that are life-threatening in at-risk groups such as the old-aged, can initially present with flu-like symptoms. Therefore it is important to consider a wide differential diagno- sis which should be guided by the patient’s history, which includes travel, occupa- tional exposure, contact with animals and sick individuals, history of symptoms as well as the local epidemiology of disease. Diagnosis of suspected human infection with an avian influenza virus Introduction Accurate and rapid clarification of suspected cases of H5N1 infection by laboratory diagnosis is of paramount importance in the initiation and continuation of appropri- ate treatment and infection control measures. Isolation of virus from specimens of suspected cases of avian influenza should be conducted in specialised reference laboratories with at least Biosafety Level 3 facilities. Specimen collection Specimens for virus detection or isolation should be collected within 3 days after the onset of symptoms and rapidly transported to the laboratory. A nasopharyngeal aspirate, nasal swab, nasal wash, nasopharyngeal swab, or throat swab are all suit- able for diagnosis. In cases where patients are intubated, a transtracheal aspirates and a bronchoalveolar lavage can be collected. Virological diagnostic modalities Rapid identification of the infecting agent as an influenza A virus can be performed by ordinary influenza rapid tests that differentiate between types. However com- mercial rapid chromatographic methods have a sensitivity of only 70% for avian influenza compared to culture (Yuen 2005). This assay allows for the rapid differentiation of human H5 influenza infection from other influenza types and subtypes but cannot exclude H5N1 infection due to lack of sensitivity. Cytopathic effects are non-specific and influenza A virus infection of cells can be detected by immunofluorescence for nucleoprotein. Serology: A fourfold rise in titre from acute to convalescent specimens is also diag- nostic of infection in patients that recovered (Yuen 2005). Other laboratory findings Leucopenia and especially lymphopenia (which has been shown to be a sign of poor prognosis in patients from Thailand), thrombocytopenia and moderately elevated transaminase levels are common findings (Beigel 2005). New developments and the future of influenza di- agnostics A few trends in influenza diagnosis have been observed. Yet these tests’ value is limited by their relatively low sen- sitivity especially for the diagnosis of avian influenza. The only remaining hurdle remains its relative high cost; but the highly competitive market has already made these tests more affordable. Conclusion Molecular diagnostic techniques play a more and more prominent role in laboratory diagnosis of influenza. Influenza serology’s main value lies in epidemiological investigations of yearly epidemics, avian to human transmissions and drug and vaccine trials. We can thus conclude that virological diagnosis for influenza has value for the in- dividual patient, epidemiological investigations and infection control. The appropri- ate selection of a particular test will is determinded by the test characteristics and the specific diagnostic or public health needs. A positive diagnostic test is the difference between someone with flu-like illness and a definite diagnosis of influenza or between a suspected human case of avian influenza and a confirmed case. Enzyme-linked immunosorbent assay for detection of antibodies to influenza A and B and parainfluenza type 1 in sera of patients. Surveillance of childhood influenza virus infection: what is the best diagnostic method to use for archival samples? Enzyme immunoassay, complement fixation and hemagglu- tination inhibition tests in the diagnosis of influenza A and B virus infections. Comparison of complement fixation and hemagglutination inhibition assays for detecting antibody responses following influenza virus vaccination. Rapid identification of viruses by indirect immunofluorescence: standardization and use of antiserum pool to nine respiratory viruses. Diagnosis of influenza in the com- munity: relationship of clinical diagnosis to confirmed virological, serologic, or molecular detection of influenza. In rare cases, the initial presentation may be atypical (febrile seizures, Ryan- Poirier 1995; bacterial sepsis, Dagan 1984). Typical symptoms of uncomplicated influenza Abrupt onset Systemic: feverishness, headaches, myalgias (extremities, long muscles of the back; eye muscles; in children: calf muscles), malaise, prostration Respiratory: dry cough, nasal discharge – may be absent in elderly people who may pres- ent with lassitude and confusion instead Hoarseness, dry or sore throat often appear as systemic symptoms diminish Croup (only in children) Table 2: Frequency of baseline symptoms* Symptom (%) Fever ≥ 37. Fever and systemic symptoms typically last 3 days, occasionally up to 4–8 days, and gradually diminish; however, cough and malaise may persist for more than Complications of Human Influenza 161 2 weeks. Physical findings of uncomplicated influenza Fever: rapidly peaking at 38–40°C (up to 41°C, especially in children), typically lasting 3 days (up to 4–8 days), gradually diminishing; second fever spikes are rare. Face: flushed Skin: hot and moist Eyes: watery, reddened Nose: nasal discharge Ear: otitis Mucous membranes: hyperaemic Cervical lymph nodes: present (especially in children) Adults are infectious from as early as 24 hours before the onset of symptoms until about seven days thereafter. Children are even more contagious: young children can shed virus for several days before the onset of their illness (Frank 1981) and can be infectious for > 10 days (Frank 1981). Severely immunocompromised persons can shed influenza virus for weeks or months (Klimov 1995, Boivin 2002). During non-epidemic periods, respiratory symptoms caused by influenza may be difficult to distinguish from symptoms caused by other respiratory pathogens (see Laboratory Findings).