Insertion of Suprapubic Catheter

Dissection at the base of the bladder to reach the anterior vaginal wall and uterine cervix creates edema, interrupts the small nerve pathways, and thereby sets up the physiologic changes that produce urinary bladder atony. Therefore, catheter drainage of the urinary bladder is an essential feature of many pelvic surgical procedures. Fortunately, in most cases, these conditions reverse themselves in 3-5 days, and catheter drainage is no longer needed.

Suprapubic bladder catheterization is superior to transurethral bladder catheterization because it is cleaner. It also leaves the urethra open for voiding when urinary function has returned. The use of an ordinary Foley catheter (No. 16 French with 5-mL bag) is preferable to the commercially available suprapubic catheter kits because a Foley catheter, when inserted as described in this section, is usually not dislodged from the bladder during sleep or activity. In addition, the Foley catheter is less costly and is available in all surgical clinics. The instrument used for insertion of the Foley catheter is an ordinary Randall stone forceps. The fulcrum of this instrument is toward the rear, which keeps the overall diameter of the axis virtually unchanged except at the jaws and gives it an advantage over a Kelly clamp.

The operation provides drainage of the urinary bladder through a clean surgical incision and ensures that the catheter does not slip out of the patient or become dislodged within the abdominal wall.

Physiologic Changes. The procedure reduces edema at the base of the bladder, allowing the return of normal vesical function.

Points of Caution. After grasping the catheter with the jaws of the Randall forceps (Fig. 4) and before inflating the Foley balloon, the catheter should be drawn through the bladder until the tip can be seen in the urethral meatus. This ensures that the catheter tip and balloon are in the bladder and not in the subcutaneous or subfascial space.

Technique


This procedure can be performed in the inpatient treatment rooms of a hospital, clinic, or doctor's office. Local anesthesia is adequate for most patients. The bladder does not have to be empty. The patient is placed in the dorsal lithotomy position. The periurethral area and suprapubic area are surgically prepped and draped. A routine pelvic examination is performed prior to placement of the suprapubic catheter. If local anesthesia is to be used, a 4 x 4 cm area around the insertion site is infiltrated with 1% lidocaine. Infiltration should include the fascia and, if at all possible, a small area of the bladder wall.

A Randall stone forceps is inserted through the urethral meatus and used to elevate the dome of the bladder from the inside, pushing the suprapubic abdominal wall upward to the palpating finger.

Upward pressure is maintained on the forceps, and a small incision is made in the suprapubic skin and fascia until the forceps can be felt with the blade of the knife.

A sudden upward thrust of the forceps pierces the bladder wall and pushes the forceps through the incision. The jaws of the forceps are opened and used to grasp the tip of the Foley catheter.

The Foley catheter is pulled through the bladder, and the forceps is withdrawn from the urethra until the tip of the Foley catheter can be seen in the urethral meatus.

Traction is placed on the Foley catheter from above while the balloon is simultaneously inflated. This draws the catheter back into the body of the bladder.

When 5 mL of sterile saline solution have completely filled the Foley balloon, the catheter is firmly retracted upward.
It is not necessary to suture the catheter to the abdominal skin. A sterile dressing is applied, and the Foley catheter is connected to straight drainage......http://www.atlasofpelvicsurgery.com
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Communication Techniques in Nursing

Communication techniques are very important in which ever profession you are, especially care giving professions. As such, communication techniques in nursing are very significant. The way in which a care giving professional communicates with the patient can bring about a sea change in how the patient feels. Hence, scroll down to know about therapeutic communication techniques for nursing.

he way you communicate with others in personal and public arenas reflects a lot about your personality. If you are communicating positively then you would obviously get a same kind of response and vibes (unless you encounter a jerk!). Pertaining to all this, since the past few years, communication skills and techniques have gained a lot of importance in almost all the professions. It is more so with professions where you meet numerous people like hospitality, public relations, human resources, health care, media and so on. But the field where communication has an impact which can really make the other person's life better is nursing within health care. The way a nurse deals with the patients is extremely important for the well-being of the patient, mentally and physically. The question which crops up here is, are there communication techniques in nursing? Well, yes there are. Find out what they are in the text below.

Techniques of Communication in Nursing

General Communication Techniques
Speaking or Verbal Communication: If most of us would not have been able to speak, I wonder what we all would have done. I mean, just try and gauge the amount of time we spend speaking and talking in a day! But coming back to nursing, nurses or any other type of care givers need to speak clearly first of all. Maintaining slow, even tone helps the patient to understand what they want to say. Once they put across the point, wait for the patient to respond. Nursing requires you to be slow and gentle, so not rushing thorough is one of the techniques for communicating effectively.

Non-Verbal Communication: When dealing with patients who cannot hear well, nurses ideally need to use hands along with speech to tell what they want to say. Further, they also need to look out for non verbal cues they are reflecting - the body language, voice and so on. Please say the things which you are convinced about. Use other methods like writing or drawing out pictures and the likes so that the patient gets to know what you want to say if he or she is unable to understand you. Even silence can work wonders when it is about non verbal communication. These are very important nursing communication strategies. Read more on qualities of a good nurse.

These and the few other techniques like helpful behavior and positive mentality are important components of communication skills for nursing practice. Now, lets take a look at therapeutic communication techniques for nursing.

Nursing Therapeutic Communication Techniques
Attention: To attract and hold the patient's attention and to add a personal touch, use the name of the patient. Similarly, just as you would call the patient by his or her name, it is always nice to introduce yourself too. It adds a comfort level to the interaction and lays the foundation for a good rapport. Other things which can ensure a nurse the optimum attention from a patient are: checking out on their basic needs, avoiding distractions, having an eye contact and few other seemingly insignificant things, which are, however, very crucial.

Behavior: While dealing with patients, a nurse should empathize and acknowledge the mentality of the patient. A nurse's behavior should reflect that and if that is not the case, it does communicate many things to the patient. Encouragement is another essential factor in case of communication techniques in nursing and patient care. Already the patient is sort of demoralized and if the nurse discourages the patient on top of it, the patient would have it. So, as therapeutic technique, encouragement works wonders. Generally being helpful, concerned, bright and friendly is the best therapeutic behavioral technique.

Help in Dealing with Disorientation: Hospitalization is a very traumatic experience for the elderly and thus they might tend to get disoriented. So, if they say something which is not true, just calmly tell them the truth in a normal tone, without challenging what they have said. If patients are dealing with memory loss, give them gentle and polite reminders all the time. Show them or tell them how to do a particular thing.

Be Interactive: Wherever and whenever possible, a patient should be included in decision-making. After all, it is about the patient. Let the patient be communicated as if he or she is in control. Avoid talking about patients to others as if they do not exist. Being interactive does not mean that you nag or pester the patient to open up. Let the patient open up and express his or her feelings only when they want to. Do not rush into that.

Communication techniques in nursing are umpteen if you delve even deeper into the scheme of things. The above was just a glimpse of what are the fundamentals in it. There are many more therapeutic communication techniques for nursing like being patient, being clear, listening to the patient and so on. As one gains experience, he or she imbibes these qualities.

To cut a long story short, the penultimate aim is to make the patient feel better and foster a feeling that he or she is going to be just fine. If you do that, there is nothing as satisfying as that for all the Florence Nightingales out there!

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Post-power Syndrome

Post-power syndrome is a psychiatric term for someone who lives in the shadow of the days past success (career, intelligence, or anything else), and could not accept the reality that exist today. Patients always want to express and show how great he was in the past.

Some of the factors that caused the post-power syndrome, among others.

1. Early retirement and work fired
When people are getting early retirement or who fired the work could not accept a state that energy is not used anymore, especially if he feels can still contribute significantly to the company it will be easy to occur post-power syndrome.

2. Condition that requires her to quit her career
Examples accidents experienced by a football player who led his leg was amputated, can cause post-power syndrome.

How to Help People with post-power syndrome

1. Understanding of their beloved ones
It would be very helpful person if the person is to see that their loved ones still can understand his situation or lack of ability to earn a living, he would be more receptive to think it could have a cold. This will restore the ability and productivity, rather than always sarcastic, grumbling, even mocked him.

2. Support from the environment
Families can be very helpful during this post-power syndrome. Understanding families and children must be very necessary in an effort to expedite passage of this period, with a wise way we as a family member can suggest something that could be used to do anything within its capabilities.

3. Creating a positive activity
If a post-power syndrome sufferers can find a place to channel capacity, would be very helpful. For example, an employee who has retired or been fired but he was able to do new business or other activities such as agribusiness, it's easier and faster to adapt quickly and can accept the current situation.

In some cases the post-power syndrome causes mental disorder severe enough suppose can not think rationally in a certain period, depression, and may cause health problems.
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Insomnia

Insomnia Overview

Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30%-50% of the general population are affected by insomnia, and 10% have chronic insomnia.

Insomnia is a symptom, not a stand-alone diagnosis or a disease. By definition, insomnia is "difficulty initiating or maintaining sleep, or both" and it may be due to inadequate quality or quantity of sleep. Insomnia is not defined by a specific number of hours of sleep that one gets, since individuals vary widely in their sleep needs and practices. Although most of us know what insomnia is and how we feel and perform after one or more sleepless nights, few seek medical advice. Many people remain unaware of the behavioral and medical options available to treat insomnia.

Insomnia is generally classified based on the duration of the problem. Not everyone agrees on one definition, but generally:

* symptoms lasting less than one week are classified as transient insomnia,

* symptoms between one to three weeks are classified as short-term insomnia, and

* those longer than three weeks are classified as chronic insomnia.

Statistics on Insomnia

Insomnia affects all age groups. Among adults, insomnia affects women more often than men. The incidence tends to increase with age. It is typically more common in people in lower socioeconomic (income) groups, chronic alcoholics, and mental health patients. Stress most commonly triggers short-term or acute insomnia. If you do not address your insomnia, however, it may develop into chronic insomnia.

Insomnia Causes

Insomnia may be caused by a host of different reasons. These causes may be divided into situational factors, medical or psychiatric conditions, or primary sleep problems. Insomnia could also be classified by the duration of the symptoms into transient, short-term, or chronic. Transient insomnia generally last less than seven days; short-term insomnia usually lasts for about one to three weeks, and chronic insomnia lasts for more than three weeks.

Many of the causes of transient and short-term insomnia are similar and they include:

* Jet lag

* Changes in shift work

* Excessive or unpleasant noise

* Uncomfortable room temperature (too hot or too cold)

* Stressful situations in life (exam preparation, loss of a loved one, unemployment, divorce, or separation)

* Presence of an acute medical or surgical illness or hospitalization

* Withdrawal from drug, alcohol, sedative, or stimulant medications

* Insomnia related to high altitude (mountains)

Chronic or long-term insomnia

The majority of causes of chronic or long-term insomnia are usually linked to an underlying psychiatric or physiologic (medical) condition.

Psychological related insomnia

The most common psychological problems that may lead to insomnia include:

* anxiety,

* stress,

* schizophrenia,

* mania (bipolar disorder), and

* depression.

In fact, insomnia may be an indicator of depression. Many people will have insomnia during the acute phases of a mental illness.

Physiological related insomnia

Physiological causes span from circadian rhythm disorders (disturbance of the biological clock), sleep-wake imbalance, to a variety of medical conditions. The following are the most common medical conditions that trigger insomnia:

* Chronic pain syndromes

* Chronic fatigue syndrome

* Congestive heart failure

* Night time angina (chest pain) from heart disease

* Acid reflux disease (GERD)

* Chronic obstructive pulmonary disease (COPD)

* Nocturnal asthma (asthma with night time breathing symptoms)

* Obstructive sleep apnea

* Degenerative diseases, such as Parkinson's disease and Alzheimer's disease (Often insomnia is the deciding factor for nursing home placement.)

* Brain tumors, strokes, or trauma to the brain

High risk groups for insomnia

In addition to the above medical conditions, certain groups may be at higher risk for developing insomnia:

* travelers

* shift workers with frequent changing of shifts

* seniors

* adolescent or young adult students

* pregnant women, and

* menopausal women

Medication related insomnia

Certain medications have also been associated with insomnia. Among them are:

* Certain over-the-counter cold and asthma preparations.

* The prescription varieties of these medications may also contain stimulants and thus produce similar effects on sleep.

* Certain medications for high blood pressure have also been associated with poor sleep.

* Some medications used to treat depression, anxiety, and schizophrenia.

Other causes of insomnia

* Common stimulants associated with poor sleep include caffeine and nicotine. You should consider not only restricting caffeine and nicotine use in the hours immediately before bedtime but also limiting your total daily intake.

* People often use alcohol to help induce sleep, as a nightcap. However, it is a poor choice. Alcohol is associated with sleep disruption and creates a sense of nonrefreshed sleep in the morning.

* A disruptive bed partner with loud snoring or periodic leg movements also may impair your ability to get a good night's sleep.

Primary Sleep Disorders

In addition to the causes and conditions listed above, there are also a number of conditions that are associated with insomnia in the absence of another underlying condition. These are called primary sleep disorders, in which the sleep disorder is the main cause of insomnia. These conditions generally cause chronic or long-term insomnia. Some of the diseases are listed below:

* Idiopathic Insomnia (unknown cause) or childhood insomnia, which start early on in life and results in lifelong sleep problems. This may run in families.

* Central Sleep Apnea. This is a complex disorder. It can be the primary cause of the insomnia itself or it may be caused by other conditions, such as brain injury, heart failure, high altitude, and low oxygen levels.

* Restless leg syndrome (a condition associated with creeping sensations in the leg during sleep that are relieved by leg movement)

* Periodic limb movement disorder (a condition associated with involuntary repeated leg movement during sleep)

* Circadian rhythm disorders (disturbance of the biological clock) which are conditions with unusual timing of sleep (for example, going to sleep later and waking up late, or going to sleep very early and getting up very early).

* Sleep state misperception, in which the patient has a perception or feeling of not sleeping adequately, but there are no objective (polysomnographic or actigraphic) findings of any sleep disturbance.

* Insufficient sleep syndrome, in which the patient's sleep is insufficient because of environmental situations and lifestyle choices, such as sleeping in a bright or noisy room.

* Inadequate sleep hygiene, in which the individual has poor sleep or sleep preparation habits (described in the following treatment section.)

Insomnia Symptoms

Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms intertwine with those of other medical or mental conditions.

* Some people with insomnia may complain of difficulty falling asleep or waking up frequently during the night. The problem may begin with stress. Then, as you begin to associate the bed with your inability to sleep, the problem may become chronic.

* Most often daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include the following:

o Poor concentration and focus

o Difficulty with memory

o Impaired motor coordination (being uncoordinated)

o Irritability and impaired social interaction

o Motor vehicle accidents because of fatigued, sleep-deprived drivers

* People may worsen these daytime symptoms by their own attempts to treat the symptoms.

o Alcohol and antihistamines may compound the problems with sleep deprivation.

o Others have tried nonprescription sleep aids.

When to Seek Medical Care

When to call the doctor

* A person with insomnia needs a doctor's attention if it lasts longer than three to four weeks, or sooner if it interferes with a person's daytime activities and ability to function.

* Insomnia may be a symptom of another medical or psychological problem, which a patient may need to address first or at the same time.

When to go to the hospital

* Generally, a patient will not be hospitalized for most types of insomnia. However, accidents may result from poor coordination and attention lapse seen with sleep deprivation.

* Worsening pain or increased difficulty breathing at night also may indicate a person need to seek emergency medical care.

Exams and Tests

The doctor will begin an evaluation of insomnia with a good medical history.

* The doctor will seek to identify any medical or psychological illness that may be contributing to the patient's insomnia. A thorough medical history and examination including screening for psychiatric disorders and drug and alcohol use is paramount in evaluation of a patient with sleep problems.

o For example, the patient may be asked about chronic snoring and recent weight gain. This may direct an investigation into the possibility of obstructive sleep apnea. In such an instance, the doctor may request an overnight sleep test (polysomnogram). Sleep studies are frequently done in specialized "sleep labs" by doctors trained in sleep medicine, frequently working under pulmonary (lung) specialists. This test is not part of the routine initial workup for insomnia, however.

o The diary will include the patient's personal assessment of their alertness at various times of the day on two consecutive days within the two week period.

* The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness.

* Actigraphy is another technique to assess sleep-wake patterns over time. Actigraphs are small, wrist-worn devices (about the size of a wristwatch) that measure movement. They contain a microprocessor and on-board memory and can provide objective data on daytime activity.

Insomnia Treatment

In general, transient insomnia resolves when the underlying trigger is removed or corrected. Most people seek medical attention when their insomnia becomes more chronic.

The main focus of treatment for insomnia should be directed towards finding the cause. Once a cause is identified, it is important to manage and control the underlying problem, as this alone may eliminate the insomnia. Treating the symptoms of insomnia without addressing the main cause is rarely successful.

The following therapies may be used in conjunction with therapies directed towards the underlying medical or psychiatric cause. They are also the recommended therapies for some of the primary insomnia disorders.

Generally, treatment of insomnia entails both non-pharmacologic (non-medical) and pharmacologic (medical) aspects. It is best to tailor treatment for individual patient based on the potential cause. Studies have shown that combining medical and non-medical treatments typically is more successful in treating insomnia than either one alone.

Non-medical treatment and behavioral therapy

Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus control, and sleep restriction. These also referred to as cognitive behavioral therapies.

Sleep hygiene

Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple steps can be taken to improve a patient's sleep quality and quantity. These steps include:

* Sleep as much as you need to feel rested; do not oversleep.

* Exercise regularly at least 20 minutes daily, ideally 4-5 hours before your bedtime.

* Avoid forcing yourself to sleep.

* Keep a regular sleep and awakening schedule.

* Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.) Avoid "night caps," (alcoholic drinks prior to going to bed).

* Do not smoke, especially in the evening.

* Do not go to bed hungry.

* Adjust the environment in the room (lights, temperature, noise, etc.)

* Do not go to bed with your worries; try to resolve them before going to bed.

Relaxation therapy

Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed.

Stimulus control

Stimulus control therapy also consists of a few simple steps that may help patients with chronic insomnia.

* Go to bed when you feel sleepy.

* Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep and sexual activity.

* If you do not fall asleep 30 minutes after going to bed, get up and go to another room and resume your relaxation techniques.

* Set your alarm clock to get up at a certain time each morning, even on weekends. Do not oversleep.

* Avoid taking long naps in the daytime.

Sleep restriction

Restricting your time in bed only to sleep may improve your quality of sleep. This therapy is called sleep restriction. It is achieved by averaging the time in bed that the patient spends only sleeping. Rigid bedtime and rise time are set, and patient is forced to get up even if they feel sleepy. This may help the patient sleep better the next night because of the sleep deprivation for the previous night. Sleep restriction has been helpful in some cases.

Other simple measures that can be helpful to treat insomnia include:

* Avoid large meals and excessive fluids before bedtime

* Control your environment.

o Light, noise, and elevated room temperature can disrupt sleep. Shift workers and night workers especially must address these factors. Dimming the lights in the bedroom, relaxation, limiting the noise, and avoiding stressful tasks before going to bed may be beneficial. (Refer to sleep hygiene and relaxation therapy above.)

o Avoid doing work in the bedroom that should be done somewhere else. For example, do not work or operate your business out of your bedroom and avoid watching TV, reading books, and eating in your bed.

A person's body's circadian rhythm (biological clock) is particularly sensitive to light. Parents who need to sleep during the day may have to make child care arrangements to allow them to sleep.

Medications and Medical Therapies

There are numerous possible medications to treat insomnia. Generally, it is advised that they should not be used as the only therapy and that treatment is more successful if combined with non-medical therapies. In a study, it was noted that when sedatives were combined with behavioral therapy, more patients were likely to wean off the sedatives than if sedatives were used alone.

* Benzodiazepine sedatives: six of these sedative drugs have been used to treat insomnia. There are reports of subjective improvement of quality and quantity of sleep when using these medications. These include temazepam (Restoril), flurazepam (Dalmane), triazolam (Halcion), estazolam (ProSom, Eurodin), lorazepam (Ativan), and clonazepam (Klonopin).

* Nonbenzodiazepine sedatives: These include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien).

* Melatonin: Melatonin is secreted by the pineal gland, a pea-sized structure at the center of your brain. Melatonin is produced during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. At night, melatonin is produced to help your body regulate your sleep-wake cycles. The amount of melatonin produced by your body seems to decrease as you get older. Melatonin may be beneficial in patients with circadian rhythm problems.

* Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the Food and Drug Administration (FDA) for treatment of insomnia characterized by difficulty falling asleep.

* Some antidepressants [for example, amitriptyline (Elavil, Endep) and trazodone (Desyrel)] have been used for the treatment of insomnia in patients with co-existing depression because of some sedative properties. Generally, they may not be helpful for insomnia in people without depression.

* Antihistamines with sedative properties [for example, diphenhydramine (Benadryl) or doxylamine] have also been used in treating insomnia as they may induce drowsiness, but they do not improve sleep and should not be used to treat chronic insomnia.

* Valeriana officinalis (Valerian) is a popular herbal medication used in the United States for treating insomnia, however, to date there are no convincing studies to show any real benefit in patients with chronic insomnia.

Follow-up

Follow the doctor's recommendations for the patient's medical and psychological conditions. The patient will be asked to give their doctor feedback after they have followed a treatment plan.

Often the patient will have more than one option and more than one medication available to help them. A patient should not lose hope if the first medication does not give them the results they want or if they experience side effects or concerns. Report back to a doctor for advice.

Prevention

The following are suggestions to help anticipate and modify situations likely to be associated with insomnia. They are not foolproof, nor will they safeguard the patient from the consequences of sleep deprivation once it has occurred.

Insomnia from jet lag

* Behavioral and short-term drug therapy has been used.

* If you can anticipate a trip, begin to shift your bedtime to coincide with the time schedule in your destination.

* Short-acting tranquilizers (benzodiazepines) have been shown to be useful. Melatonin, a hormone secreted by the pineal gland that regulates our sleep-wake cycles, has also been used.

Insomnia from shift changes

* Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep deprivation in shift workers.

* You should shift your schedules forward in a clockwise direction - from days to evening to night shift - and allow sufficient time to adapt (at least one week) between shift changes.

* Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as a rhythm synchronizer.

* Shift workers should stress the importance of good sleep habits with regular bedtime and awakening.

o Supplemental naps may be necessary to ensure work time alertness.

o Discuss the use of naps with a doctor.

o Some people promote using short-acting sedatives in the first few days following a shift change, but not everyone agrees.

Insomnia from acute stresses

* Stress may be positive or negative, and concerns about sleep may vary. Many stressors will go away with support and reassurance.

* Education about the importance of good sleep habits is also helpful.

* Some people may need short-term treatment with medications. A doctor will often work toward the lowest effective dose with a short-acting sedative to achieve proper sleep.

General recommendations include the following:

* Work to improve your sleep habits.

o Learn to relax. Self-hypnosis, biofeedback and relaxation breathing are often helpful.

o Control your environment. Avoid light, noise, and excessive temperatures. Use the bed only to sleep and avoid using it for reading and watching TV. Sexual activity is an exception.

o Establish a bedtime routine. Fix wake time.

* Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and reduce the use of stimulants including caffeine and nicotine.

* If you do not fall asleep within 20-30 minutes, try a relaxing activity such as listening to soothing music or reading.

* Limit daytime naps to less than 15 minutes unless directed by your doctor.

o It is generally preferable to avoid naps whenever possible to help consolidate your night's sleep.

o There are certain sleep disorders, however, that will benefit from naps. Discuss this issue with your doctor.

http://www.emedicinehealth.com
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Huntington's disease

Huntington's disease is an inherited disorder that causes the degeneration of brain cells. This results in a progressive loss of the control of movement and mental ability, and changes in personality.

Around 4,800 people in the UK are living with Huntington's disease. It used to be called Huntington's chorea. Chorea means jerky, involuntary movements - a main symptom of the condition.

Huntington's disease usually develops between the ages of 30 and 50, but it can start at any age. Symptoms get worse gradually, sometimes over a period of up to 20 years. At the moment, there is no cure for the disease, but there are ways to help manage the symptoms.
Symptoms

The symptoms of Huntington's disease are sometimes overlooked. This is because they are mild at first and people without the disease can have the same symptoms. People who have Huntington's disease sometimes have problems for a long time before they find out that they have the condition.

Early symptoms include:

* mild tremor
* clumsiness
* lack of concentration and irritability
* difficulty remembering things
* mood changes, including depression
* aggressive antisocial behaviour

Over time the symptoms become progressively worse. Eventually, full-time nursing care will be needed. Later symptoms fall into three categories:
Physical symptoms

Physical symptoms include chorea (involuntary movements of the limbs, face and body). Chorea may lead to difficulty walking, speaking and swallowing. People often lose weight because of difficulty eating and by burning more calories due to the continuous movement. The ability to coordinate movement gets gradually worse as the disease progresses.
Emotional symptoms

Emotional symptoms include depression, not only because of the burden of having a progressive disorder, but as a direct result of the damage to certain brain cells. You may become frustrated at being unable to work or do previously simple tasks. You may behave stubbornly, and have mood swings. People with Huntington's may also become more irritable and antisocial than usual, or have less inhibitions.
Cognitive symptoms

Cognitive symptoms include a loss of drive and initiative. People with Huntington's may appear to be lazy or uninterested in life, spending days doing little or neglecting personal hygiene. You may also lose the ability to organise yourself. This is because planning skills and the ability to do more than one task at once deteriorate. In the later stages, you may get memory loss and be less able to understand speech.

The behavioural changes that occur are often the most distressing for you, your family and your carers. A previously full and active life may be lost with a gradual reduction in independence and mobility. At the same time, your personality can become gradually more self-centred and unmotivated, straining personal relationships.
Causes

Huntington's disease is caused by a faulty gene that runs in families. The gene, which was discovered in 1993, produces a protein called Huntingtin. Scientists are still researching how the faulty gene causes the disease.

Most genes in the body are present in two copies: one from your mother and one from your father. The gene that causes Huntington's disease is dominant. This means that if you inherit a copy of this gene from either parent, you will go on to develop the disease at some point in your life.

If you have one parent with Huntington's disease you have a 50 percent chance of inheriting the faulty gene. The risk is 50 percent for each child. It isn't altered by gender or whether brothers and sisters are affected. Only people who have the faulty gene can pass it on to their children.

Occasionally there is no family history of the condition. This may be because previous generations weren't diagnosed - either because of early death from other causes, or loss of contact through adoption.

Huntington's disease causes progressive damage to cells in areas of your brain called the basal ganglia and cerebral cortex. These areas are involved in the control of movement, planning, motivation and personality.
Juvenile Huntington's disease

A juvenile form of Huntington's disease, which develops before the age of 20, also exists. About five percent of people with Huntington's disease are affected by the condition when this young. The symptoms are similar to those of adult Huntington's, but muscular rigidity is more likely to occur. Epilepsy - which causes fits - is also more common among those with juvenile Huntington's disease compared with adults who have the condition.
Treatment

Although there is currently no cure for Huntington's disease, there are drugs to help manage some of your symptoms. There are medicines that can reduce the involuntary movements, and antidepressant medicines may alleviate depression. Mood stabilisers and antipsychotic drugs can help with some of the emotional disturbances.

Counselling can also be helpful, both for you and your family. Dieticians can advise on adequate calorie and nutrient intake to stop weight loss.
Future promise

Scientists are investigating several drug treatments to slow the progress of Huntington's disease. Some of these have shown promise and are planned to be tested in clinical trials. Examples include the antibiotic minocycline and coenzyme Q10. However, this research is speculative; more work is needed before any recommendations can be made.

Some clinical studies have used stem cells (the most basic form of cells from which others develop) to grow cells that can be transplanted into the brain of people affected by the disease. This approach may eventually improve the outlook for people with Huntington's disease. However, this research is still in the very early stages of development.
Genetic tests

There are tests available to find out whether you have the faulty gene. They fall into three categories: diagnostic, pre-symptomatic and antenatal.
Diagnostic tests

These are carried out if you have symptoms of Huntington's disease and you come from a family where others have the condition. The aim is to confirm the diagnosis.
Pre-symptomatic tests

These tests are carried out if you have no symptoms of Huntington's disease, but you have family members who are affected by it. The test tells you whether you will develop the disease, but not when it will happen.

The decision to take these tests is a serious one and shouldn't be rushed into. A positive result can be devastating since it may tell you that one day you will become severely ill. There are also issues surrounding testing when your parents have themselves not been tested. This is because a positive result means that one of your parents also has the faulty gene.

You should take advice from a genetic counsellor about the implications of taking the test before you go ahead. In the UK you can't have the test if you are under the age of 18.
Antenatal tests

These tests may be carried out early in pregnancy on the unborn children of couples from families affected by Huntington's disease. They can be used to calculate the risk of that child going on to develop the disease in their adult life.
Pre-implantation Genetic Diagnosis (PGD)

If you know that you carry the gene for Huntington's disease, you can opt for PGD. This is a type of in vitro fertilisation (IVF). Only embryos which are not carrying the faulty Huntington gene are used, so the baby is not at risk of having the disease.
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Cardiac Marker Tests

Definition

Cardiac marker tests identify blood analytes associated with myocardial infarction (MI), commonly known as a heart attack.
Purpose

Cardiac markers help physicians to assess acute coronary syndromes and to identify and manage high-risk patients. Creatine kinase-MB (CK-MB), myoglobin, homocysteine, C-reactive protein (CRP), troponin T (cTnT), and troponin I (cTnI) are all used for assessment of the suspected acute myocardial infarction. CK-MB, cTnT, and cTnI may also be used to identify and manage high-risk patients.

Precautions

C-reactive protein results may be affected by the use of oral contraceptives, NSAIDs, steroids, salicyltes, intrauterine devices (IUDs), and overnight sample refrigeration. Homocysteine levels may be affected by smoking, diabetes, and coffee.
Description
Creatine kinase (CK)

Creatine kinase is an enzyme responsible for transferring a phosphate group from ATP to creatine. It is composed of M and/or B subunits that form CK-MM, CKMB, and CK-BB isoenzymes. Total CK (the activity of the MM, MB, and BB isoenzymes) is not myocardial-specific. However, the MB isoenzyme (also called CK-2) comprises about 40% of the CK activity in cardiac muscle and 2% or less of the activity in most muscle groups and other tissues. In the proper clinical setting, MB is both a sensitive and specific marker for myocardial infarction. MB usually becomes abnormal three to four hours after an MI, peaks in 10 to 24 hours, and returns to normal within 72 hours. However, an elevated serum MB may occur in people with severe skeletal muscle damage (such as in muscular dystrophy or a crush injury) and renal failure. In such cases, the CK index (MB divided by total CK) is very helpful. If the index is under 4%, a nonmyocardial cause of a high MB should be suspected. C-MB is considered the benchmark for cardiac markers of myocardial injury. Measurement of CK-MB may be performed via electrophoresis or immunoassays; the latter demonstrates better analytical sensitivity and better precision.

CK-MB isoforms can be used to determine whether thrombolytic therapy (such as treatment with tissue plasminogen activator to dissolve a blood clot in the coronary artery) has succeeded. MB isoforms are different molecular forms of MB found in the circulation. When MB is released into the blood, the terminal lysine of the M sub-unit is removed by an enzyme in the plasma. This results in a molecule with faster electrophoretic mobility, called CK-21. This is the prevalent form of MB in the blood. The slower form, designated CK-22, is the unmodified cardiac form of MB. After successful thrombolytic therapy, the unmodified form of MB is rapidly flushed into the blood, causing it to become the dominant isoform.
Myoblobin

Myoglobin is a protein found in both skeletal and myocardial muscle. It is released rapidly after tissue injury and may be elevated as early as one hour after myocardial injury, though it may also be elevated due to skeletal muscle trauma. However, if myoglobin values do not rise within three to four hours after a person shows acute symptoms, it is highly unlikely that he or she had an MI. There are several measurement methods available, including fluorometric, nephelometric, and turbid-metric assays; plus immunochromatography-based tests designed for qualitative, point-of-care testing.
Troponin T and troponin I

Troponin C, I, and T are proteins that form the thin filaments of muscle fibers and regulate the movement of contractile proteins in muscle tissue. Skeletal and cardiac forms are structurally distinct, and antibodies can be produced that react only with the cardiac forms of troponin I and troponin T.

Cardiac troponin T (cTnT) and cardiac troponin I (cTnI) are the newest additions to the list of cardiac markers. Troponins are specific to heart muscle. They have enabled the development of assays that can detect heart muscle injury with great sensitivity and specificity. While these markers have been used mainly to aid in the diagnosis of chest-pain patients with nondiagnostic electrocardiograms, they are also used as prognostic indicators of a MI. According to the American Heart Association, "Several studies have identified a measurable relationship between cardiac troponin levels and long-term outcome after an episode of chest discomfort. They suggest that these tests may be particularly useful to evaluate levels of risk. In other words, it's possible that the results of a troponin test could be used to identify people at either low risk or high risk for later, serious heart problems."

Several commercially available quantitative immunoassays are available for for the measurement of cTnI and cTnT. There is also a qualitative cTnI test, targeted at bedside testing.
C-reactive protein (CRP)

CRP is a protein found in serum or plasma at elevated levels during a inflammatory processes. The protein can be measured via a variety of methods, including EIA or ELISA, for the quantitative or semiquantitative determination of C-reactive protein in human serum, particle agglutination tests that provide semiquantitative results, and laser and rate nephelometery tests that measure antigen-antibody complexes by light dispersion.

CRP binds to the C polysaccharide of the capsule of Streptococcus pneumoniae. It is a sensitive marker of acute and chronic inflammation and infection, and in such cases is increased several hundred-fold. Several recent studies have demonstrated that CRP levels are useful in predicting the risk for a thrombotic event. These studies suggest that a high-sensitivity assay for CRP be used that is capable of measuring the very low level normally found in serum (0.1 to 2.5 mg/L). Heart patients who have persistent CRP levels between 4 and 10 mg/L, with clinical evidence of low-grade inflammation, should be considered to be at increased risk for thrombosis. People can be stratified into four groups of increased risk based upon the quartile in which their CRP levels fall.
Homocysteine

Homocysteine is an amino acid. According to the American Heart Association, studies have shown that too much homocysteine in the blood is related to a higher risk of coronary heart disease, stroke, and peripheral vascular disease; and that it may also have an effect on atherosclerosis. High levels of homocysteine are the result of inheritance or dietary excess and have been implicated in vascular-wall injury. One immunoassay is available for it. It is believed that laboratory testing for plasma homocysteine levels can improve the assessment of risk, particularly in patients with a personal or family history of cardiovascular disease, but in whom the well-established risk factors (smoking, high blood cholesterol, high blood pressure, physical inactivity, obesity, and diabetes) do not exist. Homocysteine levels are obtained via high-performance chromatography with electrochemical detection.
Preparation

These assays require a sample of blood, which is typically obtained via a standard venipuncture procedure. Homocysteine tests require the patient to fast. Homocysteine is stable only in separated refrigerated or frozen plasma for 48 hours.
Aftercare

Discomfort or bruising may occur at the puncture site, or the person may feel dizzy or faint. Applying pressure to the puncture site until the bleeding stops reduces bruising. Warm packs to the puncture site relieve discomfort.
Complications

There are no complications associated with these tests.
Results

Normal results vary, based on the laboratory and method used. Unless otherwise specified, the following information is from the American College of Cardiology and the American Heart Association.

* Total CK: Reference value is 38 to 174 units/L for men and 96 to 140 units/L for women. The values begin to rise within four to six hours and peak at 24 hours. Values return to normal within three to four days.
* CK-MB: Reference value is 10 to 13 units/L. The values begin to rise within three to four hours and peak at 10 to 24 hours. Values return to normal within two to four days.
* Troponin T: Reference value is less than 0.1 ng/mL. The values begin to rise within two to four hours and peak at 10 to 24 hours. Values return to normal within five to 14 days.
* Troponin I: Reference value is less than 1.5 ng/mL. The values begin to rise within two to four hours and peak at 10 to 24 hours. Values return to normal within five to 10 days.
* CK-MB isoforms: Reference value is a ratio of 1.5 or greater. The values begin to rise within two to four hours and peak at six to 12 hours. Values return to normal within 12 to 24 hours.
* Myoglobin: Reference value is less than 110 ng/mL. The values begin to rise within one to two hours and peak at four to eight hours. Values return to normal within 12 to 24 hours.
* Homocysteine: The normal fasting level for plasma is five to 15 micromol/L. Moderate, intermediate, and severe hyperhomocysteinemia refer to concentrations between 16 and 30, between 31 and 100, and less than 100 micromol/L, respectively.
* C-reactive protein: According to the U.S. Food and Drug Administration, in healthy people, reference values are below 5 mg/dL; in various diseases, this threshold is often exceeded within four to eight hours after an acute inflammatory event, with CRP values reaching approximately 20 to 500 mg/dL.

Health care team roles

Cardiac marker tests are usually performed by clinical laboratory scientists, medical technologists, or clinical laboratory technicians.//enotes.com
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Chest Physical Therapy

Definition

Chest physical therapy (CPT) is the term for a group of treatments designed to improve respiratory efficiency, promote expansion of the lungs, strengthen respiratory muscles, and eliminate secretions from the respiratory system.
Purpose

The purpose of chest physical therapy, also called chest physiotherapy, is to help patients breathe more freely and to get more oxygen into the body.

Chest physical therapy includes postural drainage, chest percussion, chest vibration, turning, breathing exercises, coughing, and incentive spirometry. CPT is usually done in conjunction with other treatments to rid the airways of secretions. These other treatments include suctioning, nebulizer treatments, and the administration of expectorant drugs.

Chest physical therapy can be used with newborns, infants, children, and adults. People who benefit from chest physical therapy exhibit a wide range of problems that make it difficult to clear secretions from their lungs.

Patients who may receive chest physical therapy include those with cystic fibrosis, neuromuscular diseases (such as Guillain-Barré syndrome), progressive muscle weakness (such as myasthenia gravis), or tetanus. People with lung diseases such as pneumonia, bronchitis, and some forms of chronic obstructive pulmonary disease (COPD), including chronic bronchitis, also benefit from chest physical therapy. CPT should not be used in the treatment of patients diagnosed with asthma.

People without specific lung problems but who are likely to aspirate their mucous secretions because of diseases such as cerebral palsy or muscular dystrophy also receive chest physical therapy, as do those who are bedridden or confined to a wheelchair. In addition, CPT may be part of treatment after surgery for patients who develop difficulty taking deep breaths.
Precautions

While the doctor ultimately determines which type of therapy can be performed, health care professionals know that not all forms of chest physical therapy are appropriate for all patients. Postural drainage and percussion should not be administered to patients who:

* have just eaten or are vomiting
* have acute asthma or tuberculosis
* have brittle bones or broken ribs
* are bleeding from the lungs or are coughing up blood
* are experiencing intense pain
* have increased pressure in the skull
* have head or neck injuries
* have collapsed lungs or a damaged chest wall
* recently experienced a heart attack
* have a pulmonary embolism or lung abscess
* have an active hemorrhage
* have injuries to the spine
* have open wounds or burns
* have had recent surgery

Description

Chest physical therapy can be performed in a variety of settings including critical care units, hospitals, nursing homes, outpatient clinics, and in the patient's home. Depending on the circumstances, chest physical therapy may be performed by anyone ranging from a respiratory care therapist to a trained member of the patient's family. Patients can be taught to perform some therapies.

Lengths of therapies and their costs vary. Some therapies may be part of ongoing treatment for a chronic condition. Special equipment may be needed for some procedures, such as percussion, and may be covered by the patient's health plan.

Chest physical therapy encompasses a variety of procedures; which ones are applied depends on the patient's needs. Hospitalized patients are reevaluated frequently to establish which procedures are most effective and best tolerated. Patients receiving long term chest physical therapy are reevaluated about every three months.
Turning

Turning from side to side permits lung expansion. Patients who cannot turn themselves are turned by a care- giver. The head of the bed is also elevated to promote drainage if the patient can tolerate this position. Critically ill patients and those dependent on mechanical respiration are turned once every one to two hours around the clock.
Coughing

Coughing helps break up secretions in the lungs so that the mucus can be suctioned out or expectorated. However, for patients with conditions like COPD, it can be painful to cough normally. An important part of chest

physical therapy is teaching patients to clear their airways by gentler methods, such as with a controlled cough or by "huffing."

Before either technique, patients are advised to sit upright and drink a glass of water. For the controlled cough, patients purse their lips and take a deep breath. They hold their breath for several seconds and then make two brief, gentle coughs. Huffing also starts with pursing the lips and taking a deep breath. After holding the breath for several seconds, patients exhale by using the stomach muscles to push the air out. The vocal chords remain open so that the cough has almost a whispery sound. Coughing and huffing are repeated several times a day as needed.
Deep breathing exercises

Deep breathing helps expand the lungs and forces better distribution of the air into all areas. The patient may initially need to lie down to do these exercises, but eventually it is done while sitting upright, then while walking.

Patients may find it helpful to monitor their breathing by placing a hand on their abdomen to provide a sense of their regular breathing pattern. The patient then starts by taking a deep breath through the nose, then purses the lips as if to whistle. The patient then exhales the air slowly through pursed lips. The exhalation should take twice as long as the inhalation. A patient may start by inhaling for two seconds and then exhaling for four. After taking several deep breaths, the patient breathes at a normal rhythm and begins another cycle of deep breathing. The patient builds up to taking deeper breaths, following a schedule given by the health care team. Generally, COPD patients practice deep breathing exercises for 20 minutes each day.
Incentive spirometry

The incentive spirometer helps the patient improve lung function. This self-administered therapy involves inhaling into a tube attached to a device. The specific technique and goal depends on the type of spirometer. The patient receives directions from the doctor, nurse, or respiratory therapist.

With a breath flow-oriented device, the patient inhales through a tube to raise a ball inside the plastic spirometer chamber. The drop in pressure causes the ball to rise, and the goal is to keep the ball in the air for as long as possible.

For a volume-oriented device, the patient sets a pointer on the chamber at the desired breath volume level. The patient inhales into the tube and attempts to raise a piston inside the chamber so that the volume marker reaches that level.

Hybrid volume accumulators combine a flow-oriented device with a volume-oriented device. A piston inside a cylinder responds to negative pressure from the patient's inhalation.

Some devices have a component designed for exhalation. If the model does not include an exhaling function, the patient breathes out air naturally.

At the end of the session, the patient takes a deep breath and then coughs. The length of therapy and the number of exercises done depend on the patient's condition and is determined by a respiratory therapist or other health professional.
Postural drainage

Postural drainage uses gravity to assist in draining secretions from the lungs and into the central airway where they can either be coughed up or suctioned out. This therapy generally lasts a maximum of 30 minutes. If various positions are tried to induce a cough, the patient may remain in one position for from five to 15 minutes. The health care team guides the patient in determining the amount of time needed. Each position reaches a specific area of the lungs. Chest drainage positions include:

* the patient seated with head back
* the patient seated with head bent forward
* the patient lying face up with feet higher than the head
* the patient lying face down with feet higher than the head
* the patient lying first on one side, then the other, with feet higher than the head

Critical care patients and those depending on mechanical ventilation receive postural drainage therapy four to six times daily. Patients at home are given schedules set by their doctor or respiratory therapist. Percussion and vibration may be performed in conjunction with postural drainage.
Percussion

Percussion, also called cupping or clapping, involves rhythmically striking the chest wall with cupped hands. Mechanical devices can also be used. Percussion results in breaking up thick secretions in the lungs so that they can be more easily removed. Percussion is performed on each lung segment for one to two minutes at a time.
Vibration

Vibration therapy is done for one minute after percussion therapy or may be used instead of percussion therapy for patients who may be too sore or frail to tolerate percussion. The purpose is also to help break up lung secretions. Vibration can be performed either mechanically or manually. When done manually, the person performing the vibration places his or her hands against the patient's chest and creates vibrations by quickly contracting and relaxing arm and shoulder muscles while the patient exhales. The procedure is repeated several times each day for about five exhalations.
Preparation

Preparation for chest physical therapy starts with an evaluation of the patient's condition to determine which chest physical therapy techniques would be most beneficial. Since most therapies are done at home, patient education is extremely important. The doctor, nurse, physical therapist, or respiratory therapist instructs the patient or caregiver in chest physical therapy techniques. The therapy should be explained and demonstrated by the health professional. Then the patient or caregiver should try the therapy. This will demonstrate whether the patient understands the therapy or if more instruction is needed.
Aftercare

Patients should be advised to practice oral hygiene procedures to lessen the bad taste and odor of the secretions that they spit out.
Complications

Risks and complications associated with chest physical therapy depend on the health of the patient. Although chest physical therapy usually poses few problems, the health care team should be aware that in some patients it may cause:• oxygen deficiency if the head is kept lowered for drainage

* increased intracranial pressure
* temporary low blood pressure
* bleeding in the lungs
* pain or injury to the ribs, muscles, or spine
* vomiting
* inhaling secretions into the lungs
* heart irregularities

Results

The health care team should tell patients that CPT is often an ongoing treatment, with some or all therapies done daily. A positive response to treatment can be assessed by:

* increased volume of sputum secretions
* ease in breathing
* changes in breath sounds
* improved vital signs
* improved chest x ray
* increased oxygen in the blood as measured by arterial blood gas values

Health care team roles

The doctor typically orders chest physical therapy for a patient. A nurse or respiratory therapist provides therapy when a patient is hospitalized. For people seen on an outpatient basis, the emphasis is generally on patient education.
Patient education

Effective patient education is vital because chest physical therapy is often performed at home. A doctor, nurse, or respiratory therapist explains and demonstrates techniques such as breathing, percussion, and incentive spirometry. The patient or caregiver performs the therapy under the health professional's observation to be sure it can be done correctly independently.

Nurses and respiratory therapists also participate in public awareness education, such as anti-smoking campaigns.
Training

Chest physical therapy is part of training for physicians and nurses specializing in cardiopulmonary treatment, and for respiratory therapists (also known as respiratory care practitioners). Therapists must have at least an associate degree, which is earned after completion of a two-year program. There are also four-year bachelor degree programs for this profession. Graduates with both types of degrees are certified after passing the examination given by the National Board for Respiratory Care.
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