tag:blogger.com,1999:blog-7847263090096807902024-03-21T04:14:45.256-07:00ACHIEVE OPTIMAL LEVEL OF HEALTH & MAXIMUM LEVEL OF INDEPENDENCEPHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.comBlogger89125tag:blogger.com,1999:blog-784726309009680790.post-48364710204632584262014-05-15T07:03:00.002-07:002014-05-15T07:06:37.633-07:00MR. ABU BAKAR <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFXc1CYV-URSHLqEHalDAvL-05vf3FgKtpa3l17X0j6gsfb4Cs7G0NEXJs2-0823CVQKNTorr1x1scVMiAHlZSMRPEtKjGI7HQhXdT8s-Jhpq-hLMhyphenhyphenM5kM5GXf_eBl3xxT-G7u4UwuZxN/s1600/2014-05-14+20.40.40.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFXc1CYV-URSHLqEHalDAvL-05vf3FgKtpa3l17X0j6gsfb4Cs7G0NEXJs2-0823CVQKNTorr1x1scVMiAHlZSMRPEtKjGI7HQhXdT8s-Jhpq-hLMhyphenhyphenM5kM5GXf_eBl3xxT-G7u4UwuZxN/s400/2014-05-14+20.40.40.jpg" /></a></div><blockquote></blockquote>
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</span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-47047004405250342942013-11-29T08:23:00.003-08:002013-11-29T09:23:08.403-08:00PICNIC<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBuvHQM6cEcDntolpB_ZIegaKr0d-cWsZIg4hPG5VR7MbkSuOn2CNyMuVRhvEXmN2F5ENMsiJlsMM9aVQHy51QwWaQegSYnOAQ4DNfI1MZOrDc55l-2woI7zSzEBeCChVBl8sEWn4qlAz4/s1600/20131127_114049.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBuvHQM6cEcDntolpB_ZIegaKr0d-cWsZIg4hPG5VR7MbkSuOn2CNyMuVRhvEXmN2F5ENMsiJlsMM9aVQHy51QwWaQegSYnOAQ4DNfI1MZOrDc55l-2woI7zSzEBeCChVBl8sEWn4qlAz4/s320/20131127_114049.jpg" /></a></div><blockquote></blockquote>
Picnic is a part of Physical Medicine & Rehabilitation Hospital's program provided by social worker department of Physical Medicine & Rehabilitation Hospital for the patients. Picnic was held on November 27, 2013 in Kuwait Zoo from 10 AM to 12 Noon and attended by 7 patients ( from ward 3 and ward 5 ) , social worker, occupation therapist and nurse. The aim of picnic is to refresh and make patients happy because patients stay in the hospital for long time. A side from that the patients can learn and recognize/memorize the object specially for the patients who have cognitive impairment.
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</span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com1tag:blogger.com,1999:blog-784726309009680790.post-44566710317038446842013-09-18T06:00:00.003-07:002013-09-18T12:31:57.926-07:00Cognitive Impairment
What is cognitive impairment?<blockquote></blockquote>
Cognitive impairment occurs when problems with thought processes occur. It can include loss of higher reasoning, forgetfulness, learning disabilities, concentration difficulties, decreased intelligence, and other reductions in mental functions. Cognitive impairment may be present at birth or can occur at any point in a person’s lifespan.
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Some early causes of cognitive impairment include chromosome abnormalities and genetic syndromes, malnutrition, prenatal drug exposure, poisoning due to lead or other heavy metals, hypoglycemia (low blood sugar), neonatal jaundice (high bilirubin levels developing after birth), hypothyroidism (underactive thyroid), complications of prematurity, trauma or child abuse such as shaken baby syndrome, or oxygen deprivation in the womb or during or after birth.
Cognitive impairment that develops in childhood or adolescence can result from many conditions. Examples include side effects of cancer therapy, malnutrition, heavy metal poisoning, autism (abnormal development of communication and social skills), metabolic conditions, and systemic lupus erythematosus (disorder in which the body attacks its own healthy cells and tissues).
With age, other conditions such as stroke, dementia, delirium, brain tumors, chronic alcohol use or abuse, substance abuse, some vitamin deficiencies, and some chronic diseases may cause cognitive impairment. Head injury and infection of the brain or of the covering of the brain and spinal cord (meninges) can cause cognitive impairment at any age.
In some cases, cognitive impairment may be reversible if the underlying cause is identified and treated. Seek immediate medical care (call 911) for the sudden onset of cognitive impairment, especially if it is accompanied by high fever (higher than 101 degrees Fahrenheit), neck stiffness or rigidity, rash, head injury, changes in level of consciousness or alertness, flushing or dry skin, severe nausea and vomiting, fruity breath, or other symptoms that cause you concern. Seek prompt medical care for new onset of cognitive impairment or if existing impairment worsens.<blockquote></blockquote>
What other symptoms might occur with cognitive impairment?<blockquote></blockquote>
Cognitive impairment may accompany other symptoms, which vary depending on the underlying disease, disorder or condition. Symptoms that frequently affect the brain may also involve other body systems or disorders.
Infection symptoms that may occur along with cognitive impairment
Cognitive impairment may accompany symptoms related to infection including:
Fever<blockquote></blockquote>
Headache<blockquote></blockquote>
Malaise or lethargy<blockquote></blockquote>
Muscle twitching, spasms or seizures<blockquote></blockquote>
Nausea with or without vomiting<blockquote></blockquote>
Rash<blockquote></blockquote>
Stiff or rigid neck<blockquote></blockquote>
Metabolic symptoms that may occur along with cognitive impairment<blockquote></blockquote>
Cognitive impairment may accompany other symptoms related to metabolic disorders including:<blockquote></blockquote>
Abdominal pain<blockquote></blockquote>
Abnormal heart rhythm such as rapid heart rate (tachycardia) or slow heart rate (bradycardia)<blockquote></blockquote>
Changes in skin<blockquote></blockquote>
Confusion or loss of consciousness for even a brief moment<blockquote></blockquote>
Difficulty breathing or rapid breathing
Nausea with or without vomiting<blockquote></blockquote>
Fatigue<blockquote></blockquote>
Feeling very thirsty<blockquote></blockquote>
Frequent urination or decrease in urine output<blockquote></blockquote>
Fruity breath<blockquote></blockquote>
Muscle weakness<blockquote></blockquote>
Other symptoms that may occur along with cognitive impairment<blockquote></blockquote>
Cognitive impairment may accompany symptoms related to other problems, such as injury, stroke or dementia. These symptoms may include:<blockquote></blockquote>
Change in sleep patterns<blockquote></blockquote>
Changes in mood, personality or behavior<blockquote></blockquote>
Confusion or loss of consciousness for even a brief moment<blockquote></blockquote>
Difficulty with memory, thinking, talking, comprehension, writing or reading<blockquote></blockquote>
Impaired balance and coordination<blockquote></blockquote>
Loss of vision or changes in vision<blockquote></blockquote>
Nausea with or without vomiting<blockquote></blockquote>
Numbness, weakness or paralysis<blockquote></blockquote>
Seizure<blockquote></blockquote>
Severe headache<blockquote></blockquote>
Serious symptoms that might indicate a life-threatening condition<blockquote></blockquote>
In some cases, cognitive impairment may be a symptom of a life-threatening condition that should be immediately evaluated in an emergency setting. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:<blockquote></blockquote>
Change in level of consciousness or alertness such as passing out or unresponsiveness<blockquote></blockquote>
Change in mental status or sudden behavior change such as confusion, delirium, lethargy, hallucinations or delusions<blockquote></blockquote>
Garbled or slurred speech or inability to speak<blockquote></blockquote>
High fever (higher than 101 degrees Fahrenheit)<blockquote></blockquote>
High-pitched, shrill cries in an infant or small child<blockquote></blockquote>
Paralysis or inability to move a body part<blockquote></blockquote>
Poor feeding, unusual sleepiness, or irritability in a child or infant<blockquote></blockquote>
Seizure<blockquote></blockquote>
Stiff or rigid neck<blockquote></blockquote>
Sudden change in vision, loss of vision, or eye pain<blockquote></blockquote>
Trauma to the head<blockquote></blockquote>
Worst headache of your life<blockquote></blockquote>
What causes cognitive impairment?<blockquote></blockquote>
Cognitive impairment can result from conditions that occur during fetal development, at birth, shortly after birth, or at any point in life. Sometimes, the cause of cognitive impairment cannot be determined, especially in a newborn or small child.
Congenital causes of cognitive impairment
Cognitive impairment may be present at birth and may be genetic or chromosomal or result from complications of pregnancy. Congenital causes of cognitive impairment include:<blockquote></blockquote>
Chromosomal abnormalities such as Down syndrome, fragile X syndrome, cri du chat syndrome, Prader-Willi syndrome, and others<blockquote></blockquote>
Congenital hypothyroidism (underactive thyroid)<blockquote></blockquote>
Genetic abnormalities such as phenylketonuria, Tay-Sachs disease, galactosemia, Hunter syndrome, Hurler syndrome, adrenoleukodystrophy, and others<blockquote></blockquote>
Intrauterine growth retardation (poor growth of fetus)<blockquote></blockquote>
Prenatal drug or alcohol exposure<blockquote></blockquote>
Prenatal infections<blockquote></blockquote>
Birth-related causes of cognitive impairment
Cognitive impairment can also be caused by complications related to delivery including:<blockquote></blockquote>
Infection<blockquote></blockquote>
Lack of oxygen during labor or birth
Preterm birth or its complications such as intracranial hemorrhage (uncontrolled bleeding in the brain)<blockquote></blockquote>
Causes of cognitive impairment that occur after birth or during childhood and adolescence<blockquote></blockquote>
Cognitive impairment can also be caused by conditions that occur after birth or during childhood and adolescence including:<blockquote></blockquote>
Autism (abnormal development of communication and social skills)<blockquote></blockquote>
Head injury<blockquote></blockquote>
Heavy metal poisoning such as lead poisoning<blockquote></blockquote>
Infection<blockquote></blockquote>
Kidney disease (which includes any type of kidney problem such as kidney stones, kidney failure, and kidney anomalies)<blockquote></blockquote>
Malnutrition<blockquote></blockquote>
Metabolic conditions<blockquote></blockquote>
Neonatal jaundice (yellowing of the skin and whites of the eyes occurring after birth)<blockquote></blockquote>
Side effects of cancer therapy<blockquote></blockquote>
Systemic lupus erythematosus (a disorder in which the body attacks its own healthy cells and tissues)<blockquote></blockquote>
Causes of cognitive impairment that occur in adults<blockquote></blockquote>
Cognitive impairment can also be caused by conditions that occur in adulthood including:<blockquote></blockquote>
Alcohol or drug abuse<blockquote></blockquote>
Brain or spinal cord injury<blockquote></blockquote>
Certain vitamin deficiencies<blockquote></blockquote>
Congestive heart failure (deterioration of the heart’s ability to pump blood)<blockquote></blockquote>
Dementia<blockquote></blockquote>
Infections<blockquote></blockquote>
Kidney disease (which includes any type of kidney problem such as kidney stones, kidney failure, and kidney anomalies)<blockquote></blockquote>
Liver disease (which includes any type of liver problem such as hepatitis, cirrhosis, and liver failure)<blockquote></blockquote>
Medication side effects<blockquote></blockquote>
Serious or life-threatening causes of cognitive impairment<blockquote></blockquote>
In some cases, cognitive impairment may be a symptom of a serious or life-threatening condition that should be immediately evaluated in an emergency setting. These include:<blockquote></blockquote>
Brain tumor<blockquote></blockquote>
Encephalitis (inflammation and swelling of the brain due to a viral infection or other causes)<blockquote></blockquote>
Heat stroke<blockquote></blockquote>
Kidney failure<blockquote></blockquote>
Meningitis (infection of the membranes that cover the brain and spinal cord)<blockquote></blockquote>
Profound dehydration<blockquote></blockquote>
Sepsis (severe infection of the bloodstream)<blockquote></blockquote>
Spinal cord injury or tumor<blockquote></blockquote>
Stroke<blockquote></blockquote>
Traumatic head injury<blockquote></blockquote>
Questions for diagnosing the cause of cognitive impairment<blockquote></blockquote>
To diagnose your condition, your doctor or licensed health care practitioner will ask you several questions related to your cognitive impairment including:<blockquote></blockquote>
When did you first notice symptoms of cognitive impairment?<blockquote></blockquote>
What specific symptoms have you noticed?<blockquote></blockquote>
Did anything such as an injury or illness precede the symptoms?<blockquote></blockquote>
Were there any prenatal complications or complications of birth?<blockquote></blockquote>
Do you have any other medical conditions?<blockquote></blockquote>
What medications are you taking? Are you taking any new medications?<blockquote></blockquote>
Have you taken any street drugs?<blockquote></blockquote>
Do you drink alcohol?<blockquote></blockquote>
What are the potential complications of cognitive impairment?<blockquote></blockquote>
Because cognitive impairment can be due to serious diseases, failure to seek treatment can result in serious complications and permanent damage. Once the underlying cause is diagnosed, it is important for you to follow the treatment plan that you and your health care professional design specifically for you to reduce the risk of potential complications including:<blockquote></blockquote>
Developmental delays and failure to thrive<blockquote></blockquote>
Learning disability<blockquote></blockquote>
Paralysis or inability to move a body part<blockquote></blockquote>
Permanent cognitive impairment<blockquote></blockquote>
Permanent loss of sensation<blockquote></blockquote>
Personality changes<blockquote></blockquote>
Physical disability<blockquote></blockquote>
Reference : http://www.localhealth.com/article/cognitive-impairment
</span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-26965778039168289962013-09-09T00:54:00.001-07:002013-09-09T01:00:01.041-07:009 PATIENT SAFETY SOLUTIONSLOOK ALIKE SOUND ALIKE (LASA)<blockquote></blockquote>
Separate location for placing Look Alike Sound Alike medication<blockquote></blockquote>
Arrange Look Alike Sound Alike medication in non-alphabetical orders<blockquote></blockquote>
Reading the label before handling and preparing Look Alike Sound Alike medication and should be placed in labeled shelves<blockquote></blockquote>
Tall man lettering, color difference and bold face technique are used to be easily differentiate Look Alike Sound Alike medications<blockquote></blockquote>
MEDICATION RECONCILIATION<blockquote></blockquote>
History of current treatment should be taken by the doctor from the patient, relatives or from medical record if available<blockquote></blockquote>
Compare the current treatment with the new added treatment and document it in the reconciliation list<blockquote></blockquote>
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CONTROLLED OF CONCENTRATED ELECTROLYTES<blockquote></blockquote>
“MUST BE DILLUTED”<blockquote></blockquote>
CAN KILLED……..!!!!!!<blockquote></blockquote>
Check and verify doctors order<blockquote></blockquote>
A proper computation of dilution is needed and asks about double checking<blockquote></blockquote>
Note all the things you have done<blockquote></blockquote>
Keep on monitoring patient status<blockquote></blockquote>
Identification of patient is a must when starting the infusion<blockquote></blockquote>
Label the prepared solution to avoid confusion<blockquote></blockquote>
Learn doing proper handover all the time<blockquote></blockquote>
PATIENT HANDOVER<blockquote></blockquote>
Use SBAR<blockquote></blockquote>
Situation : chief complaint, current status<blockquote></blockquote>
Background : previous history<blockquote></blockquote>
Assessment : result of assessment, vital signs, investigations and symptoms<blockquote></blockquote>
Recommendation : suggested and anticipated changes, complications, critical monitoring<blockquote></blockquote>
AVOIDING CATHETER & TUBING MISCONECTION<blockquote></blockquote>
Doctor’s order must be checked and verified<blockquote></blockquote>
Re-check all lines and tubes before and after each shift<blockquote></blockquote>
Avoid positioning of the functionally similar tube close to each other as much as possible<blockquote></blockquote>
Stick label on high risk catheter (e.g. arterial, epidural & intrathecal)<blockquote></blockquote>
Encourage patient and relatives to inform the healthcare providers on duty when they notice any problems on changes on the line or tubes<blockquote></blockquote>
Trace all lines from their origin to the connection port to verify attachment before making any connection or reconnection or to administer medications and other solutions<blockquote></blockquote>
PATIENT I.D BRACELET<blockquote></blockquote>
please….WEAR ME<blockquote></blockquote>
Write complete patient information clearly<blockquote></blockquote>
Ensure that 2 identifiers are available (e.g. full 3 names and birth date)<blockquote></blockquote>
Apply the bracelet to an appropriate limb within one hour<blockquote></blockquote>
Replace the bracelet if any part of the patient’s information has become not clear<blockquote></blockquote>
Make sure that you must ask patient name rather than telling his/her name<blockquote></blockquote>
Each time care is provided, patient identification must be done by healthcare provider<blockquote></blockquote>
CORRECT PROCEDURE AT CORRECT BODY SITE<blockquote></blockquote>
Identification and verification of the right person, procedure and body site should be completed before transferring the patient to the treatment area as a safety priority<blockquote></blockquote>
A written consent should be obtained after discussion with the patient<blockquote></blockquote>
Establish the performance of correct procedure at correct body site as a safety priority<blockquote></blockquote>
Relevant and complete documentation is needed during and after the procedure<blockquote></blockquote>
Check the equipment’s needed for the procedure must be checked if it correct and functioning properly<blockquote></blockquote>
SINGLE USE OF INJECTION<blockquote></blockquote>
Remember the ten rights when you give patient medication<blockquote></blockquote>
Always use the single injection as safety priority<blockquote></blockquote>
Recapping should not be done to avoid needle stick or pick<blockquote></blockquote>
Hand hygiene and proper protection must be applied before giving the medication<blockquote></blockquote>
Waste management procedure, rules and regulation practices should be identified and implemented in a safe way
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IMPROVED HAND HYGIENE<blockquote></blockquote>
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PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-30718041926760587342013-09-08T23:49:00.003-07:002013-09-08T23:49:58.520-07:005 MOMENTS FOR HAND HYGIENE<span class="fullpost">
</span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtbWgZCnXrptGv-i3blEnIuERs3hhp3h46fU8X8xbylhNIW8btAOcwuj3xlxSowmc3PJEf4dxZyRz72rYyFbY5O-SRIHcTKbJA5hn0mBn6BSab5qHb0RxuiwyR5OpTQO7Yw-jgqUUAi6qm/s1600/qq.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtbWgZCnXrptGv-i3blEnIuERs3hhp3h46fU8X8xbylhNIW8btAOcwuj3xlxSowmc3PJEf4dxZyRz72rYyFbY5O-SRIHcTKbJA5hn0mBn6BSab5qHb0RxuiwyR5OpTQO7Yw-jgqUUAi6qm/s640/qq.jpg" /></a></div>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-65006088898238291552013-09-08T23:46:00.000-07:002013-09-08T23:46:19.070-07:00HANDS WASHING<span class="fullpost">
</span><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAIphdeTDCKCAZYpboauA1l94ZJzQ9_RZkSk-3lHDkIjVBMuTI7oqNYHYkVmP6tt0DJhg2NPinwsGqrQIepMvQKyKQg6XvCCa3t7IyREtE15LtB61Er8QIFLqyWEAeGGCsqU7P4xc91FXd/s1600/how_to_handwash_lge.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAIphdeTDCKCAZYpboauA1l94ZJzQ9_RZkSk-3lHDkIjVBMuTI7oqNYHYkVmP6tt0DJhg2NPinwsGqrQIepMvQKyKQg6XvCCa3t7IyREtE15LtB61Er8QIFLqyWEAeGGCsqU7P4xc91FXd/s400/how_to_handwash_lge.gif" /></a></div>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-90226121410139495332012-04-03T08:57:00.002-07:002012-04-03T09:02:36.031-07:00ISOLATION TECHNIQUEDefinition<br /><br />Isolation refers to the precautions that are taken in the hospital to prevent the spread of an infectious agent from an infected or colonized patient to susceptible persons.<br /><br />Purpose<br /><br />Isolation practices are designed to minimize the transmission of infection in the hospital, using current understanding of the way infections can transmit. Isolation should be done in a user friendly, well-accepted, inexpensive way that interferes as little as possible with patient care, minimizes patient discomfort, and avoids unnecessary use.<br /><span class="fullpost"><br />Precautions<br /><br />The type of precautions used should be viewed as a flexible scale that may range from the least to the most demanding methods of prevention. These methods should always take into account that differences exist in the way that diseases are spread. Recognition and understanding of these differences will avoid use of insufficient or unnecessary interventions.<br /><br />Description<br /><br />Isolation practices can include placement in a private room or with a select roommate, the use of protective barriers such as masks, gowns and gloves, a special emphasis on handwashing (which is always very important), and special handling of contaminated articles. Because of the differences among infectious diseases, more than one of these precautions may be necessary to prevent spread of some diseases but may not be necessary for others.<br />The Centers for Disease Control and Prevention (CDC) and the Hospital Infection Control Practice Advisory Committee (HICPAC) have led the way in defining the guidelines for hospital-based infection precautions. The most current system recommended for use in hospitals consists of two levels of precautions. The first level is Standard Precautions which apply to all patients at all times because signs and symptoms of infection are not always obvious and therefore may unknowingly pose a risk for a susceptible person. The second level is known as Transmission-Based Precautions which are intended for individuals who have a known or suspected infection with certain organisms.<br />Frequently, patients are admitted to the hospital without a definite diagnosis, but with clues to suggest an infection. These patients should be isolated with the appropriate precautions until a definite diagnosis is made.<br /><br />Standard precautions<br /><br />Standard Precautions define all the steps that should be taken to prevent spread of infection from person to person when there is an anticipated contact with:<br />• Blood<br />• Body fluids<br />• Secretions, such as phlegm<br />• Excretions, such as urine and feces (not including sweat) whether or not they contain visible blood<br />• Nonintact skin, such as an open wound<br />• Mucous membranes, such as the mouth cavity.<br />Standard Precautions includes the use of one or combinations of the following practices. The level of use will always depend on the anticipated contact with the patient:<br />• Handwashing, the most important infection control method<br />• Use of latex or other protective gloves<br />• Masks, eye protection and/or face shield<br />• Gowns<br />• Proper handling of soiled patient care equipment<br />• Proper environmental cleaning<br />• Minimal handling of soiled linen<br />• Proper disposal of needles and other sharp equipment such as scalpels<br />• Placement in a private room for patients who cannot maintain appropriate cleanliness or contain body fluids.<br /><br />Transmission based precautions<br /><br />Transmission Based Precautions may be needed in addition to Standard Precautions for selected patients who are known or suspected to harbor certain infections. These precautions are divided into three categories that reflect the differences in the way infections are transmitted. Some diseases may require more than one isolation category.<br /><br />AIRBORNE PRECAUTIONS. Airborne Precautions prevent diseases that are transmitted by minute particles called droplet nuclei or contaminated dust particles. These particles, because of their size, can remain suspended in the air for long periods of time; even after the infected person has left the room. Some examples of diseases requiring these precautions are tuberculosis, measles, and chickenpox.<br />A patient needing Airborne Precautions should be assigned to a private room with special ventilation requirements. The door to this room must be closed at all possible times. If a patient must move from the isolation room to another area of the hospital, the patient should be wearing a mask during the transport. Anyone entering the isolation room to provide care to the patient must wear a special mask called a respirator.<br /><br />DROPLET PRECAUTIONS. Droplet Precautions prevent the spread of organisms that travel on particles much larger than the droplet nuclei. These particles do not spend much time suspended in the air, and usually do not travel beyond a several foot range from the patient. These particles are produced when a patient coughs, talks, or sneezes. Examples of disease requiring droplet precautions are meningococcal meningitis (a serious bacterial infection of the lining of the brain), influenza, mumps, and German measles (rubella).<br />Patients who require Droplet Precautions should be placed in a private room or with a roommate who is infected with the same organism. The door to the room may remain open. Health care workers will need to wear masks within 3 ft of the patient. Patients moving about the hospital away from the isolation room should wear a mask.<br /><br />CONTACT PRECAUTIONS. Contact Precautions prevent spread of organisms from an infected patient through direct (touching the patient) or indirect (touching surfaces or objects that that been in contact with the patient) contact. Examples of patients who might be placed in Contact Precautions are those infected with:<br />• Antibiotic-resistant bacteria<br />• Hepatitis A<br />• Scabies<br />• Impetigo<br />• Lice.<br />This type of precaution requires the patient to be placed in a private room or with a roommate who has the same infection. Health care workers should wear gloves when entering the room. They should change their gloves if they touch material that contains large volumes of organisms such as soiled dressings. Prior to leaving the room, health care workers should remove the gloves and wash their hands with medicated soap. In addition, they may need to wear protective gowns if there is a chance of contact with potentially infective materials such as diarrhea or wound drainage that cannot be contained or if there is likely to be extensive contact with the patient or environment.<br />Patient care items, such as a stethoscope, that are used for a patient in Contact Precautions should not be shared with other patients unless they are properly cleaned and disinfected before reuse. Patients should leave the isolation room infrequently.<br /><br />Types of Isolation :<br /> Strict isolation.<br /> Contact isolation.<br /> Respiratory isolation<br /> Tuberculosis or acid-fast bacillus (AFB) isolation.<br /> Enteric precautions<br /> Drainage/secretion precautions<br />1. Strict Isolation<br /> Designed for highly contagious infections that are spread by both airborne droplet nuclei and contact transmission. <br /> Examples include:<br /> varicella,<br /> Disseminated herpes zoster, <br /> Viral hemorrhagic fevers. <br />Technique<br /> Private room.<br /> With negative airflow.<br /> The use of masks, gowns, and gloves for all persons entering the room.<br />2. Contact isolation<br /> designed for highly transmissible infections that are not spread by airborne droplet nuclei but are transmitted primarily by close and direct contact. <br /> Examples<br /> viral respiratory infections in children, such as respiratory syncytial virus (RSV) <br /> Patients with large draining wounds require contact precautions.<br />Technique<br /> Technique includes : <br /> Private room, <br /> Masks for those personnel providing close direct care to the patient, <br /> Gowns if soiling is likely,<br /> Gloves for touching infective material. <br />3. Respiratory Isolation<br /> designed to prevent transmission of diseases spread over short distances through the air (droplet transmission). <br />Examples include :<br /> children with Haemophilus influenza, <br /> epiglottitis,<br /> meningitis,<br /> pneumonia.<br /> patients with serious meningococcal disease;<br /> mumps and pertussis. <br />Technique<br /> Technique includes.<br /> Private room.<br /> Or cohering patients with the same organism.<br /> And masks for those personnel providing close direct care to the patient.<br />4. Tuberculosis or Acid-fast Bacillus (AFB)<br /> isolation—designed for patients suspected or known to have pulmonary or laryngeal tuberculosis. <br /> technique includes a private room with negative airflow<br /> and the use of appropriate respiratory protection (see tuberculosis). <br />5. Enteric precautions<br /> designed to prevent infections that are transmitted by direct or indirect contact with fecal material, <br /> such as Salmonella gastroenteritis.<br />Technique<br /> private room only if the patient has poor hygiene and is likely to contaminate the environment,<br /> gowns if soiling is likely, <br /> and gloves for touching infective material. <br />Drainage/secretion precautions<br /> designed to prevent infections transmitted by direct or indirect contact with purulent material or other drainage from an infected body site. <br /> Technique includes :<br /> gowns if soiling is likely<br /> and gloves for touching infective material. <br /><br /><br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com1tag:blogger.com,1999:blog-784726309009680790.post-47711831629711575512011-10-29T10:10:00.000-07:002011-10-29T10:21:49.287-07:00Insertion of Suprapubic CatheterDissection 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.<br /><span class="fullpost"><br />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.<br /><br />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.<br /><br />Physiologic Changes. The procedure reduces edema at the base of the bladder, allowing the return of normal vesical function.<br /><br />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.<br /><br />Technique<br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiECMRIFOuFD9WWCKbEybuMn62gSC9dnFW4URE8Ca7NISJWrOeb5Rj8zc3kjj9Qu_IsGxmxKImD5_vmfXqTBOeEpCJ0nR8enkqxvMHCPoJ4wvMiACQLe-hTlSViU3zNqm6PyiCaqWXgTsaU/s1600/chap3sec1image1.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 285px; height: 295px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiECMRIFOuFD9WWCKbEybuMn62gSC9dnFW4URE8Ca7NISJWrOeb5Rj8zc3kjj9Qu_IsGxmxKImD5_vmfXqTBOeEpCJ0nR8enkqxvMHCPoJ4wvMiACQLe-hTlSViU3zNqm6PyiCaqWXgTsaU/s320/chap3sec1image1.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668963114627374994" /></a><br />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.<br /><blockquote></blockquote><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggNSYl2e9Vwo5e77Q0tx563l5V40T8rNvZ5fF78mYEJTu9XJ8yRWiv84GbfX432X7rWKJNb6YH6wswCu5MJWNf_9BIY3822tKfQ-fE6IrNqL-r3LLZkLIiurT-qROIX0PdCJ1ylddaXS6O/s1600/chap3sec1image2.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 297px; height: 320px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggNSYl2e9Vwo5e77Q0tx563l5V40T8rNvZ5fF78mYEJTu9XJ8yRWiv84GbfX432X7rWKJNb6YH6wswCu5MJWNf_9BIY3822tKfQ-fE6IrNqL-r3LLZkLIiurT-qROIX0PdCJ1ylddaXS6O/s320/chap3sec1image2.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668963432158971010" /></a><br /><br />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.<blockquote></blockquote><br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7JH6Lj5R02NJMLS7bo06OzyfrJeADDXPhnUoquqTNszIdigxsWOJ4SF-UnepSxoHVv8sl82ruJxQPzmYsbgFJh3ifY09HZd0nYtZR0O8RqkPNaTiP53Ro2rRmSe3TGuCcKoVGbWlCl3ny/s1600/chap3sec1image3.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 270px; height: 268px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7JH6Lj5R02NJMLS7bo06OzyfrJeADDXPhnUoquqTNszIdigxsWOJ4SF-UnepSxoHVv8sl82ruJxQPzmYsbgFJh3ifY09HZd0nYtZR0O8RqkPNaTiP53Ro2rRmSe3TGuCcKoVGbWlCl3ny/s320/chap3sec1image3.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668963772721070290" /></a><br />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.<blockquote></blockquote><br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnefrmh6D1yZhLmwnCJTTOiDUOURt44ohJMVKO38oSQ1vhTP7xVkbSsaChD-AfknVMlCwhcVB1HWN_R0TpE1BGVwIKa_jZDK0MKahqttSHJ42fA3adb9Sjfn5wlGiVp8RU_lEcr2UrsVJ6/s1600/chap3sec1image4.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 313px; height: 298px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnefrmh6D1yZhLmwnCJTTOiDUOURt44ohJMVKO38oSQ1vhTP7xVkbSsaChD-AfknVMlCwhcVB1HWN_R0TpE1BGVwIKa_jZDK0MKahqttSHJ42fA3adb9Sjfn5wlGiVp8RU_lEcr2UrsVJ6/s320/chap3sec1image4.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668964221651133906" /></a><br /><br />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.<blockquote></blockquote><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgE5PEP0TNKQLbgSlx8pG48zFJl0WQSrCI3XizYtT2moR_zOXzXUL6qvIIn2CFjJTnubPtI-gqzqYat3S0vU3ZmP9Y23pPNUJXr0N2rB4sAzgfktHITQJf4JsrooGdaM63lfrh-ezmJ8ZXC/s1600/chap3sec1image5.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 209px; height: 216px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgE5PEP0TNKQLbgSlx8pG48zFJl0WQSrCI3XizYtT2moR_zOXzXUL6qvIIn2CFjJTnubPtI-gqzqYat3S0vU3ZmP9Y23pPNUJXr0N2rB4sAzgfktHITQJf4JsrooGdaM63lfrh-ezmJ8ZXC/s320/chap3sec1image5.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668964494728848050" /></a><br /><br />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.<blockquote></blockquote><br /><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLEa7jMQYSXO_yGgriax11N7PWKvBMeWuzg4w20UZiOpu9ttGgopAXJUKAJK8g7MOpfTbuJxT5GD-VcTTSQPGIMbUDQodMm4rp2yzPJrC_Ktj7ulSjduZQeg-esOsPVkZo7MWmV37zh25_/s1600/chap3sec1image6.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 200px; height: 195px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLEa7jMQYSXO_yGgriax11N7PWKvBMeWuzg4w20UZiOpu9ttGgopAXJUKAJK8g7MOpfTbuJxT5GD-VcTTSQPGIMbUDQodMm4rp2yzPJrC_Ktj7ulSjduZQeg-esOsPVkZo7MWmV37zh25_/s320/chap3sec1image6.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668964793581553394" /></a><br />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.<blockquote></blockquote><br /><a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDzdmtZJ3CNhiXPLtAe5xXoiVE1UhNQ5BVNQTzQI-USPUDkLI27fBrf0lV15i0CZTMMqz4LjnTNQfH5h4SaoRObg99JXvQUsdJYQVos-blYHosLgC7Bst-f7nlK55SDPNy0rBWj0ytVOwQ/s1600/chap3sec1image7.jpg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 225px; height: 209px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDzdmtZJ3CNhiXPLtAe5xXoiVE1UhNQ5BVNQTzQI-USPUDkLI27fBrf0lV15i0CZTMMqz4LjnTNQfH5h4SaoRObg99JXvQUsdJYQVos-blYHosLgC7Bst-f7nlK55SDPNy0rBWj0ytVOwQ/s320/chap3sec1image7.jpg" border="0" alt=""id="BLOGGER_PHOTO_ID_5668965064821569826" /></a><br /><br />When 5 mL of sterile saline solution have completely filled the Foley balloon, the catheter is firmly retracted upward.<br />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<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-18681028994062992802011-10-10T00:04:00.000-07:002011-10-10T00:09:14.875-07:00Post-power Syndrome<a onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}" href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEibkEDIwoi05YC4zqX3qI6zO5XofwvMir2dJb1xtcPS1Yyy8mPRvTrSMhpDHYoBVEkuuwAD1VS0wRl-pzGqwX_2LRrLdQ3JSy0RjxNB96Rp8DBXGHdI43cGiMviH3TgYjy6WI5I9T2y4nRj/s1600/lens16104281_1291430263stress.jpeg"><img style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 250px; height: 187px;" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEibkEDIwoi05YC4zqX3qI6zO5XofwvMir2dJb1xtcPS1Yyy8mPRvTrSMhpDHYoBVEkuuwAD1VS0wRl-pzGqwX_2LRrLdQ3JSy0RjxNB96Rp8DBXGHdI43cGiMviH3TgYjy6WI5I9T2y4nRj/s320/lens16104281_1291430263stress.jpeg" border="0" alt=""id="BLOGGER_PHOTO_ID_5661756181796296514" /></a><br />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.<br /><br />Some of the factors that caused the post-power syndrome, among others.<br /><br />1. Early retirement and work fired<br />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.<br /><span class="fullpost"><br />2. Condition that requires her to quit her career<br />Examples accidents experienced by a football player who led his leg was amputated, can cause post-power syndrome.<br /><br />How to Help People with post-power syndrome<br /><br />1. Understanding of their beloved ones<br />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.<br /><br />2. Support from the environment<br />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.<br /><br />3. Creating a positive activity<br />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.<br /><br />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.<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-42488728243354904152010-03-05T12:00:00.000-08:002010-03-05T12:08:50.463-08:00InsomniaInsomnia Overview<br /><br />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.<br /><br />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.<br /><span class="fullpost"><br />Insomnia is generally classified based on the duration of the problem. Not everyone agrees on one definition, but generally:<br /><br /> * symptoms lasting less than one week are classified as transient insomnia,<br /><br /> * symptoms between one to three weeks are classified as short-term insomnia, and<br /><br /> * those longer than three weeks are classified as chronic insomnia.<br /><br />Statistics on Insomnia<br /><br />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. <br /><br />Insomnia Causes<br /><br />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.<br /><br />Many of the causes of transient and short-term insomnia are similar and they include:<br /><br /> * Jet lag<br /><br /> * Changes in shift work<br /><br /> * Excessive or unpleasant noise<br /><br /> * Uncomfortable room temperature (too hot or too cold)<br /><br /> * Stressful situations in life (exam preparation, loss of a loved one, unemployment, divorce, or separation)<br /><br /> * Presence of an acute medical or surgical illness or hospitalization<br /><br /> * Withdrawal from drug, alcohol, sedative, or stimulant medications<br /><br /> * Insomnia related to high altitude (mountains)<br /><br />Chronic or long-term insomnia<br /><br />The majority of causes of chronic or long-term insomnia are usually linked to an underlying psychiatric or physiologic (medical) condition.<br /><br />Psychological related insomnia<br /><br />The most common psychological problems that may lead to insomnia include:<br /><br /> * anxiety,<br /><br /> * stress,<br /><br /> * schizophrenia,<br /><br /> * mania (bipolar disorder), and<br /><br /> * depression.<br /><br />In fact, insomnia may be an indicator of depression. Many people will have insomnia during the acute phases of a mental illness.<br /><br />Physiological related insomnia<br /><br />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:<br /><br /> * Chronic pain syndromes<br /><br /> * Chronic fatigue syndrome<br /><br /> * Congestive heart failure<br /><br /> * Night time angina (chest pain) from heart disease<br /><br /> * Acid reflux disease (GERD)<br /><br /> * Chronic obstructive pulmonary disease (COPD)<br /><br /> * Nocturnal asthma (asthma with night time breathing symptoms)<br /><br /> * Obstructive sleep apnea<br /><br /> * Degenerative diseases, such as Parkinson's disease and Alzheimer's disease (Often insomnia is the deciding factor for nursing home placement.)<br /><br /> * Brain tumors, strokes, or trauma to the brain<br /><br />High risk groups for insomnia<br /><br />In addition to the above medical conditions, certain groups may be at higher risk for developing insomnia:<br /><br /> * travelers<br /><br /> * shift workers with frequent changing of shifts<br /><br /> * seniors<br /><br /> * adolescent or young adult students<br /><br /> * pregnant women, and<br /><br /> * menopausal women<br /><br />Medication related insomnia<br /><br />Certain medications have also been associated with insomnia. Among them are:<br /><br /> * Certain over-the-counter cold and asthma preparations.<br /><br /> * The prescription varieties of these medications may also contain stimulants and thus produce similar effects on sleep.<br /><br /> * Certain medications for high blood pressure have also been associated with poor sleep.<br /><br /> * Some medications used to treat depression, anxiety, and schizophrenia.<br /><br />Other causes of insomnia<br /><br /> * 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.<br /><br /> * 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.<br /><br /> * A disruptive bed partner with loud snoring or periodic leg movements also may impair your ability to get a good night's sleep.<br /><br />Primary Sleep Disorders<br /><br />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:<br /><br /> * Idiopathic Insomnia (unknown cause) or childhood insomnia, which start early on in life and results in lifelong sleep problems. This may run in families.<br /><br /> * 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.<br /><br /> * Restless leg syndrome (a condition associated with creeping sensations in the leg during sleep that are relieved by leg movement)<br /><br /> * Periodic limb movement disorder (a condition associated with involuntary repeated leg movement during sleep)<br /><br /> * 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).<br /><br /> * 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.<br /><br /> * 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.<br /><br /> * Inadequate sleep hygiene, in which the individual has poor sleep or sleep preparation habits (described in the following treatment section.)<br /><br />Insomnia Symptoms<br /><br />Doctors associate a variety of signs and symptoms with insomnia. Often, the symptoms intertwine with those of other medical or mental conditions.<br /><br /> * 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.<br /><br /> * Most often daytime symptoms will bring people to seek medical attention. Daytime problems caused by insomnia include the following:<br /><br /> o Poor concentration and focus<br /><br /> o Difficulty with memory<br /><br /> o Impaired motor coordination (being uncoordinated)<br /><br /> o Irritability and impaired social interaction<br /><br /> o Motor vehicle accidents because of fatigued, sleep-deprived drivers<br /><br /> * People may worsen these daytime symptoms by their own attempts to treat the symptoms.<br /><br /> o Alcohol and antihistamines may compound the problems with sleep deprivation.<br /><br /> o Others have tried nonprescription sleep aids.<br /><br />When to Seek Medical Care<br /><br />When to call the doctor<br /><br /> * 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.<br /><br /> * Insomnia may be a symptom of another medical or psychological problem, which a patient may need to address first or at the same time.<br /><br />When to go to the hospital<br /><br /> * 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.<br /><br /> * Worsening pain or increased difficulty breathing at night also may indicate a person need to seek emergency medical care.<br /><br />Exams and Tests<br /><br />The doctor will begin an evaluation of insomnia with a good medical history.<br /><br /> * 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.<br /><br /> 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.<br /><br /> 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.<br /><br /> * The Epworth Sleepiness Scale is an example of a validated questionnaire that can be used to assess daytime sleepiness.<br /><br /> * 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.<br /><br />Insomnia Treatment<br /><br />In general, transient insomnia resolves when the underlying trigger is removed or corrected. Most people seek medical attention when their insomnia becomes more chronic.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />Non-medical treatment and behavioral therapy<br /><br />Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus control, and sleep restriction. These also referred to as cognitive behavioral therapies.<br /><br />Sleep hygiene<br /><br />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:<br /><br /> * Sleep as much as you need to feel rested; do not oversleep.<br /><br /> * Exercise regularly at least 20 minutes daily, ideally 4-5 hours before your bedtime.<br /><br /> * Avoid forcing yourself to sleep.<br /><br /> * Keep a regular sleep and awakening schedule.<br /><br /> * Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.) Avoid "night caps," (alcoholic drinks prior to going to bed).<br /><br /> * Do not smoke, especially in the evening.<br /><br /> * Do not go to bed hungry.<br /><br /> * Adjust the environment in the room (lights, temperature, noise, etc.)<br /><br /> * Do not go to bed with your worries; try to resolve them before going to bed.<br /><br />Relaxation therapy<br /><br />Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed.<br /><br />Stimulus control<br /><br />Stimulus control therapy also consists of a few simple steps that may help patients with chronic insomnia.<br /><br /> * Go to bed when you feel sleepy.<br /><br /> * Do not watch TV, read, eat, or worry in bed. Your bed should be used only for sleep and sexual activity.<br /><br /> * If you do not fall asleep 30 minutes after going to bed, get up and go to another room and resume your relaxation techniques.<br /><br /> * Set your alarm clock to get up at a certain time each morning, even on weekends. Do not oversleep.<br /><br /> * Avoid taking long naps in the daytime.<br /><br />Sleep restriction<br /><br />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.<br /><br />Other simple measures that can be helpful to treat insomnia include:<br /><br /> * Avoid large meals and excessive fluids before bedtime<br /><br /> * Control your environment.<br /><br /> 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.)<br /><br /> 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.<br /><br />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. <br /><br />Medications and Medical Therapies<br /><br />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.<br /><br /> * 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).<br /><br /> * Nonbenzodiazepine sedatives: These include eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien).<br /><br /> * 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.<br /><br /> * 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.<br /><br /> * 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.<br /><br /> * 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.<br /><br /> * 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.<br /><br />Follow-up<br /><br />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.<br /><br />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.<br /><br />Prevention<br /><br />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.<br /><br />Insomnia from jet lag<br /><br /> * Behavioral and short-term drug therapy has been used.<br /><br /> * If you can anticipate a trip, begin to shift your bedtime to coincide with the time schedule in your destination.<br /><br /> * 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.<br /><br />Insomnia from shift changes<br /><br /> * Behavioral therapy has been useful in modifying the insomnia and symptoms of sleep deprivation in shift workers.<br /><br /> * 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.<br /><br /> * Bright light is a potent stimulus to circadian rhythm. Bright light is being examined as a rhythm synchronizer.<br /><br /> * Shift workers should stress the importance of good sleep habits with regular bedtime and awakening.<br /><br /> o Supplemental naps may be necessary to ensure work time alertness.<br /><br /> o Discuss the use of naps with a doctor.<br /><br /> o Some people promote using short-acting sedatives in the first few days following a shift change, but not everyone agrees.<br /><br />Insomnia from acute stresses<br /><br /> * Stress may be positive or negative, and concerns about sleep may vary. Many stressors will go away with support and reassurance.<br /><br /> * Education about the importance of good sleep habits is also helpful.<br /><br /> * 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.<br /><br />General recommendations include the following:<br /><br /> * Work to improve your sleep habits.<br /><br /> o Learn to relax. Self-hypnosis, biofeedback and relaxation breathing are often helpful.<br /><br /> 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.<br /><br /> o Establish a bedtime routine. Fix wake time.<br /><br /> * Avoid large meals, excessive fluid intake, and strenuous exercise before bedtime and reduce the use of stimulants including caffeine and nicotine.<br /><br /> * If you do not fall asleep within 20-30 minutes, try a relaxing activity such as listening to soothing music or reading.<br /><br /> * Limit daytime naps to less than 15 minutes unless directed by your doctor.<br /><br /> o It is generally preferable to avoid naps whenever possible to help consolidate your night's sleep.<br /><br /> o There are certain sleep disorders, however, that will benefit from naps. Discuss this issue with your doctor.<br /><br />http://www.emedicinehealth.com<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-42311014678104775182010-02-27T07:52:00.000-08:002010-02-27T07:53:53.554-08:00Huntington's diseaseHuntington'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.<br /><br />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.<br /><span class="fullpost"><br />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.<br />Symptoms<br /><br />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.<br /><br />Early symptoms include:<br /><br /> * mild tremor<br /> * clumsiness<br /> * lack of concentration and irritability<br /> * difficulty remembering things<br /> * mood changes, including depression<br /> * aggressive antisocial behaviour<br /><br />Over time the symptoms become progressively worse. Eventually, full-time nursing care will be needed. Later symptoms fall into three categories:<br />Physical symptoms<br /><br />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.<br />Emotional symptoms<br /><br />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.<br />Cognitive symptoms<br /><br />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.<br /><br />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.<br />Causes<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br />Juvenile Huntington's disease<br /><br />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.<br />Treatment<br /><br />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.<br /><br />Counselling can also be helpful, both for you and your family. Dieticians can advise on adequate calorie and nutrient intake to stop weight loss.<br />Future promise<br /><br />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.<br /><br />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.<br />Genetic tests<br /><br />There are tests available to find out whether you have the faulty gene. They fall into three categories: diagnostic, pre-symptomatic and antenatal.<br />Diagnostic tests<br /><br />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.<br />Pre-symptomatic tests<br /><br />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.<br /><br />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.<br /><br />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.<br />Antenatal tests<br /><br />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.<br />Pre-implantation Genetic Diagnosis (PGD)<br /><br />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.<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-9385149651923810582010-02-27T07:35:00.000-08:002010-02-27T07:39:57.532-08:00Cardiac Marker TestsDefinition<br /><br />Cardiac marker tests identify blood analytes associated with myocardial infarction (MI), commonly known as a heart attack.<br />Purpose<br /><br />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.<br /><span class="fullpost"><br />Precautions<br /><br />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.<br />Description<br />Creatine kinase (CK)<br /><br />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.<br /><br />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.<br />Myoblobin<br /><br />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.<br />Troponin T and troponin I<br /><br />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.<br /><br />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."<br /><br />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.<br />C-reactive protein (CRP)<br /><br />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.<br /><br />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.<br />Homocysteine<br /><br />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.<br />Preparation<br /><br />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.<br />Aftercare<br /><br />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.<br />Complications<br /><br />There are no complications associated with these tests.<br />Results<br /><br />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.<br /><br /> * 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.<br /> * 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.<br /> * 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.<br /> * 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.<br /> * 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.<br /> * 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.<br /> * 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.<br /> * 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.<br /><br />Health care team roles<br /><br />Cardiac marker tests are usually performed by clinical laboratory scientists, medical technologists, or clinical laboratory technicians.//enotes.com<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-92085558359263739482010-02-27T07:33:00.000-08:002010-02-27T07:34:42.994-08:00Chest Physical TherapyDefinition<br /><br />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.<br />Purpose<br /><br />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.<br /><span class="fullpost"><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br />Precautions<br /><br />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:<br /><br /> * have just eaten or are vomiting<br /> * have acute asthma or tuberculosis<br /> * have brittle bones or broken ribs<br /> * are bleeding from the lungs or are coughing up blood<br /> * are experiencing intense pain<br /> * have increased pressure in the skull<br /> * have head or neck injuries<br /> * have collapsed lungs or a damaged chest wall<br /> * recently experienced a heart attack<br /> * have a pulmonary embolism or lung abscess<br /> * have an active hemorrhage<br /> * have injuries to the spine<br /> * have open wounds or burns<br /> * have had recent surgery<br /><br />Description<br /><br />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.<br /><br />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.<br /><br />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.<br />Turning<br /><br />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.<br />Coughing<br /><br />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<br /><br />physical therapy is teaching patients to clear their airways by gentler methods, such as with a controlled cough or by "huffing."<br /><br />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.<br />Deep breathing exercises<br /><br />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.<br /><br />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.<br />Incentive spirometry<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />Some devices have a component designed for exhalation. If the model does not include an exhaling function, the patient breathes out air naturally.<br /><br />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.<br />Postural drainage<br /><br />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:<br /><br /> * the patient seated with head back<br /> * the patient seated with head bent forward<br /> * the patient lying face up with feet higher than the head<br /> * the patient lying face down with feet higher than the head<br /> * the patient lying first on one side, then the other, with feet higher than the head<br /><br />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.<br />Percussion<br /><br />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.<br />Vibration<br /><br />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.<br />Preparation<br /><br />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.<br />Aftercare<br /><br />Patients should be advised to practice oral hygiene procedures to lessen the bad taste and odor of the secretions that they spit out.<br />Complications<br /><br />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<br /><br /> * increased intracranial pressure<br /> * temporary low blood pressure<br /> * bleeding in the lungs<br /> * pain or injury to the ribs, muscles, or spine<br /> * vomiting<br /> * inhaling secretions into the lungs<br /> * heart irregularities<br /><br />Results<br /><br />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:<br /><br /> * increased volume of sputum secretions<br /> * ease in breathing<br /> * changes in breath sounds<br /> * improved vital signs<br /> * improved chest x ray<br /> * increased oxygen in the blood as measured by arterial blood gas values<br /><br />Health care team roles<br /><br />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.<br />Patient education<br /><br />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.<br /><br />Nurses and respiratory therapists also participate in public awareness education, such as anti-smoking campaigns.<br />Training<br /><br />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.<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-87040552600236992002010-01-15T12:04:00.000-08:002010-01-15T12:05:43.318-08:00Catheterization, Femalehttp://www.enotes.com<br /><br />Definition<br /><br />Urinary catheterization is the insertion of a catheter through the urethra into the urinary bladder for withdrawal of urine. Straight catheters are used for intermittent withdrawals; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.<br /><span class="fullpost"><br />Purpose<br /><br />Intermittent catheterization is used for the following reasons:• To obtain a sterile urine specimen for diagnostic evaluation; to empty bladder content when the patient is unable to void (urinate) due to urinary retention, bladder distention, and obstruction, or to measure residual urine after urination.<br /><br /> * To instill medication for a localized therapeutic effect and to instill contrast material (dye) into the bladder through the urethral catheter for cystourethralgraphy (x ray of the bladder and urethra).<br /> * To empty the bladder for increased space in the pelvic cavity to protect the bladder during labor and delivery and during pelvic and abdominal surgery.<br /> * To strictly monitor the urinary output and fluid balance of critically ill patients.<br /><br />Indwelling catheterization is:<br /><br /> * Indicated as palliative care for terminally ill or severely impaired incontinent patients, for whom bed and clothing changes are uncomfortable, and as a way to manage skin ulceration caused or exacerbated by incontinence.<br /> * Used to maintain a continuous out flow of urine for patients undergoing surgical procedures that cause a delay in bladder sensation, and for persons with chronic neurological disorders that cause paralysis or loss of sensation in the perineal area.<br /> * Indicated for urologic surgery, bladder outlet obstruction, and for patients with an initial episode of acute urinary retention to allow the bladder to regain its tone.<br /><br />Precautions<br /><br />Because the urinary tract is normally a sterile system, catheterization presents the risk of causing a urinary tract infection (UTI). The catheterization procedure must be sterile and the catheter must be free from bacteria.<br /><br />Urinary catheterization aids or replaces the body's normal ability to urinate. Intermittent use of the procedure can stimulate normal bladder function, however frequent and continuous catheterization can lead to total dependency. Catheterization is invasive and has the potential of injuring the urethra and bladder, inviting urinary tract infections. Therefore aseptic techniques should be use in all catheter management activities.<br /><br />The normal flow of urine from the kidneys through the ureters, bladder, urethra prevents the movement of bacteria up through the urinary system. The antibacterial properties of the bladder wall, urethra lining, and low urine pH also serve as protective barriers to urinary tract infections. Urinary tract infections occur when bacteria invade the protective barriers of one or more urinary structures.<br />Infection control<br /><br />Every attempt should be made to keep the urinary drainage system closed. Breaks in the system invite infections. Health care workers and patients should wash their hands before and after manipulation of the patient's catheter or collection system to control UTI. Cross-contamination is the most frequent cause of nosocomial (hospital acquired) catheter related infections. Good hand washing practices are the best prevention measure.<br /><br />The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.<br /><br />Frequent intermittent catheterization and long term use of indwelling catheterization predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus or urothelium (urinary lining) with catheters that are too large or inserted with insufficient use of lubricant. Patients with an indwelling catheter must be reassessed periodically to determine if alternative treatment will be more effective in treating the problem.<br />Description<br /><br />The female urethral orifice is a vertical, slit-like or irregularly ovoid (egg shaped) opening, 4 or 5 mm in diameter, located between the clitoris and the vagina. The urinary meatus (opening) is concealed between the labia minora, which are the small folds of tissue that need to be separated in order to visualize the opening and insert the catheter. With proper positioning, good lighting and gloved hands, these anatomical landmarks can be identified. If necessary, provide perineal care to ensure a clean procedural environment.<br /><br />Catheterization of the female patient is traditionally performed without the use of local anesthetic gel to facilitate catheter insertion. But since there are no lubricating glands in the female urethra (as found in the male urethra), the risk of trauma from a simple catheter insertion is more likely; therefore, ample supply of an anesthetic or antibacterial lubricant should be used.<br />Preparation<br /><br />Health care practitioners performing the catheterization should have a good understanding of the anatomy and physiology of the urinary system, trained in antiseptic techniques and in catheter insertion and catheter care.<br /><br />Determine the primary purpose for the catheterization and give the patient and/or caregiver a detail explanation. Patients requiring self-catheterization should be instructed and trained in the technique by a qualified health professional.<br /><br />Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agent, perineal drapes, gloves, lubricant, specimen container, label, and tape. Anesthetic or antibacterial lubricant, catheter, and drainage system may need to be added. It is always wise to review the content of the pre-packaged catheterization set while assembling the materials.<br />Catheter choices<br /><br />TYPES. Silastic catheters have been recommended for short-term catheterization after surgery because they are known to decrease incidence of urethritis. However, due to lower cost and acceptable outcomes, latex is the catheter of choice for long-term catheterization. Silastic catheters should be used for patients who are allergic to latex products.<br /><br />There are also additional types of catheters:<br /><br /> * PTFE-coated latex Foley catheters<br /> * hydrogel-coated latex Foley catheters<br /> * pure silicone Foley catheters<br /> * silicone-coated latex Foley catheter<br /><br />SIZE. The diameter of the catheter is measured in millimeters. Authorities recommend the "narrowest and softest tube" that will serve the purpose. Rarely is a catheter larger than size 18 F required, and sizes 14 or 16 F are used more often. Catheters greater than size 16 F have been associated with patient discomfort and urine bypassing. A size 12 catheter has been successfully used in children and female patients with urinary restriction.<br /><br />LENGTH. Female adult patients should be given the choice of a short, female length or a standard length catheter for urethral catheterization.<br /><br />BALLOON SIZE. Select a catheter with a balloon-filling volume of 0.33 fl oz (10 ml) for routine drainage. Sterile water must always be used to inflate the balloon as other fluids may contain particles, which could block the inflation channel. Some indwelling catheters are manufactured pre-filled with 0.33 fl oz (10 ml) of sterile water, ready for balloon inflation after catheter insertion.<br /><br />DRAINAGE SYSTEM. Review the design, capacity, and emptying mechanism of the variety of urine drainage bags with the patient. Select the system that is most adaptable to the patient's lifestyle and her ability to manage the device independently. For women with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.<br />Procedure<br /><br />The standard technique for catheter insertion is:<br /><br /> * Explain the procedure to the patient, position the patient and ensure privacy and good lighting.<br /> * Wash hands, remove outer tray wrapper and put on sterile gloves before opening the sterile inner packet. Prepare a sterile field and place a specimen collection vessel between the patient's legs.<br /> * Cleanse the labia according to established guidelines and identify the urethral meatus. If an anesthetic lubricating gel is used, instill approximately 0.16 fl oz (5 ml) of 2% lignocaine hydrochloride gel into the urethra or apply the gel to the meatus to achieve surface anesthesia within three to five minutes.<br /> * Hold the catheter in the dominant hand and gently insert it into the urethral meatus; pass it slowly through the urethra and into the bladder. If the catheter is accidentally inserted into the vagina or the tip is contaminated, discard it and take new sterile catheter before proceeding.<br /> * Once the urine starts to flow, collect the specimen and pass the catheter an additional 2 inches (5 cm) to ensure that the balloon is in the bladder before slowly inflating the balloon with 10 ml sterile water.<br /><br />Aftercare<br /><br />Patients using intermittent catheterization to manage incontinence may require a period of adjustment as they try to establish a catheterization schedule that is adequate for their normal fluid intake.<br /><br />Antibiotics should not be prescribed as a preventative measure for patients at risk for urinary tract infections. Prophylactic use of antibacterial agents may lead to the development of drug-resistant bacteria. Patients who practice intermittent self-catheterization can reduce their risks for UTI by using antiseptic techniques for insertion and catheter care.<br /><br />Attach the indwelling catheter to the drainage system, slightly curve the tubing, and anchor it to prevent urethral traction. In women the catheter should be secured to the anteromedial thigh with non-allergenic adhesive.<br />Complications<br /><br />Complications that are liable to occur include:<br /><br /> * Trauma and/or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.<br /> * Trauma to the urethra and/or bladder from incorrect insertion or removal of the catheter with the balloon inflated. Repeated trauma may cause scaring and/or stricture, or narrowing of the urethra.<br /> * Bypassing of urine around the catheter. Inserting a smaller catheter size can minimize this problem.<br /><br />Sexual activity and menopause can also compromise the sterility of the urinary tract. Irritation of the urethra during intercourse promotes the migration of perineal bacteria into the urethra and bladder, causing UTIs. Postmenopausal women may experience more UTIs than younger women. The presence of residual urine in the bladder secondary to incomplete voiding provides an ideal environment for bacterial growth.<br />Results<br /><br />Urinary catheterization should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization.<br /><br />Catheters should not be changed routinely. When each patient is monitored for indication of obstruction, infection, or complications before the catheter is changed, some patients require catheter changes weekly, and others may need a change in several weeks. Fewer catheter changes will reduce trauma to the urethra and reduce incidence of UTI.<br />Health care team roles<br />Observation<br /><br />Before commencing with the catheterization, the nurse should observe the patient's general condition, pal-pate the pubic area to note gross distension. The patient should be monitored for indications of infections and encourage adequate fluid intake.<br /><br />The nurse should seek medical advice if the catheter cannot be inserted easily, or if the patient complains of undue pain or bleeding other than that associated with minor trauma.<br />Patient education<br /><br />The patient and/or caregiver should be taught to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital and nursing homes and home care units.<br /><br />The sexuality of the patient with an indwelling catheter for continuous urinary drainage is seldom considered. If a patient is sexually active, the practitioner must explain that intercourse can take place with the catheter in place. The patient or her partner can be taught to remove the catheter before, and replace it with a new one following intercourse.<br />KEY TERMS<br /><br />Catheterization—A procedure of inserting a catheter through the urethra into the bladder to remove urine.<br /><br />Catheter—A tube for evacuating or injecting fluid.<br /><br />Contaminate—To make an item unsterile or unclean by direct contact.<br /><br />Foley catheter—A double channel retention catheter. One channel provides for the inflow and outflow of bladder fluid, the second (smaller) channel is used to fill a balloon that holds the catheter in the bladder.<br /><br />Intermittent catheterization—Periodic catheterization to facilitate urine flow. The catheter is removed when the bladder is sufficiently empty.<br /><br />Perineal area—The genital area between the vulva and anus in a woman.<br /><br />Urinary incontinence—The inability to retain urine or control one's urine flow.<br /><br />Urinary retention—The inability to void (urinate) to discharge urine.<br /><br />Urethritis—Inflammation of the urinary bladder.<br />Resources<br />BOOKS<br /><br />Nettina, Sandra M. Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott, 2001, pp.692-697.<br />PERIODICALS<br /><br />Colley, Wendy. RGN, DNCret. FETC. "Know How." Nursing Times (July 2, 1997).<br /><br />Cravens, David D., Steven Zweig. "Urinary Catheter Management." American Family Physicians 61, no. 2 (January 15, 2000): 369.<br /><br />Sanyay Saint, Joann G. Elmore, Sean D. Sullivan, Scott S. Emerson, Thomas D. Koepsell, "The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis." American Journal of Medicine 105, no. 3 (September 1998): 236.<br /><br />Aliene S. Linwood, B.S.N., RN, D.P.A., FACHE<br /><br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-24888362712141324022010-01-15T12:02:00.000-08:002010-01-15T12:03:58.189-08:00Catheterization, Malehttp://www.enotes.com<br /><br />Definition<br /><br />Urinary catheterization is the procedure of inserting a catheter through the urethra into the bladder to remove urine. Intermittent catheterization is performed for periodic relief of bladder distension; indwelling (Foley) catheters are inserted and retained in the bladder for continuous drainage of urine into a closed system.<br /><span class="fullpost"><br />Purpose<br /><br />Intermittent catheterization is recommended to obtain a sterile urine specimen, to relieve urinary retention, for urologic surgery or surgery on contiguous structures, for critically ill patients requiring accurate measurement of intake and output, and for temporary obstruction of the bladder opening due to injury.<br /><br />Indwelling catheterization is recommended for continuous drainage of urine when the bladder outlet obstruction can not be corrected by medical or surgical intervention; in cases of intractable skin ulceration caused or exacerbated by exposure to urine; and as palliative care for terminally ill or severely impaired incontinent patients.<br />Precautions<br /><br />The urinary tract is normally a sterile system. The normal flow of urine from the kidneys through the ureters, bladder, and urethra prevents the migration of bacteria up through the urinary system. Antibacterial properties of the bladder wall, urethra, low pH of urine, and the prostatic fluid in men also inhibit bacteria growth. Urinary tract infections (UTI) usually result from bacterial invasion of the protective barriers of one or more urinary structures. As a result, urinary catheterization should be avoided whenever possible. Precautions must be taken to keep the procedure sterile and the catheter free from bacteria. The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.<br /><br />Frequent intermittent catheterization and long-term use of indwelling catheters predisposes the patient to UTI. Care should be taken to avoid trauma to the urinary meatus and urothelium (urinary lining) with catheters that are too large or inserted with an insufficient amount of lubricant. Further medical advice should be sought if the catheter cannot be inserted easily, or the patient complains of undue pain or bleeding other than that associated with minor trauma.<br /><br />Every attempt should be made to keep the urinary drainage system closed. Breaks in the system invite infections. Health care workers and patients should wash their hands before and after manipulation of the patient's catheter or collection system to control UTI. Cross-contamination is the most frequent cause of nosocomial (hospital acquired) catheter related infections. Good hand washing practices are the best prevention measure. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.<br />Description<br /><br />Intermittent catheterization is preferable to chronic indwelling catheterization in certain patients with bladder dysfunction. It has become the standard care for patients with spinal cord injuries. Elderly patients, following surgical repair of hip fractures, regain the ability to control urination more quickly on a program of intermittent catheterization every six to eight hours compared to the use of indwelling catheters.<br /><br />Intermittent catheterization may be performed four or five times a day by the health care practitioner or care-giver. Patients who are interested in self-catheterization should be instructed and trained by a qualified health professional. This is also true for patients who require indwelling catheterization, as the procedure for insertion is similar to that for intermittent catheterization, with added responsibility of inflating the balloon.<br />Preparation<br /><br />Health care practitioner performing the catheterization should have a good understanding of the male urinary system anatomy and physiology and should be trained in aseptic technique, catheter insertion technique, and catheter care.<br /><br />Sterile disposable catheterization sets are available in clinical settings and for home use. These sets contain most of the items needed for the procedure, such as antiseptic agents, perineal drapes, gloves, lubricant, specimen container, label, and adhesive strips. Local anesthetic gel, antibacterial lubricant, catheter, and drainage system may need to be added. It is wise to check the content of the pre-packaged catheterization set when assembling materials and supplies.<br />Catheter choices<br /><br />Silastic catheters have a decreased incidence of urethritis and are recommended for short-term and intermittent catheterization. Latex is the catheter of choice for long-term catheterization. Silastic catheters are recommended for patients who are allergic to latex products.<br /><br />There are additional types of Foley catheters:<br /><br /> * PTFE-coated latex<br /> * hydrogel-coated latex<br /> * silicone-coated latex<br /> * pure silicone<br /><br />Select the smallest and softest catheter available. Catheters larger than 18 F are seldom used. Catheters size 14 or 16 F are used more frequently. A size 12 F catheter has been used successfully in catheterizing men with acute urinary retention. When indwelling catheters are required, select a catheter that can be inflated with 5 to 10 ml of sterile water.<br /><br />Review the design, capacity, and emptying mechanism of a variety of urine drainage systems available. Select the system that is most adaptable to the patient's lifestyle and ability to manage the device independently. For patients with normal bladder sensation, a catheter valve for intermittent drainage may be an acceptable option.<br />Procedural precautions<br /><br />Before starting the catheterization, observe the patient's general condition and palpate the suprapubic area to detect gross distension. The genital area should be washed with a mild soap and warm water and patted dry.<br /><br />Phimosis is constriction of the prepuce (foreskin) so that it cannot be drawn back over the glans penis. This may make it difficult to identify the external urethral meatus. Care should be taken when catheterizing men with phimosis to avoid trauma from forced retraction of the prepuce or by incorrect positioning of the catheter.<br /><br />The male urethra is longer than the female urethra and has two curves in it as it passes through the penis to the bladder, which makes catheter insertion more difficult. One curve can be straightened out by lifting the penis; the other curve is fixed. The penis should be held upright, at right angle to the patient's body when the catheter is inserted. The male urinary meatus is located at the end of the penis and is exposed by retracting the prepuce in uncircumcised patients. Men with a retracted penis can be even more difficult to catheterize. Gentle finger pressure on both sides of the penis will often cause the penis to emerge and extend from the body to facilitate the catheterization.<br /><br />To perform the procedure:<br /><br /> * Position the patient in a horizontal recumbent position.<br /> * Place the opened catheterization tray on the bedside stand in comfortable reaching distance.<br /> * Retract the foreskin. Using an aseptic technique, clean the prepuce and insert anesthetic gel to anesthetize the glans penis and dilate the prepuce exposing the meatus. Anesthetic gel can then be introduced into the urethra and catheterization can commence.<br /> * Use two or three aseptic swabs to clean the meatus with circular motion, beginning with the center of the opening and rotating outwards.<br /> * Lubricate about 8 inches (20 cm) of the catheter.<br /> * Hold the penis in the dominant hand and pull it upward and slightly backward to straighten the urethra.<br /> * Gently insert the catheter with a smooth continuous motion until urine begins to flow. Do not force.<br /> * Once the urine starts to flow, collect the specimen. Advance the catheter an additional 5 cm before inflating the balloon with 5 to 10 ml of sterile solution to hold the catheter in place.<br /> * Connect the indwelling catheter to the drainage system. Put a slight curve in the catheter and anchor it to the upper outer thigh with hypoallergenic adhesive to prevent urethral traction.<br /><br />Aftercare<br /><br />Patients using intermittent catheterization as treatment of incontinence or retention will have a period of adjustment as they try to establish a catheterization schedule adequate for their normal fluid intake. The urinary drainage system should be kept closed. Breaks in the drainage unit may result in an infection. Avoiding cross-contamination is important in controlling catheter-related UTIs. Practitioners and caretakers should always wash their hands before and after handling a patient's catheter or urine collection unit.<br /><br />The extended portion of the catheter should be washed with a mild soap and warm water to remove accumulated debris. Patients with indwelling catheters should be re-evaluated periodically to determine if an alternative treatment method will be more effective.<br /><br />Catheters should not be changed routinely. Each patient should be monitored for indication of obstruction or complications before changing the catheter. Some patients require catheter changes weekly, and others may need a change in several weeks.<br /><br />In summary, the following guidelines are recommended for male catheterization:<br /><br /> * Catheterize the patient only when it is absolutely necessary.<br /> * Secure the catheter properly.<br /> * Maintain a closed sterile urine collection system and unobstructed urine flow.<br /> * Avoid catheter irrigation unless it is needed to prevent or relieve bladder obstruction.<br /> * Always use the smallest effective catheter.<br /> * Do not change the catheter as an elective treatment option.<br /> * Isolated minor episodes of UTI should not be treated with antibiotics. Antibiotic prophylaxis promotes emergence of drug-resistant bacteria.<br /> * Provide continuing education in catheter care for practitioners and caretakers.<br /><br />Complications<br /><br />A few complications that may rise during the procedure are:<br /><br /> * urinary tract infections and catheter obstruction<br /> * trauma and/or the introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia<br /> * trauma to the bladder, urethra, and meatus caused by incorrect insertion of the catheter or forceful removal with the bladder inflated by confused patients<br /> * scaring, stricture and/or narrowing of the urethra due to repeated trauma<br /> * urine bypass around the catheter (A smaller catheter size may minimize leakage.)<br /> * leakage around the catheter due to forceful bladder spasms that overwhelm the catheter's drainage capacity<br /><br />Results<br /><br />Urinary catheterization aids or replaces the body's normal ability to urinate. Intermittent use of the procedure can stimulate normal bladder function. However frequent and continuous catheterization can lead to total<br /><br />dependency. Practically every patient with chronic catheterization and frequent intermittent catheterization will develop bacteriuria. Some physicians do not recommend antibiotic therapy for asymptomatic bacteriuria. When symptomatic infections are treated in patients with indwelling catheters, the catheter is removed and a fresh urine specimen is obtained for culture to determine the source of the infection and direct the medical therapy.<br />Health care team roles<br /><br />The physician orders the catheter and a registered nurse performs the procedure and provides patient education. Catheterization is a rather simple procedure, but female nurses are sometimes reluctant to perform urethral catheterization on male patients despite established patient care guidelines and advice on the male catheterization procedure. However, both intermittent and indwelling male catheterization is required to achieve optimum quality of life; therefore nurses should make the best possible practice and techniques available. Before commencing with the catheterization, the health care professional observes the patient's general condition, palpates the pubic area to note gross distension, monitors the patient for indications of infections, and encourages adequate fluid intake.<br />Patient education<br /><br />The nurse usually teaches the patient and/or caregiver to use aseptic technique for catheter care. Nursing interventions and patient education can make a difference in the incidence of urinary tract infections in the hospital, nursing homes, and home care units.<br /><br />The sexuality of the patient with an indwelling catheter for continuous urinary drainage is seldom considered. If a patient is sexually active, the patient or her partner can be taught to remove the catheter before inter-course, and replace it with a new one following inter-course.<br />KEY TERMS<br /><br />Bacteriuria—Bacteria in the urine (asymptomatic or symptomatic).<br /><br />Foley catheter—A double channel retention catheter. One channel provides for the inflow and outflow of fluid; the second and smaller channel is used to fill a balloon that holds the catheter in the bladder.<br /><br />Phimosis—Tightness of the foreskin, which cannot be drawn back from the glans penis.<br /><br />Prepuce—A fold of cutaneous tissue over the glans penis.<br /><br />Urinary catheterization—The insertion of a catheter through the urethra into a patient's bladder.<br /><br />Urinary incontinence—The inability to retain urine or control one's urine flow.<br /><br />Urinary retention—The inability to void (urinate) to discharge urine.<br />Resources<br />BOOKS<br /><br />Nettina, Sandra M. Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott, 2001, pp.692-697.<br />PERIODICALS<br /><br />Cravens, David D. and Steven Zweig. "Urinary Catheter Management." American Family Physician 16, no. 12 (January 15, 2000): 369.<br /><br />Marchiondo, Kathleen. "A New Look at Urinary Tract Infection." American Journal of Nursing 98, no. 3 (March 1998):p34-39.<br /><br />Pomfret, Ian. "Women at Work." Nursing Times 95, no. 6 (February 10, 1999): 59-60.<br /><br />Aliene S. Linwood, BSN, RN, D.P.A., FACHE<br /><br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-37970136294017339762010-01-15T11:53:00.000-08:002010-04-24T11:22:12.991-07:00Osteoporosishttp://www.enotes.com<br /><br />Definition<br /><br />The word osteoporosis literally means "porous bones." It occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, bone mass, and therefore bone strength, is decreased. As a result, bones become fragile and break easily. Even a sneeze or a sudden movement may be enough to break a bone in someone with severe osteoporosis.<br /><span class="fullpost"><br />Description<br /><br />Osteoporosis is a serious public health problem. Some 28 million people in the United States are affected by this potentially debilitating disease, which is responsible for 1.5 million fractures (broken bones) annually. These fractures, which are often the first sign of the disease, can affect any bone, but the most common locations are the hip, spine, and wrist. Breaks in the hip and spine are of special concern because they almost always require hospitalization and major surgery, and may lead to other serious consequences, including permanent disability and even death.<br /><br />To understand osteoporosis, it is helpful to understand the basics of bone formation. Bone is living tissue that is constantly being renewed in a two-stage process (resorption and formation) that occurs throughout life. In the resorption stage, old bone is broken down and removed by cells called osteoclasts. In the formation stage, cells called osteoblasts build new bone to replace the old. During childhood and early adulthood, more bone is produced than removed, reaching its maximum mass and strength by the mid-30s. After that, bone is lost at a faster pace than it is formed, so the amount of bone in the skeleton begins to slowly decline. Most cases of osteoporosis occur as an acceleration of this normal aging process—a form referred to as primary osteoporosis. The condition can also be caused by other disease processes or prolonged use of certain medications that result in bone loss—a form called secondary osteoporosis.<br /><br />Osteoporosis occurs most often in older people and in women after menopause. It affects nearly half of all men and women over the age of 75. Women, however, are five times more likely than men to develop the disease. They have smaller, thinner bones than men to begin with, and they lose bone mass more rapidly after menopause (usually around age 50), when they stop producing a bone-protecting hormone called estrogen. In the five to seven years following menopause, women can lose about 20% of their bone mass. By age 65 or 70, though, men and women lose bone mass at the same rate. As an increasing number of men reach an older age, they are becoming more aware that osteoporosis is an important health issue for them as well.<br />Causes and symptoms<br /><br />A number of factors increase the risk of developing osteoporosis. They include:<br /><br /> * Age. Osteoporosis is more likely as people grow older and their bones lose tissue.<br /> * Gender. Women are more likely to have osteoporosis because they are smaller and so start out with less bone. They also lose bone tissue more rapidly as they age. While women commonly lose 30–50% of their bone mass over their lifetimes, men lose only 20–33% of theirs.<br /> * Race. Caucasian and Asian women are at higher risk for the disease than women of African or Hispanic ethnicities.<br /> * Figure type. Women with small bones and those who are thin are more liable to have osteoporosis.<br /> * Early menopause. Women who stop menstruating early because of heredity, surgery or a lot of physical exercise may lose large amounts of bone tissue early in life. Conditions such as anorexia and bulimia may also lead to early menopause and osteoporosis.<br /> * Lifestyle. People who smoke or drink too much, or do not get enough exercise have an increased chance of getting osteoporosis.<br /> * Diet. Those who do not get enough calcium or protein may be more likely to have osteoporosis. People who constantly diet are more prone to the disease. It has been shown that adolescent girls (but not boys) have insufficient calcium intake levels in the diet. This calcium deficiency occurs during a period of rapid bone growth, stunting the peak bone mass ultimately achieved; thus, these individuals are at greater risk of developing osteoporosis.<br /> * Genetics. People with a family history of osteoporosis are more likely to contract the disease.<br /> * Chronic use of medication. Certain types of medication, such as steroids, interfere with the body's ability to absorb calcium or accelerate calcium depletion, damaging bone density.<br /><br />Osteoporosis is often called the "silent" disease, because bone loss occurs without symptoms. People often do not know they have the disease until a bone breaks, frequently in a minor fall that would not normally cause a fracture. A common occurrence is compression fractures of the spine. These can happen even after a seemingly normal activity, such as bending or twisting to pick up a light object. The fractures can cause severe back pain, but sometimes they go unnoticed—either way, the vertebrae collapse down on themselves, and the person actually loses height. The hunchback appearance of many elderly women, sometimes called "dowager's hump" or "widow's hump," is due to this effect of osteoporosis on the vertebrae.<br />Diagnosis<br /><br />Certain types of doctors may have more training and experience than others in diagnosing and treating people with osteoporosis. These include geriatricians, who specialize in treating the aged; endocrinologists, who specialize in treating diseases of the body's endocrine system (glands and hormones); and orthopedic surgeons, who treat fractures, such as those caused by osteoporosis.<br /><br />Before making a diagnosis of osteoporosis, the doctor usually takes a complete medical history, conducts a physical exam, and orders x-rays, as well as blood and urine tests, to rule out other diseases that cause loss of bone mass. The doctor may also recommend a bone density test. This is the only way to determine if osteoporosis is present. It can also show how far the disease has progressed.<br /><br />Several diagnostic tools are available to measure the density of a bone. The most accurate and advanced of the densitometers uses a technique called DEXA (dual energy x-ray absorptiometry). With the DEXA scan, a double x-ray beam takes pictures of the spine, hip, or entire body. It takes about 20 minutes to do, is painless, and exposes the patient to only a small amount of radiation—about one-fiftieth that of a chest x ray. The ordinary x ray is one, though it is the least accurate for early detection of osteoporosis, because it does not reveal bone loss until the disease is advanced and most of the damage has already been done. Other tools that are more likely to catch osteoporosis at an early stage are computed tomography scans (CT scans) and machines called densitometers, which are designed specifically to measure bone density. The CT scan, which takes a large number of x rays of the same spot from different angles, is an accurate test, but uses higher levels of radiation than other methods.<br /><br />People should talk to their doctors about their risk factors for osteoporosis and if, and when, they should get the test. A woman should have bone density measured at menopause, and periodically afterward, depending on the condition of their bones. Men should be tested around age 65. Men and women with additional risk factors, such as those who take certain medications, may need to be tested earlier.<br />Treatment<br /><br />There are a number of good treatments for primary osteoporosis, most of them medications. In addition, calcium (0.5 to 2 g/day) and vitamin D (400 to 800 IU/day) supplementation can reduce the rate of bone loss in women who are more than five years postmenopausal. Fracture reduction efficacy of calcium and vitamin D supplementation, administered independently, has been demonstrated in women older than 75 years of age.<br /><br />For people with secondary osteoporosis, treatment may focus on curing the underlying disease.<br />Drugs<br /><br />For most women who have gone through menopause, the best treatment for osteoporosis is hormone replacement therapy (HRT). Many women participate in HRT when they undergo menopause, to alleviate symptoms such as hot flashes, but hormones have other important roles as well. They protect women against heart disease, the number one killer of women in the United States, and they help to relieve and prevent osteoporosis. HRT increases a woman's supply of estrogen, which helps build new bone, while preventing further bone loss.<br /><br />Some women, however, do not want to take or are not candidates for hormones, because some studies show they are linked to an increased risk of breast cancer or uterine cancer. Other studies reveal that risk is due to increasing age. (Breast cancer tends to occur more often as women age.) Whether or not a woman takes hormones is a decision she should make carefully with her doctor. Women should talk to their doctors about personal risks for osteoporosis, as well as their risks for heart disease and breast cancer.<br /><br />Novel delivery systems of HRT have been developed. For example, Vivelle is a estradiol transdermal system that is used for prevention of osteoporosis. It uses a "patch" to continously deliver the hormone estradiol through the skin.<br /><br />Studies have shown women who started taking HRT within five years of menopause show significantly reduced rates of hip fractures than women who began HRT more than five years postmenopausal. However, even while taking HRT, 10 to 20% of women continue to lose bone density and therefore may require additional intervention.<br /><br />For people who cannot or will not take estrogen, other agents can be good choices. These include:<br /><br /> * bisphosphonates<br /> * calcitonin<br /> * selective estrogen receptor modulators<br /> * sodium fluoride<br /> * androgens<br /><br />Although there are a number of bisphosphonates used for the treatment of various forms of osteoporosis and resorptive bone diseases, alendronate (sold under the brand name Fosamax), etidronate (sold under the brand name Didronel), and risedronate (sold under the brand name Actonel) are some of the agents most commonly used for therapeutic treatment of postmenopausal osteoporosis. Biphosphonates act by decreasing bone resorption or breakdown. For example, alendronate attaches itself to bone that has been targeted by bone-eating osteoclasts. It protects the bone from these cells. Osteoclasts help the body break down old bone tissue.<br /><br />Alendronate has shown to be an effective agent in preventing bone loss and building bone in recently post-menopausal women and is especially useful in women who have contraindications for HRT. It has been licensed for the treatment and prevention of vertebral and nonvertebral postmenopausal osteoporosis. Alendronate has proven safe in very large, multi-year studies, but not much is known about the effects of its long-term use. Side effects are generally minimal with abdominal pain, nausea, dyspepsia, constipation and diarrhea occurring in 3% to 7% of patients treated with alendronate. It can be taken daily, and now a new formulation has been developed that can be taken weekly.<br /><br />Etidronate has been shown to reduce the rate of new vertebral and nonvertebral fractures. It appears to be well tolerated in clinical studies.<br /><br />Calcitonin is a hormone that has been used as an injection for many years. It is also marketed as a nasal spray. It also slows down bone-eating osteoclasts. Side effects are minimal, but calcitonin builds bone by only 1.5% a year, which may not be enough for some women to recover the bone they lose.<br /><br />Selective estrogen receptor modulators (SERMs) such as raloxifene, droloxifene, idoxifene, and tamoxifen are used as alternatives to hormone replacement therapy (HRT) which commonly use estrogen. SERMs have been shown to protect against postmenopausal bone loss without the estrogenic side effects. Raloxifene was the first SERM to be approved in the osteoporosis market for prevention and treatment of osteoporosis. Raloxifene binds to estrogen receptors and mimics estrogen's action on bone by preventing bone loss, and improving cholesterol metabolism, therefore acting as an agonist. It also acts as an estrogen antagonist in the uterus and the breasts, by not imitating the action of estrogen. These drugs may thus improve blood lipid profiles and protect against breast cancer. There is an enhanced risk of venous thromboembolic events during raloxifene therapy, especially during the first four months of therapy. It also has a propensity to induce hot flashes, and leg pain.<br /><br />Sodium fluoride has been used as an anabolic agent to stimulate bone formation. However, a high incidence of side effects, mainly gastrointestinal symptoms and lower extremity pain syndrome have occurred in clinical trials.<br /><br />Androgens have been used for reducing bone loss. Androgens are classified as anabolic steroids, which include nandrolone, stanozolol and testosterone, are used as antiresorptive agents. Androgens are important for postmenopausal women as they serve as a substrate for the peripheral production of estrogens.<br /><br />The treatments currently available are antiresorptive, which limits the ability to increase bone mass. Other bone-building agents are under investigation including parathyroid hormone which has been clinically evaluated but is still awaiting FDA approval as of March 2001. The biphosphonates have demonstrated the most dramatic reduction in fracture rates and may be the best choice for women with severe osteoporosis. Estrogen's effect may be similar, but has not been established in large randomized trials. Raloxifene may be particularly useful in women who wish to benefit from a breast cancer risk reduction. Calcitonin may be the least potent but may be useful in women who cannot tolerate other therapies.<br />Surgery<br /><br />Unfortunately, treatment for osteoporosis is usually tied to fractures that result from advanced stages of the disease. For complicated fractures, such as broken hips, hospitalization and a surgical procedure are required. In hip replacement surgery, the broken hip is removed and replaced with a new hip made of plastic, or metal and plastic. Though the surgery itself is usually successful, complications of the hip fracture can be serious. Those individuals have a 5%–20% greater risk of dying within the first year following that injury than do others in their age group. A large percentage of those who survive are unable to return to their previous level of activity, and many end up moving from self-care to a supervised living situation or nursing home. Getting early treatment and taking steps to reduce bone loss are vital.<br />Alternative treatment<br /><br />Alternative treatments for osteoporosis focus on maintaining or building strong bones. A healthy diet low in fats and animal products and containing whole grains, fresh fruits and vegetables, and calcium-rich foods (such as dairy products, dark-green leafy vegetables, sardines, salmon, and almonds), along with nutritional supplements (such as calcium, magnesium, and vitamin D), and weight-bearing exercises are important components of both conventional prevention and treatment strategies and alternative approaches to the disease. In addition, alternative practitioners recommend a variety of botanical medicines or herbal supplements. Herbal supplements designed to help slow bone loss emphasize the use of calcium-containing plants, such as horsetail (Equisetum arvense), oat straw (Avena sativa), alfalfa (Medicago sativa), licorice (Glycyrrhiza galbra), marshmallow (Althaea officinalis), and yellow dock (Rumex crispus). Homeopathic remedies focus on treatments believed to help the body absorb calcium. These remedies are likely to include such substances as Calcarea carbonica (calcium carbonate) or silica. In traditional Chinese medicine,<br />KEY TERMS<br /><br />Alendronate—A nonhormonal drug used to treat osteoporosis in postmenopausal women.<br /><br />Anticonvulsants—Drugs used to control seizures, such as in epilepsy.<br /><br />Biphosphonates—Compounds (like alendronate) that slow bone loss and increase bone density.<br /><br />Calcitonin—A hormonal drug used to treat post-menopausal osteoporosis.<br /><br />Estrogen—A female hormone that also keeps bones strong. After menopause, a woman may take hormonal drugs with estrogen to prevent bone loss.<br /><br />Glucocorticoids—Any of a group of hormones (like cortisone) that influence many body functions and are widely used in medicine, such as for treatment of rheumatoid arthritis inflammation.<br /><br />Hormone replacement therapy (HRT)—Also called estrogen replacement therapy, this controversial treatment is used to relieve the discomforts of menopause. Estrogen and another female hormone, progesterone, are usually taken together to replace the estrogen no longer made by the body. It has the added effect of stopping bone loss that occurs at menopause.<br /><br />Menopause—The ending of a woman's menstrual cycle, when production of bone-protecting estrogen decreases.<br /><br />Osteoblasts—Cells in the body that build new bone tissue.<br /><br />Osteoclasts—Cells that break down and remove old bone tissue.<br /><br />Selective estrogen receptor modulator—A hormonal preparation that offers the beneficial effects of hormone replacement therapy without the increased risk of breast and uterine cancer associated with HRT.<br /><br />practitioners recommend herbs thought to slow or prevent bone loss, including dong quai (Angelica sinensis) and Asian ginseng (Panax ginseng). Natural hormone therapy, using plant estrogens (from soybeans) or progesterone (from wild yams), may be recommended for women who cannot or choose not to take synthetic hormones.<br /><br />It should be noted, however, that very few clinical trials are conducted on alternate therapies and therefore efficacy cannot be established.<br />Prognosis<br /><br />There is no cure for osteoporosis, but it can be controlled. Most people who have osteoporosis fare well once they get treatment. The medicines available now build bone, protect against bone loss, and halt the progress of this disease.<br />Health care team roles<br /><br />Doctors, nurses, physical therapists, radiation technologists, and dietitians all play roles in the process of controlling osteoporosis. Because osteoporosis is treatable but not curable, the main responsibility for controlling the progress of the disease rests with the patient. All of these team members play an important role in identifying risk of osteoporosis before it strikes and in convincing the patient to take appropriate steps (including lifestyle modification) to minimize the dangers of fracturing major bones.<br />Prevention<br /><br />Building strong bones, especially before the age of 35, and maintaining a healthy lifestyle are the best ways of preventing osteoporosis. To build as much bone mass as early as possible in life, and to help slow the rate of bone loss later in life:<br />Get calcium in foods<br /><br />Experts recommend 1,500 milligrams (mg) of calcium per day for adolescents, pregnant or breast-feeding women, older adults (over 65), and postmenopausal women not using hormone replacement therapy. All others should get 1,000 mg per day. Foods are the best source for this important mineral. Milk, cheese, and yogurt have the highest amounts. Other foods that are high in calcium are green leafy vegetables, tofu, shell-fish, Brazil nuts, sardines, and almonds.<br />Take calcium supplements<br /><br />Many people, especially those who do not like or cannot eat dairy foods, do not get enough calcium in their diets and may need to take a calcium supplement. Supplements vary in the amount of calcium they contain. Those with calcium carbonate have the most amount of useful calcium. Supplements should be taken with meals and accompanied by six to eight glasses of water a day. Calcium supplements and antacids interfere with absorption of alendronate and should be taken at least one half hour later.<br />Get vitamin D<br /><br />Vitamin D helps the body absorb calcium. People can get vitamin D from sunshine with a quick (15–20 minutes) walk each day or from foods such as liver, fish oil, and vitamin-D fortified milk. During the winter months it may be necessary to take supplements (400–800 IU/day).<br />Avoid smoking and alcohol<br /><br />Smoking reduces bone mass, as does heavy drinking. To reduce risk, do not smoke and limit alcoholic drinks to no more than two per day. An alcoholic drink is1.5 oz (44 mL) of hard liquor, 12 oz (355 mL) of beer, or 5 oz (148 mL) of wine.<br />Exercise<br /><br />Exercising regularly builds and strengthens bones. Weight-bearing exercises—where bones and muscles work against gravity—are best. These include aerobics, dancing, jogging, stair climbing, tennis, walking, and lifting weights. People who have osteoporosis may want to attempt gentle exercise, such as walking, rather than jogging or fast-paced aerobics, which increase the chance of falling. Try to exercise three to four times per week for 20–30 minutes each time. As physical activity improves muscle strength and coordination it may also aid in reducing the risk of fall-related fractures.<br /><br />Those at risk should avoid medications known to compromise bone density, such as glucocorticoids, thyroid hormones and chronic heparin therapy.<br />Resources<br />BOOKS<br /><br />Adams, John S. and Barbara P. Lukertet. Osteoporosis: Genetics, Prevention and Treatment. Boston: Kluwer Academic, 1999.<br /><br />Kessler, George J., et al. The Bone Density Diet: 6 Weeks to a Strong Body and Mind. New York: Ballantine Books, 2000.<br /><br />Krane, Stephen M., and Michael F. Holick. "Metabolic Bone Disease: Osteoporosis." In Harrison's Principles of Internal Medicine. 14th ed. Ed. by Anthony S. Fauci, et al. New York: McGraw-Hill, 1998.<br /><br />Lane, Nancy E., ed. The Osteoporosis Book. New York: Oxford University Press, 1998.<br /><br />McIlwain, Harris, et al. Osteoporosis Cure: Reverse the Crippling Effects With New Treatment. New York: Avon Books, 1998.<br /><br />Notelovits, Morris, et al. Stand Tall! Every Woman's Guide to Preventing and Treating Osteoporosis. 2nd ed. Gainesville, FL: Triad Publishing Co., 1998.<br />PERIODICALS<br /><br />Feder, G., et al. "Guidelines for the Prevention of Falls in People over 65." British Medical Journal 321 (2000): 1007-1011.<br /><br />McClung, Michael R., et al. "Effect of Risedronate on the Risk of Hip Fracture in Elderly Women." The New England Journal of Medicine 344, no. 5 (2001): 333-40.<br />ORGANIZATIONS<br /><br />Arthritis Foundation, 1330 W. Peachtree St., PO Box 7669, Atlanta, GA 30357-0669. (800) 283-7800. <http://www.arthritis.org>.<br /><br />National Center for Complementary and Alternative Medicine (NCCAM), 31 Center Dr., Room #5B-58, Bethesda, MD 20892-2182. (800) NIH-NCAM. Fax: (301) 495-4957. <http://nccam.nih.gov>.<br /><br />National Osteoporosis Foundation, 1150 17th Street, Suite 500 NW, Washington, DC 20036-4603. (800) 223-9994. <http://www.nof.org>.<br /><br />Osteoporosis and Related Bone Diseases-National Resource Center. 1150 17th St., NW, Ste. 500, Washington, DC 20036-4603. (800) 624-BONE. <http://www.osteo.org>.<br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-62272478208995197512010-01-15T11:51:00.000-08:002010-01-15T11:53:05.968-08:00Alzheimer's Diseasehttp://www.enotes.com<br /><br />Definition<br /><br />Alzheimer's disease (AD) is the most common form of dementia, a neurologic disease characterized by a progressive loss of mental ability severe enough to interfere with normal activities of daily living, lasting at least six months, and not present from birth. AD usually occurs in old age and is marked by a decline in cognitive functions such as remembering, reasoning, and planning.<br /><span class="fullpost"><br />Description<br /><br />A person with AD usually has a gradual decline in mental functions, often beginning with slight memory loss, followed by losses in the ability to maintain employment, to plan and execute familiar tasks, and to reason and exercise judgment. Communication ability, mood, and personality may also be affected. Most people who have AD die within eight years of their diagnosis, although that interval may be as short as one year or as long as 20 years. AD is the fourth leading cause of death in adults after heart disease, cancer, and stroke.<br /><br />In 2001, four million Americans have been diagnosed with AD. That number is expected to grow to as many as 14 million by the middle of the twenty-first century as the baby-boomer population ages. These numbers may be seriously underestimated due to new research that suggests mild cognitive impairment may be early stages of AD.<br /><br />While a small number of people in their 40s and 50s develop the disease (called early-onset AD), AD predominantly affects the elderly. AD affects about 10% of all people over the age of 65 and nearly half of those over85. Slightly more women than men are affected with AD, since women tend to live longer and occupy a larger proportion of the most affected age groups.<br /><br />The costs for caring for loved ones with AD is considerable, and has been estimated at approximately $174,000 per person over the course of the disease. More than 70% of people with AD are cared for at home at an estimated annual cost of $196 billion. These costs are not supplemented by outside sources. If patients are cared for by paid home caregivers or are placed in nursing homes, the total annual out-of-pocket costs by families or third party payees account for $83 billion and $32 billion respectively.<br />Causes and symptoms<br />Causes<br /><br />The cause of Alzheimer's disease is unknown. Some strong leads have been found through recent research, however, and these have also given some theoretical support to several new experimental treatments.<br /><br />AD affects brain cells responsible for learning, reasoning, and memory. Autopsies of people with AD indicate that these regions of the brain become clogged with two abnormal structures, neurofibrillary tangles and senile plaques. Neurofibrillary tangles are twisted masses of protein fibers inside nerve cells (neurons). Senile plaques are composed of parts of neurons surrounding a group of brain proteins called beta-amyloid deposits. While it is not clear exactly how these structures cause problems, some researchers now believe that their formation is responsible for the mental changes of AD, presumably by interfering with the normal communication between neurons in the brain. Drugs approved by the Food and Drug Administration (FDA) increase the level of chemical signaling molecules in the brain, known as neurotransmitters, to make up for this decreased communication ability.<br /><br />What triggers the formation of plaques and tangles is unknown, although there are several possible candidates. Restriction of blood flow may be part of the problem, perhaps accounting for the beneficial effects of estrogen, which increases blood flow in the brain. However, studies in 2001 do not show estrogen as a protection against the development of AD.<br /><br />Highly reactive molecular fragments called free radicals damage cells of all kinds, especially brain cells, which have smaller supplies of protective antioxidants thought to protect against free radical damage. Vitamin E is one such antioxidant, and its use in AD is showing some benefit.<br /><br />Several genes have been implicated in AD, including the gene for amyloid precursor protein (APP) responsible for producing amyloid. Mutations in this gene are linked to some cases of the relatively uncommon earlyonset forms of AD. Other cases of early-onset AD are caused by mutations in the gene for another protein, presenilin. AD eventually affects nearly everyone with Down syndrome, caused by an extra copy of chromosome 21. Other mutations on other chromosomes have been linked to other early-onset cases.<br /><br />Potentially the most important genetic link was discovered in the early 1990s on chromosome 19. A gene on this chromosome, apoE, codes for a protein involved in transporting lipids into neurons. ApoE occurs in at least three forms: apoE2, apoE3, and apoE4. Each person inherits one apoE from each parent, and therefore can either have one copy of two different forms or two copies of one. Compared to those without ApoE4, people with one copy are about three times as likely to develop lateonset AD, and those with two copies are almost four times as likely to do so. Despite this important link, not everyone with apoE4 develops AD, and people without it can still have the disease. Why apoE4 increases the chances of developing AD is not known.<br /><br />Promising research in 2001 has discovered a protein, apoptosis-inducing factor, that kills cells by disrupting the genetic material at their cores. This discovery could lead to drugs that could turn off this protein that triggers apoptosis or biologically regulated cell death, which is important in fetal development but is also implicated in stroke, heart disease, and AD. It is thought that this protein runs out of control and shuts off otherwise healthy cells.<br /><br />There are several risk factors that seem to increase a person's likelihood of developing the disease. The most significant one is, of course, age; older people develop AD at much higher rates than younger ones. Another risk factor is having a family history of AD, Down syndrome, or Parkinson's disease. People who have had head trauma or hypothyroidism may manifest the symptoms of AD sooner.<br /><br />Many environmental factors have been suspected of contributing to AD, but population studies generally have not borne these out. A study in early 2001, however, showed a specific link between aluminum in drinking water and the incidence of AD. Other suspected risk factors were other pollutants in drinking water, aluminum in any form, and mercury in dental fillings. To date, none of these other factors has been shown to cause AD or to increase its likelihood.<br /><br />Lifestyle factors, moreover, may prove to be better indicators of risk. Lack of stimulation, mentally and physically, between the ages of 20 and 60 seems linked to the incidence of AD. Studies have not shown, though, that a sedentary lifestyle early in life causes AD or whether it is a marker for the incidence of the disease.<br /><br />Another study of African Americans and their Nigerian counterparts shows AD appearing more often in the American population than the African one. Researchers suggest that environmental or cultural factors may play a role in the formation of AD. Here, physical activity or diet may play a part.<br />Symptoms<br /><br />The symptoms of Alzheimer's disease begin gradually, usually with memory lapses. Occasional memory lapses are common to everyone and do not, by themselves, signify any change in cognitive function. The person with AD may begin with only the routine sort of memory lapse—forgetting where the car keys are—but progresses to more profound or disturbing losses such as forgetting how to even drive a car. Being lost or disoriented on a walk around the neighborhood becomes more likely as the disease progresses. A person with AD may forget the names of family members, or forget what was said at the beginning of a sentence by the end of the sentence.<br /><br />As AD progresses, other symptoms appear, including inability to perform routine tasks, loss of judgment, and personality or behavior changes. Some patients have trouble sleeping and may suffer from confusion or agitation in the evening, known as sunsetting. In some cases, people with AD repeat the same ideas, movements, words, or thoughts, a behavior known as perseveration. There may be delusional thinking or even hallucinations. In the final stages people may have severe problems with eating, communicating, and controlling their bladder and bowel functions.<br /><br />The Alzheimer's Association has developed a list of 10 warning signs of AD. A person with several of these symptoms should see a physician for a thorough evaluation:<br /><br /> * memory loss that affects job skills<br /> * difficulty performing familiar tasks<br /> * problems with language, as in word-find problems or inappropriate word substitutions<br /> * disorientation about time and place<br /> * poor or decreased judgment<br /> * problems with abstract thinking<br /> * misplacing things<br /> * changes in mood or behavior<br /> * changes in personality<br /> * loss of initiative<br /><br />Other types of dementia, including some that are reversible, can cause similar symptoms. It is important for the person with these symptoms to be evaluated by a professional who can weigh the possibility that the symptoms may have another cause. Approximately 20% of those originally suspected of having AD actually have some other disorder; about half of these cases are treatable.<br />Diagnosis<br /><br />Diagnosis of Alzheimer's disease is complex and may require visits to several different specialists over several months before a determination can be made. With new diagnostic tools and criteria, it is possible to make a provisional diagnosis that is about 90% accurate. A positive confirmation of these findings can be made only through autopsy.<br /><br />Early diagnosis is essential in helping the patient and the family make decisions about treatment, long-term care, and financial matters. Finding out that a loved one's behavior is based on a degenerative mental disease can help a family avoid unnecessary anger and feelings of impotence when dealing with the progression of the disease.<br /><br />There are two diagnoses the clinical team can make for a patient. They are probable AD or possible AD. Probable AD is determined when physicians and psychiatrists rule out all other disorders that might produce similar symptoms. A diagnosis of possible AD is made when AD is considered the primary reason for the symptoms but is complicated with the presence of another disorder that might confuse the general progression of the disease.<br /><br />Diagnosis for AD begins with the elimination of other physical and psychological causes for the patient's behavior. This is done through a multi-step process that tests for other disorders and measures the amount of deficit the patient is experiencing.<br />Patient history<br /><br />A detailed medical history should be taken, noting a list of the patient's medicines (prescription and over the counter), vitamins, and herbs. Since there are many pharmaceuticals that can cause the same mental changes as AD, a careful review of the patient's medication, alcohol, and herbal use is important. If the patient's symptoms are related to any of these, most likely the condition can be reversed through adjustments in the patient's medications or herbal use. Any illicit drugs should also be reported.<br /><br />Next, the physician should take a detailed report of any changes in the patient's mental functioning and memory. This will determine the mode of onset of symptoms, the progression of the deficits, and the impact of the impairment on daily functioning.<br />Physical exam and lab tests<br /><br />AD-like symptoms can also be provoked by other medical conditions, including tumors, infection, thyroid malfunctioning, and dementia caused by mild strokes (multi-infarct dementia). These possibilities must be ruled out through blood screens, urine tests, electroencephalographs (EEGs), and a variety of imaging techniques.<br /><br />A genetic test for the ApoE4 gene is available, but is not used for diagnosis, since possessing even two copies does not ensure that a person will develop AD.<br />Cognitive functioning evaluation<br /><br />Several types of oral and written tests are used in AD diagnosis and disease progression, including tests of mental status, language ability, functional ability, memory, and concentration. In the early stages of the disease, the results of these tests are usually normal. It should be noted that the widely-used Mini-Mental State Examination (MMSE) may not be accurate for highly educated or poorly educated individuals, or cultural minorities.<br />Neuropsychiatric evaluation<br /><br />A detailed cognitive evaluation can be done by a psychologist or psychiatrist. These tests of memory and mental functioning provide a quantitative measure of the patient's deficits.<br /><br />One of the most important parts of the diagnostic process is the evaluation of depression and delirium, since these can be present with AD or may be mistaken for it. (Delirium involves a decreased consciousness or awareness of one's environment.) Depression and memory loss are both common in the elderly, and the combination of the two can often be mistaken for AD. Depression can be treated with drugs, although some antidepressants can worsen dementia if it is present, further complicating both diagnosis and treatment.<br />Imaging studies<br /><br />Several imaging techniques can assess brain function and pathology, thus eliminating these as causes of the patient's symptoms. Most frequently used imaging scans are magnetic resonance imaging (MRI) or computed tomography (CT) scans, which detect structural changes in the brain. Brain function can be assessed through MRI, positron emission tomography (PET), and single-photon emission CT (SPECT). These tests help rule out stroke, subdural hematoma, and brain tumor as possible causes for the patient's symptoms.<br />Treatment<br /><br />Alzheimer's disease is currently incurable, though a number of pharmaceuticals and home care strategies can mange the disease. The mainstay of AD treatment continues to be good nursing care, providing both physical and emotional support, as the patient gradually is able to do less independently and whose behavior becomes more erratic. Modifications of the home to increase safety are often necessary. Creative strategies to help the patient stay as independent as possible are also indicated. The caregiver also needs support to minimize anger, despair, and burnout.<br />Drugs<br /><br />Donepezil hydrochloride (Aricept), rivastigmine (Exelon), and galantamine (Reminyl) have been approved for use in AD treatment. These drugs increase the levels of the neurotransmitter acetylcholine in the brain, thereby increasing the communication ability of the remaining neurons. They do this by inhibiting the enzymes, acetylcholinesterase and butylcholinesterase, which normally break down acetylcholine and butylcholine released by neurons. These drugs modestly increase attention span, concentration, mental acuity, and information processing. Tacrine (Cognex), the first drug used, is no longer used due to the risk of liver toxicity. All cholinesterase inhibitors have mild gastric side effects such as nausea and vomiting.<br /><br />The antioxidant, vitamin E, is also thought to delay AD onset because it prevents neuron damage caused by free radicals. Vitamin E therapy, in combination with cholinesterase inhibitors, has become a practice standard in the treatment of AD.<br /><br />Drugs that have been found ineffective are Selegiline (used in the treatment of Parkinson's disease), prednisone, and the anti-inflammatory NSAID diclofenac. Estrogen, once thought to be the keystone in treatment and prevention of AD in women, was found to be ineffective in mitigating symptoms in 2001. There is still some discussion about estrogen's ability to delay the onset of AD.<br /><br />Depression may be treated with selective serotonin reuptake inhibitors (SSRIs) such as citalopram and sertraline. Physicians may also prescribe typical antipsychotics for agitation, aggression, or hallucinations, such as olanzapine, quetiapine, or risperidone. It should be noted that AD patients have more side effects from most medications, especially psychoactive drugs, and care should be taken in their selection.<br />Alternative treatment<br /><br />Several substances are currently being tested for their ability to slow the progress of Alzheimer's disease. Among them are gingko extract, derived from the leaves of the Gingko biloba tree, and huperzine A, from the moss Huperzia serrata. Gingko extract has antioxidant, anti-inflammatory, and neuroprotective effects and has been used for many years in China and is widely prescribed in Europe for treatment of circulatory problems. It has been shown to modestly improve cognitive function. Huperzine A is a natural cholinesterase inhibitor. It is reported to produce greater improvement than the synthetic cholinesterase inhibitors and has few side effects. Since neither herbal is regulated, they may have inconsistent levels of their active ingredients per dosage.<br />Nursing care and safety<br /><br />The person with Alzheimer's disease will gradually lose the ability to dress, groom, feed, bathe, or use the toilet without help; in the late stages of the disease, the individual may be unable to move or speak. In addition, the person's behavior becomes increasing erratic. A tendency to wander may make it difficult to leave the patient unattended for even a few minutes, which would make even the home a potentially dangerous place. In addition, some patients may exhibit inappropriate sexual behaviors.<br /><br />Nursing care required for AD patients is simple enough to learn. The difficulty for many caregivers comes in the constant but unpredictable nature of the demands put on them. Additionally, the personality changes presented in AD can be heartbreaking for family members as a loved one deteriorates, seeming to become a different person. Not all AD patients develop negative behaviors: some become gentle, spending increasing amounts of time in dream-like states.<br /><br />A loss of grooming skills may be one of the early symptoms of AD. Mismatched clothing, unkempt hair, and decreased interest in personal hygiene become more common. Caregivers, especially spouses, may find these changes socially embarrassing and difficult to cope with. The caregiver will begin to assume more and more grooming duties for the patient as the disease progresses.<br /><br />Ensuring proper nutrition for the AD patient may require using a colored plate to focus the patient's attention on the food. Finger foods may be preferable to those foods requiring utensils. Later, the caregiver may need to feed the patient. As movement and swallowing become difficult, a feeding tube may be placed into the stomach through the abdominal wall, which will require special attention.<br /><br />For many caregivers, incontinence becomes the most difficult problem to deal with at home, and is a principal reason for pursuing nursing home care. In the early stages, limiting fluid intake and increasing the frequency of toileting can help. Careful attention to hygiene is important to prevent skin irritation and infection from soiled clothing.<br /><br />Safety will become of prime importance. In all cases, a person diagnosed with AD should not be allowed to drive, because of the increased potential for accidents and the increased likelihood of wandering far from home while disoriented. In the home, grab bars in the bathroom, bed rails on the bed, and clutter-free passageways can greatly increase safety. Electrical appliances should be unplugged and put away when not in use, and matches, lighters, knives, or weapons should be stored out of reach. The hot water heater temperature should be set lower to prevent accidental scalding. A list of emergency numbers, including the poison control center and the hospital emergency room, should be posted by the phone.<br /><br />A calm, structured environment with simple orientation aids such as calendars and clocks may reduce anxiety and increase safety. Labeling cabinets and drawers may keep the patient's attention focused. Scheduling meals, bathing, and other activities at regular times and places will provide emotional security and routine, since unfamiliar places and activities can be disorienting for the patient. Sleep disturbances may be minimized by keeping the patient engaged in activities during the day, offering structure and providing physical activities.<br />Care for the caregiver<br /><br />Family members or others caring for a person with AD have a difficult and stressful job, which becomes harder still as the disease progresses. It is common for caregivers to develop feelings of anger, resentment, guilt, and hopelessness, in addition to the sorrow they feel for their loved one and for themselves. Depression is an extremely common consequence of being a full-time caregiver for an AD patient. Support groups are an important way to deal with the stress of caregiving. The location and contact numbers for AD caregiver support groups are available from the Alzheimer's Association; they may also be available through a local social service agency, the patient's physician, or pharmaceutical companies that manufacture the drugs used to treat AD. Medical treatment for depression may be an important adjunct to group support.<br />Outside help, nursing homes, and governmental assistance<br /><br />Most families eventually need outside help to relieve some of the burden of around-the-clock care for an AD patient. Personal care assistants, either volunteer or paid, may be available through local social service agencies. Adult daycare facilities are becoming increasingly common. Meal delivery, shopping assistance, or respite care may be available as well.<br /><br />Providing the total care required by a person with late-stage AD can become an overwhelming burden for a family, even with outside help. At this stage, many families consider nursing home care. This decision is often one of the most difficult for the family, since it is often considered an abandonment of the loved one and a failure of the family. Counseling with a physician, clergy, or other trusted adviser may ease the difficulties of this transition. Selecting a nursing home may require a difficult balancing of cost, services, location, and availability. Keeping the entire family involved in the decision may help prevent further stress from developing later on.<br /><br />Several federal government programs may ease the cost of caring for a person with AD, including Social Security Disability, Medicare, and Supplemental Security Income. Each of these programs provides some assistance for care, medication, or other costs, but none of them will pay for nursing home care indefinitely. Medicaid is a state-funded program that may provide for some or all of the cost of nursing home care, although there are important restrictions. Details of the benefits and eligibility requirements of these programs are available through the local Social Security or Medicaid office, or from local social service agencies. Long-term care insurance can also be another option, if taken out prior to the diagnosis.<br />Prognosis<br /><br />Alzheimer's disease can weaken the aging body, making it more susceptible to life-threatening infections such as pneumonia. In the late stages of the disease, autonomic body functions may be impaired, the patient falling into a coma, and death following. In addition, other diseases common in old age—cancer, stroke, and heart disease—may lead to more severe consequences in a person with AD. On average, people with AD live eight years past their diagnosis, with a range from one to 20 years.<br />Health care team roles<br /><br />Treatment of AD is a team effort, involving primary care physicians, nurses, imaging and laboratory technicians, gerontology specialists, psychiatrists, psychologists, nursing staff, and caregivers. Physicians order tests that aid in the diagnosis and treatment of AD. These experts must educate the patient and the caregivers in the nature of the disease and its progression, although this burden usually falls on the nursing staff. Nurses are also the first line of access to medical care and support groups. Social workers, counselors, and support group facilitators may also provide emotional support, practical advice, and information about community resources. Special Alzheimer's disease facilities may be used for either respite day care or as permanent long-term care placements.<br />Prevention<br /><br />There is currently no proven way to prevent Alzheimer's disease, though some of the drug treatments may delay the development of the disease. The most likely current candidate is estrogen. However, staying active mentally and physically throughout life may be key to prevention.<br />KEY TERMS<br /><br />Acetylcholine—One of the substances in the body that helps transmit nerve impulses.<br /><br />Dementia—Impaired intellectual function that interferes with normal social and work activities.<br /><br />Donepezil hydrochloride (Aricept)—A drug that increases the brain level of the neurotransmitter acetylcholine, which is given once a day to treat AD.<br /><br />Ginko—An herb from the Ginko biloba tree that some alternative practitioners recommend for the treatment of AD.<br /><br />Neurofibrillary tangle—Twisted masses of protein inside nerve cells that develop in the brains of people with AD.<br /><br />Senile plaque—Structures composed of parts of neurons surrounding brain proteins called beta-amyloid deposits and found in the brains of people with AD.<br /><br />Sunsetting—Confusion or agitation in the evening.<br /><br />Tacrine (Cognex)—A drug that may help improve memory in people with mild to moderate cases of AD.<br />Resources<br />BOOKS<br /><br />Castleman, Michael, Dolores Gallagher-Thompson, and Matthew Naythons. There's Still a Person in There: The Complete Guide to Treating and Coping with Alzheimer's. New York: G. P. Putnam's Sons, 1999.<br /><br />Gray-Davidson, Frena. The Alzheimer's Sourcebook for Caregivers: A Practical Guide for Getting through the Day. Los Angeles: Lowell House, 1999.<br /><br />Khatchaturian, Zaven S., and M. Marcel Mesulam, eds. Alzheimer's Disease: A Compendium of Current Theories. New York: New York Academy of Sciences, 2000.<br /><br />Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day. Baltimore: The John Hopkins University Press, 1999.<br /><br />Tanzi, Rudolph E. Decoding Darkness: The Search for the Genetic Causes of Alzheimer's Disease. Cambridge, MA: Perseus Publishing, 2000.<br />PERIODICALS<br /><br />Glaser, Vicki. "Strategies for Early Diagnosis." Patient Care 35 no. 3 (February 15, 2001): 22.<br /><br />Hines, Silvia E. "Contemporary Drug Treatment." Patient Care 35 no. 3 (February 15, 2001): 54.<br /><br />Nichols, Mark. "On the Trail of a Killer: Researchers Discover a Key to the Mystery of Why Cells Die." Maclean's (April 9, 2001): 40.<br />ORGANIZATIONS<br /><br />Alzheimer's Association. 919 North Michigan Ave., Suite 1100, Chicago, IL 60611. (800) 272-3900. (312) 335-8700). <http://www.alz.org/>.<br /><br />National Institute of Aging, Alzheimer's Education, and Referral Center. (800) 438-4380.<br />OTHER<br /><br />Alzheimer's Disease Books and Videotapes. <http://www.alzheimersbooks.com>.<br /><br />Author unspecified. "Ten Warning Signs." Alzheimer's Association. <http://www.alz.org/people/understanding/warning.htm>.<br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-1860181715450142142010-01-15T11:49:00.000-08:002010-01-15T11:50:20.205-08:00Advanced Practice NurseDefinition<br /><br />Advanced practice nurses are typically those nurses prepared at the master's or doctoral level, and they fall into four categories of clinicians: clinical nurse specialists, certified registered nurse anesthetists, nurse practitioners, and certified nurse-midwives.<br /><span class="fullpost"><br />Description<br />Clinical nurse specialists<br /><br />Clinical nurse specialists (CNSs) are licensed registered nurses (RNs) with additional master's or doctorate-level training in CNS. These advanced practice nurses are clinical experts in theory-based or research-based nursing, focusing on specific specialty areas.<br /><br />CNSs have broadened patient care roles because of their advanced training. In some states, they have the authority to prescribe medications.<br /><br />CNSs assume many roles within the health care delivery system. While many are in the clinical setting, others work as educators, administrators, consultants, researchers, change agents, and case managers. CNSs can become specialized in the areas of adult psychiatry, child psychology, community health, home health, gerontology, and medical-surgical, as well as oncology, perinatal critical care, critical care, and rehabilitation. Some nurses in areas of specialty certification classify themselves as CNSs, others use the umbrella term of advanced practice nursing<br /><br />In March 2000, the number of RNs prepared to practice in at least one advanced practice role was estimated to be about 7.3% of the total RN population. The largest group among the advanced practice nurses was the nurse practitioners, followed by the CNSs. These two groups together made up about 80% of all advanced practice nurses. Although about 36.9% of the CNSs were employed in nursing, only about 24% were practicing under the position title of CNS. Nearly 25% of CNSs reported working in nursing education positions.<br />Certified registered nurse anesthetist<br /><br />Nurse anesthesia is the oldest of the advanced nursing specialties. These advanced clinical nurses, called certified registered nurse anesthetists (CRNAs), administer about 65% of the anesthetics given to patients annually in the United States.<br /><br />Nurse anesthetists make up the third largest group of advanced practice nurses, and were the first professional group in the United States to provide anesthesia services in the 1800s. Their role in surgery is to keep patients as comfortable, pain free, and safe as possible. Nurse anesthetists perform patient physical assessments; take part in preoperative teaching; develop, prepare, and implement the anesthesia plan; select, obtain, and administer anesthesia and other medications and fluids needed to manage the anesthetic; maintain anesthesia throughout the operation and manage the patient's airway and pulmonary status; respond as necessary to emergency situations ensuring airway management, administering emergency fluids or medications, and performing cardiac life support techniques; and follow patients through recovery and into the patient care unit. Essentially, they take care of patients before, during, and after having surgery or giving birth.<br /><br />CRNAs can sub-specialize in pediatric, obstetric, cardiovascular, plastic, dental, or neurosurgical anesthesia. Some have credentials in critical care nursing and respiratory care.<br />Nurse practitioner<br /><br />Nurse practitioners (NPs) are registered nurses who have advanced academic and clinical experience. Because of this additional training, NPs can diagnose and manage common and chronic illnesses, independently or as part of a health care team. Nurse practitioners often can provide primary care previously offered only by doctors and, in many states, they prescribe medications. While in many cases NPs work in collaboration with physicians, NPs have the authority to practice without a physician collaboration or supervision in 18 states.<br /><br />NPs perform physical exams; diagnose and treat many acute illnesses and injuries; provide immunizations; manage high blood pressure, diabetes, and other chronic conditions; order and interpret x rays and other lab tests; and counsel and educate patients about how they can live healthy lifestyles. NPs focus much of their practice on health maintenance, disease prevention, patient education, and counseling. While they have a strong emphasis on primary care, NPs practice in a wide variety of specialties, including neonatology, obgyn, pediatrics, school health, family and adult health, mental health, home care, geriatrics, and acute care.<br />Certified nurse-midwife<br /><br />Certified nurse-midwives (CNMs) focus on the independent management of women's health care, particularly on pregnancy, childbirth, the postpartum period, care of the newborn and the family planning, and gynecological needs of women. They have the authority to write prescriptions. CNMs deliver babies in all types of health care settings, as well as in private homes, and provide primary health care to women, often helping them to realize personal fulfillment through labor and birth. CNMs work independently and in collaboration with other health care providers. They also teach and conduct research.<br /><br />The trend seems to be that more people are choosing CNMs. As of 1998, there were nearly 278,000 CNM-attended births in the United States. About 400 nurse-midwives pass the national certification exam each year. The practice of nurse-midwifery is legal in all states and the District of Columbia. These advanced practice nurses have prescription-writing ability in 50 states and jurisdictions. Ninety percent of all visits to CNMs are for primary and preventive care. Seventy percent of that was for care during pregnancy and after birth, while 20% was for care outside of the maternity cycle.<br />Work settings<br />Clinical nurse specialists<br /><br />CNSs work in the acute care, long-term care, and intermediate care settings. They work in clinical education within health care facilities, as well as in nursing education programs as faculty teaching nursing. Other settings in which CNSs work include outpatient and ambulatory care, private practice, home health, physician office practice, sub-acute care, government or military service, community health centers, health care administration, private industry (working for drug companies or manufacturers, in managed care and other areas of the private sector), and nurse-managed centers. Within these categories, CNSs work in assisted living facilities; specialized hospital areas, such as cardiac catheterization labs; correctional facilities; dialysis units; parish nursing; and psychiatric hospitals.<br />Certified registered nurse anesthetist<br /><br />Nurse anesthetists can work with an physician anesthesiologist, independently or in groups as providers of anesthetics. They work as part of a medical team or independently in any setting in which anesthesia is given, including doctors' and dentists' offices, pain clinics, operating rooms of hospitals, and ambulatory surgery settings. CRNAs who work independently or in groups might have contracts with physicians or hospitals. Some CRNAs work in private practices, while others choose the public sector or the U.S. military. They work in universities as instructors and in research settings as investigators, collaborators, consultants, assistants, interpreters, and researchers. CRNAs also work in surgical and obstetric environments in MRI units, cardiac catheterization labs, and lithotripsy units. In these environments, they provide consultation and implementation of respiratory and ventilatory care, manage emergency situations, and start or participate in airway maintenance, ventilation, and tracheal intubation during CPR.<br />Nurse practitioner<br /><br />Nurse practitioners work in metropolitan area clinics and hospitals, as well as in rural areas, inner cities, and medically underserved locations. They work in schools, caring for children, and in nursing homes and assisted living facilities, caring for the elderly and others. NPs work in pediatric, family health, women's health, and other specialty settings. Some work in private practices or in nurse-run group practices.<br />Certified nurse-midwife<br /><br />CNMs work in clinical practice in public, university, and military hospitals. They also work in health maintenance organizations, private practices, and birthing centers. Many practice in public heath clinic, and some provide home birth services. More than 50% of CNMs work most often in the office or clinic environment, listing a hospital or physician practice as their employer.<br />Education and training<br />Clinical nurse specialists<br /><br />Nurses must have a baccalaureate degree or its equivalent to enroll in a CNS program. To use the title of CNS, the CNS must have a minimum of a master's degree from an education program that prepares CNSs. The training is graduate-level education. Some universities have a fast track program whereby they will accept individuals who do not have a baccalaureate and move them into a master's program. CNSs also take a certification exam in a specialty, offered by one of the nationally recognized certification entities.<br /><br />CNS students go through advanced theory and practice training, revolving around the three areas of influence that impact on direct patient care, supervising direct patient care, and patient care systems.<br /><br />The American Nurses Credentialing Center certifies CNSs as adult psychiatric, child psychology, community health, home health, gerontology, and medical-surgical CNSs. There also are other certifying bodies, including the Rehabilitation Nursing Certification Board, Oncology Nursing Certification Corporation, and American Association of Critical Care Nurses Certification.<br /><br />The doctoral-level CNS typically focuses on research.<br />Certified registered nurse anesthetist<br /><br />Nurse anesthetists are registered nurses who complete two to three years of higher education, beyond the bachelor's of nursing degree or other appropriate baccalaureate degree. They attend accredited nurse anesthesia educations programs, covering all areas of anesthesia. After completing an accredited program, nurse anesthetists must pass a national certification exam to obtain the CRNA designation.<br /><br />The education for a nurse anesthetist involves about 24 to 36 months of graduate course work. It includes classroom and clinical experience.<br /><br />In most cases, to be accepted into an accredited school, those who aspire to become nurse anesthetists must have an appropriate four-year degree, an RN license, and at least one year of acute care nursing experience, which varies by program.<br />Nurse practitioner<br /><br />NPs receive their advanced educations through programs that award master's degrees. RNs who aspire to become NPs should have extensive clinical experience before applying to an NP program. NP programs include the components of an intensive preceptorship under the direct supervision of a physician or experienced NP and instruction in nursing theory. An increasing number of nurses are becoming prepared as both NPs and CNSs. Those prepared in both roles are more likely to function as nurse practitioners.<br />Certified nurse-midwife<br /><br />CNMs are educated in the two disciplines of nursing and midwifery. They must possess evidence of certification according to the requirements of the American College of Nurse-Midwives. Being an RN is a requirement to become a certified nurse-midwife. In some cases, those with baccalaureate degrees in other fields are considered. Upon graduation, CNMs can receive MS (master's of science), MSN (master's of science in nursing), MPH (master's of public health) degrees or a doctoral degree. About 68% of CNMs have master's degrees, while 4% have doctoral degrees. There are also those who graduate with a certificate or from a nurse-midwifery education program. However, the number of states and employers who require master's-prepared CNMs is increasing. Once in the program, student CNMs receive labor and delivery experience in different types of settings. They must pass a national certification exam to call themselves CNMs.<br />Advanced education and training<br /><br />All advanced practice nurses with master's degree can go on to get their doctorate degrees. Often, those with doctorate-level training go into research, administration, or teaching at the university level.<br />Future outlook<br /><br />The outlook is good for all types of nurses, especially those at the RN level or higher. It is projected that if current trends continue, demand will exceed supply of RNs by about 2010. It is possible that as many as 114,000 jobs for full-time-equivalent RNs are going to go unfilled nationwide by 2015. This is due to a growing elderly population with mounting health care needs, an aging RN workforce, the expansion of primary care, and technological advances that require more highly trained nurses.<br /><br />There is a growing demand for RNs with advanced clinical skills. Almost all who graduate have jobs waiting for them.<br />Resources<br />ORGANIZATIONS<br /><br />American Association of Colleges of Nursing. One Dupont Circle, NW, Suite 530, Washington, DC 20036. (202) 463-6930. <http://www.aacn.nche.edu>.<br /><br />American Association of Nurse Anesthetists. 222 South Prospect Avenue, Park Ridge, IL 60068-4001. (847) 692-7050. <http://www.aana.com>.<br /><br />American College of Nurse-Midwives. 818 Connecticut Ave. NW, Suite 900, Washington, DC 20006. (202) 738-9860. <http://www.acnm.org>.<br /><br />American College of Nurse Practitioners. 503 Capitol Ct. NE, #300, Washington, DC 20002. (202) 546-4825. <http://www.nurse.org>.<br /><br />American Nurses Association. 600 Maryland Avenue, SW, Suite 100 West, Washington, DC 20024. (800) 274-4ANA. <http://www.ana.org>.<br /><br />National Association of Clinical Nurse Specialists. 3969 Green Street, Harrisburg, PA 17110-1575. (717) 234-6799. <http://www.nacn.org>.<br />OTHER<br /><br />The Registered Nurse Population National Sample Survey of Registered Nurses—March 2000. U.S. Department of Health and Human Services, Health Resources and Services administration. Bureau of Health Professions. Division of Nursing. <http://bhpr.hrsa.gov>.<br /><br />http://www.enotes.com<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-55400686016480690102010-01-15T11:46:00.000-08:002010-01-15T11:47:49.426-08:00Acute Kidney Failurehttp://www.enotes.com<br /><br />Definition<br /><br />Acute kidney failure (AKF) occurs when there is a sudden reduction in kidney function that results in nitrogenous wastes accumulating in the blood (azotemia).<br />Description<br /><br />The kidneys are the body's natural filtration system. They perform the critical task of processing approximately 200 quarts of fluid in the bloodstream every 24 hours. Waste products like urea and toxins, along with excess fluids, are removed from the bloodstream in the form of urine. Kidney (or renal) failure occurs when kidney functioning becomes impaired somehow.<br /><span class="fullpost"><br />Fluids and toxins begin to accumulate in the bloodstream. As fluids build up in the bloodstream, the patient with AKF may become puffy and swollen (edematous) in the face, hands, and feet. Their blood pressure typically begins to rise, and they may experience fatigue and nausea. Often urine output decreases drastically or is not produced at all.<br /><br />Unlike chronic kidney failure, which is long term and irreversible, acute kidney failure is often a temporary condition. With proper and timely treatment, it can many times be reversed, leaving no permanent or serious damage to the kidneys.<br />Causes and symptoms<br /><br />Acute kidney failure appears most frequently as a complication of serious illness, like heart and/or liver failure, serious infection, dehydration, severe burns, and excessive bleeding (hemorrhage). It may also be caused by an obstruction to the urinary tract or as a direct result of kidney disease, injury, or an adverse reaction to medicine. These conditions divide AKF into three main categories: prerenal, postrenal, and intrinsic (inside) conditions.<br /><br />Prerenal AKF does not damage the kidney, but can cause diminished kidney function and significantly decreased renal (kidney) blood flow. It is the most common type of acute renal failure, and is often the result of:<br /><br /> * dehydration<br /> * extracellular fluid (ECF) volume depletion (or other acute fluid loss from the gastrointestinal tract, kidneys, or skin)<br /> * drugs (NSAIDS, cyclosporine, radiopaque contrast materials, or any substance toxic to the kidneys)<br /> * hemorrhage<br /> * septicemia, or sepsis<br /> * congestive heart failure (CHF)<br /> * liver failure<br /> * burns<br /> * decreased intravascular volume (referred to as third spacing, also found in the presence of pancreatitis, post surgical patients, and patients with a nephrotic syndrome)<br /><br />Postrenal AKF is the result of an obstruction of some kind somewhere in the urinary tract, often in the bladder or ureters (the tubes leading from the kidney to the bladder). The kidneys compensate to such a degree that one kidney can be completely obstructed and the other will maintain nearly normal kidney function for the body. The conditions that often cause postrenal AKF are:<br /><br /> * inflammation of the prostate gland in men (prostatitis)<br /> * enlargement of the prostate gland (benign prostatic hypertrophy)<br /> * bladder or pelvic tumors<br /> * kidney stones (calculi)<br /><br />Intrinsic AKF involves a type of kidney disease or direct injury to the kidneys. This type of AKF accounts for 20-30% of AKF reported among hospitalized patients. Intrinsic AKF can result from:<br /><br /> * lack of blood supply to the kidneys (ischemia)<br /> * use of radiocontrast agents in patients with kidney problems<br /> * drug abuse or overdose<br /> * long-term use of nephrotoxic medications, like certain pain medicines<br /> * acute inflammation of the glomeruli, or filters, of the kidney (glomerulonephritis)<br /> * kidney infections (pyelitis or pyelonephritis)<br /> * infiltration by lymphoma, leukemia, or sarcoid carcinomas<br /><br />Common symptoms of AKF include:<br /><br /> * Anemia. The kidneys are responsible for producing erythropoietin (EPO), a hormone that stimulates red blood cell production. If kidney disease causes shrinking of the kidney, red blood cell production is reduced, leading to anemia.<br /> * Bad breath or bad taste in mouth. Urea in the saliva may cause an ammonia-like taste in the mouth.<br /> * Bone and joint problems. The kidneys produce vitamin D, which helps the body absorb calcium and keeps bones strong. For patients with kidney failure, bones may become brittle. In children, normal growth may be stunted. Joint pain may also occur as a result of high phosphate levels in the blood. Retention of uric acid may cause gout.<br /> * Edema. Puffiness or swelling in the arms, hands, feet, and around the eyes.<br /> * Frequent urination.<br /> * Foamy or bloody urine. Protein in the urine may cause it to foam significantly. Blood in the urine may indicate bleeding from diseased or obstructed kidneys, bladder, or ureters.<br /> * Cola-colored urine followed by oliguria (decreased urine output) or anuria (no urine output)<br /> * Headaches. High blood pressure may trigger headaches.<br /> * Hypertension, or high blood pressure. The retention of fluids and wastes causes blood volume to increase. This makes blood pressure rise.<br /> * Increased fatigue. Toxic substances in the blood and the presence of anemia may cause the patient to feel exhausted.<br /> * Itching. Phosphorus, normally eliminated in the urine, accumulates in the blood of patients with kidney failure. An increased phosphorus level may cause the skin to itch.<br /> * Lower back pain. Patients suffering from certain kidney problems (like kidney stones and other obstructions) may have pain where the kidneys are located, in the small of the back below the ribs.<br /> * Nausea. Urea in the gastric juices may cause upset stomach.<br /><br />Diagnosis<br /><br />Kidney failure is diagnosed by a doctor, whether the patient is in the hospital or seen as an outpatient. He or she will take a complete medical history and make a thorough review of the patient's medical record, looking for exposure to nephrotoxic (medicines that can be hard on the kidneys) drugs or other clues to the patient's condition. The physician will then conduct a thorough physical examination, making a careful assessment of the patient's ECF volume and effective circulating blood volume (EBV). A nephrologist, a doctor that specializes in the kidney, may be consulted to confirm the diagnosis and recommend treatment options. He or she will look for a recent history of changes in body weight and try and determine whether the patient is taking in much more fluid than he or she is excreting. Capillary wedge pressure and cardiac output values are also effective tools in pinpointing the cause and extent of the AKF.<br /><br />The patient that is suspected of having AKF will have blood and urine tests to determine the level of kidney function. A blood test will assess the levels of creatinine, blood urea nitrogen (BUN), uric acid, phosphate, sodium, and potassium. The kidney regulates these agents in the blood. Urine samples will also be collected, usually over a 24-hour period, to assess protein loss and/or creatinine clearance.<br /><br />Determining the cause of kidney failure is critical to proper treatment. Prerenal or obstructive causes are often looked into first because they are the quickest types of AKF to treat. A full assessment of the kidneys is necessary to determine if the underlying disease is treatable and if the kidney failure is chronic or acute. X rays, magnetic resonance imaging (MRI), computed tomography scan (CT), ultrasound, renal biopsy, and/or arteriogram of the kidneys may be used to determine the cause of kidney failure and level of remaining kidney function. X rays and ultrasound of the bladder and/or ureters may also be needed.<br />Treatment<br /><br />Treatment for AKF varies, since it is directed to the underlying, primary medical condition that triggered thekidney failure. Prerenal conditions may be treated with replacement fluids given through a vein, diuretics, blood transfusion, restricted salt intake, or medications. Postrenal conditions and intrarenal conditions may require surgery and/or medication.<br /><br />Frequently, patients in AKF require hemodialysis, hemofiltration, or peritoneal dialysis to filter fluids and wastes from the bloodstream until the primary medical condition can be controlled.<br />Hemodialysis<br /><br />Hemodialysis involves circulating the patient's blood outside of the body through an extracorporeal circuit (ECC), or dialysis circuit. The ECC is made up of plastic blood tubing, a filter known as a dialyzer (or artificial kidney), and a dialysis machine that monitors and maintains blood flow and administers dialysate. Dialysate is a sterile chemical solution that is used to draw waste products out of the blood. The patient's blood leaves the body through the vein and travels through the ECC and the dialyzer, where fluid removal takes place.<br /><br />During dialysis, waste products in the bloodstream are carried out of the body. At the same time, electrolytes and other chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the body.<br /><br />A dialysis "run" typically lasts three to four hours, depending on the type of dialyzer used and the physical condition of the patient. Dialysis is used several times a week until AKF has resolved.<br /><br />Blood pressure changes associated with hemodialysis may pose a risk for patients with heart problems. Peritoneal dialysis may be the preferred treatment option in these cases.<br />Hemofiltration<br /><br />Hemofiltration, also called continuous renal replacement therapy (CRRT), is a slow, continuous blood filtration therapy used to control acute kidney failure in critically ill patients. These patients are typically very sick and may have heart problems or circulatory problems. They cannot endure the rapid filtration rates of hemodialysis. They also frequently need antibiotics, nutrition, vasopressors, and other fluids given through a vein to treat their primary condition. Because hemofiltration is continuous, prescription fluids can be given to patients in kidney failure without the risk of fluid overload.<br /><br />Like hemodialysis, hemofiltration uses an ECC. A hollow fiber hemofilter is used instead of a dialyzer to remove fluids and toxins. Instead of a dialysis machine, a blood pump makes the blood flow through the ECC. The volume of blood circulating through the ECC in hemofiltration is less than that in hemodialysis. Filtration rates are slower and gentler on the circulatory system. Hemofiltration treatment will generally be used until kidney failure is reversed.<br />Peritoneal dialysis<br /><br />Peritoneal dialysis may be used if the patient in AKF is stable and not in immediate crisis. In peritoneal dialysis (PD), the lining of the patient's abdomen, the peritoneum, acts as a blood filter. A flexible tube-like instrument (catheter) is surgically inserted into the patient's abdomen. During treatment, the catheter is used to fill the abdominal cavity with dialysate. Waste products and excess fluids move from the patient's bloodstream into the dialysate solution. After a certain time period, the waste-filled dialysate is drained from the abdomen, and replaced with clean dialysate. There are three types of peritoneal dialysis, which vary according to treatment time and administration method.<br /><br />Peritoneal dialysis is often the best treatment option for infants and children. Their small size can make vein access difficult to maintain. It is not recommended for patients with abdominal adhesions or other abdominal defects (like a hernia) that might reduce the efficiency of the treatment. It is also not recommended for patients who suffer frequent bouts of an inflammation of the small pouches in the intestinal tract (diverticulitis).<br />Prognosis<br /><br />Because many of the illnesses and underlying conditions that often trigger AKF are critical, the prognosis for these patients many times is not good. Studies have estimated overall death rates for AKF at 42-88%. Many people, however, die because of the primary disease that has caused the kidney failure. These figures may also be misleading because patients who experience kidney failure as a result of less serious illnesses (like kidney stones or dehydration) have an excellent chance of complete recovery. Early recognition and prompt, appropriate treatment are key to patient recovery.<br /><br />Survival statistics also depend on the type of AKF the patient has, age at time of onset, and general health. If the patient has prerenal AKF, there is a good recovery prognosis, but the mortality rate is higher among those who fail to respond to diuretics and vasodilator therapy. Since 1980, age has become a risk factor that increased mortality in patients with acute tubular necrosis (ATN), an intrinsic form of AKF.<br /><br />Up to 10% of patients who experience AKF will suffer irreversible kidney damage. They will eventually go on to develop chronic kidney failure or end-stage renal<br /><br />disease. These patients will require long-term dialysis or kidney transplantation to replace their lost renal functioning.<br />Health care team roles<br /><br />The patient who suffers from AKF will come in contact with a number of different health care professionals during both the diagnosis and treatment phase of the illness. Patients will require (according to the type and severity of their condition) laboratory work, diagnostic radiology services, pharmaceutical and nutritional interventions, dialysis (in some cases), nursing care, and disease management by a nephrologist.<br /><br />The medical history, taken by a physician in the emergency room, the patient's family doctor, a fellow nurse practitioner, physician's assistant (PA), or a nephrologist is the most essential tool in determining the cause and type of AKF. The admitting physician or nephrologist will conduct a thorough physical, looking at the following areas for specific clues.<br /><br />Skin. Checking the patient for areas of small, purple or red spots (petechiae), hemorrhage beneath the skin (purpura), and bluish discoloration of a fairly large area of the skin (ecchymosis) can lead to a diagnosis of an inflammatory or vascular cause for the AKF.<br /><br />Eyes. Certain conditions in the eyes can point to a diagnosis of interstitial nephritis (inflammation between the cells and tissues of the kidney) or necrotizing vasculitis (inflammed blood vessels).<br /><br />Cardiovascular and volume status. Evaluating the condition of the heart and the rest of the circulatory system plus volume status (fluid balance) is the most important part of diagnosing and managing AKF. Nurses and nurses' aides will measure and chart daily intake and output (measuring how much fluid the patient takes in and how much he or she excretes in a 24-hour period of time). This is one of the best ways to get a good estimate of volume status. The pulse rate and blood pressure will be taken by the physician, nurses, and nurses' aides often in both the upright (standing or sitting on the side of the bed with legs dangling down) and supine (lying down) positions. The physician will also check the pulse in the neck, examine the heart and lungs, and check for edema (fluid buildup) in the arms and legs. Different combinations of the results of these assessments point to different causes for and types of AKF.<br /><br />Abdomen. The physician will feel for signs of urinary tract obstruction by palpating (pressing) on the bladder and the upper corners of the abdomen that may reveal an obstruction in the ureter (tube between the kidney and the bladder) somewhere. If the entire abdomen is unusually swollen and filled with fluid (ascites), the AKF may be the result of liver failure.<br /><br />Arms and legs (extremities). The physican and nursing staff will check the patients arms and legs for edema at the time of diagnosis and throughout treatment. Edema in the arms and legs is a sign of a decrease in oxygenated blood (ischemia), muscle tenderness from rhabdomyolysis (disease of the skeletal muscle), or arthritis. The presence and degree of edema is helpful in pinpointing the cause of AKF and in measuring the patient's progress with treatment.<br /><br />Nervous system. The physician will assess the patient's degree of mental clarity and nerve responses, as abnormalities in these areas of the nervous system are often common symptoms of AKF. The nursing staff also monitors the patient's mental status during the course of treatment.<br /><br />Laboratory personnel will draw blood and collect urine samples to help diagnose AKF and later, to evaluate treatment. Increases in BUN (blood urea nitrogen) and creatinine (substance formed from the metabolism of creatine) are indicators of AKF.<br /><br />The urinalysis is the most important test run in the early stage of AKF evaluation. Significant color changes point to an intrinsic cause for AKF. Urine dipstick tests that prove positive for proteinuria (too much protein) and blood are helpful in diagnosing many causes of AKF. The different types of sediment readings from spun urine samples can further help to distinguish the cause and type of AKF. Urine electrolytes indicate how well the tubules (part of the kidney's nephron) are working.<br /><br />Nurses and nurses' aides will keep track of fluids the patient takes in (intake) and eliminates (output) to help determine the type of AKF the patient is in and to help the physician manage the patient's course of treatment. Fluid management is critical in the patient with AKF, regardless of the cause.<br /><br />Patients in AKF may undergo further evaluation in the Radiology Department to determine the cause of their disease and to plan an appropriate plan of treatment. They may undergo an ultrasound examination, doppler scan, nuclear scan, MRI, renal angiography, or a renal biopsy. The ultrasound, doppler scan, and MRI are the least invasive of the procedures. Contrast material is injected for the angiogram and the renal biopsy requires taking tissue samples from the kidney itself. These procedures are performed by trained and licensed radiologic technologists and radiologists.<br /><br />Nutrition is crucial to the effective management of the patient in AKF. The dietician will work closely with the patient, physician, nursing staff, and pharmacist to ensure proper electrolyte balance, whether the patient eats regular foods or is nourished by total parenteral nutrition (TPN, nutrients mixed and fed through a tube).<br /><br />Some patients will require kidney dialysis that will be performed by nurses and technicians from the renal or urology department.<br /><br />Since many different medications are eliminated through the kidneys, the physician works closely with the pharmacist to modify dosing and minimize the use of medications that are toxic to the kidneys.<br />Prevention<br /><br />Since AKF can be caused by many things, prevention is difficult. Medications that may impair kidney function should be given cautiously. Patients with preexisting kidney conditions who are hospitalized for other illnesses or injuries should be carefully monitored for kidney failure complications. Treatments and procedures that may put them at risk for kidney failure (like diagnostic tests requiring radiocontrast agents or dyes) should be used with extreme caution.<br />KEY TERMS<br /><br />Anuria—When the body ceases to make urine entirely or falls below 100 mls.<br /><br />Azotemia—Too many nitrogenous compounds in the blood caused by the kidneys' failure to remove urea from the blood.<br /><br />Blood urea nitrogen (BUN)—A waste product that is formed in the liver and collects in the bloodstream; patients with kidney failure have high BUN levels.<br /><br />Capillary wedge pressure—The blood pressure inside of a capillary.<br /><br />Cardiac output—The volume of blood pushed out by the ventricles.<br /><br />Creatinine—A protein produced by muscle that healthy kidneys filter out.<br /><br />Edema—The abnormal accumulation of fluid in the interstitial spaces of tissue.<br /><br />Electrolytes—An element or a compound that can break into ions and conduct electrical current when melted or dissolved in water.<br /><br />Erythropoietin (EPO)—A glycoprotein hormone made in the kidneys.<br /><br />Extracellular fluid (ECF)—That part of body fluid made of interstitial fluid and blood plasma.<br /><br />Extracorporeal—Outside of, or unrelated to, the body.<br /><br />Glomeruli—The tiny structures that perform the actual mechanical filtering in the kidney.<br /><br />Gout—A condition caused by error in uric acid metabolism.<br /><br />Interstitial—The space between cells.<br /><br />Intravascular volume—The volume of fluid inside a blood vessel.<br /><br />Intrinsic—Starting from or situated inside an organ or tissue.<br /><br />Ischemia—A lack of blood supply to an organ or tissue.<br /><br />Lymphoma—Cancer of the lymph tissue.<br /><br />Nephritis—Inflammation and abnormal functioning of the kidney.<br /><br />Nephrologist—A physician who specializes in treating diseases of the kidney.<br /><br />Nephrotoxic—Toxic, or damaging, to the kidney.<br /><br />NSAIDS—Non-steroidal, antiinflammatory drug.<br /><br />Oliguria—Abnormally low urine production.<br /><br />Radiocontrast agents—Dyes administered to a patient for the purposes of a radiologic study.<br /><br />Sepsis—A bacterial infection of the bloodstream.<br /><br />Urea—A systemic diuretic.<br /><br />Vasopressors—Medications that constrict the blood vessels.<br />Resources<br />BOOKS<br /><br />Anderson, Kenneth N., Anderson, Lois, E., and Glanze, Walter D., eds. Mosby's Medical, Nursing, & Allied Health Dictionary, 5th edition. New York: Mosby, 1998.<br /><br />Beers, Mark H., M.D., and Berkow, Robert M.D., eds. The Merck Manual, 17th edition. New Jersey: Merck Research Laboratories, 1999.<br /><br />Faubert, Pierre F., and Porush, Jerome G. Renal Disease in the Elderly. New York: Marcel Dekker, Inc., 1999.<br /><br />Gennari, F. John, ed. Medical Management of Kidney and Electrolyte Disorders. New York: Marcel Dekker, Inc.,2001.<br /><br />Greenberg, Arthur, Cheung, Alfred K., Coffmann, Thomas M., Falk, Ronald J., and J. Charles, Jeanette, eds. Primer on Kidney Diseases, Second Edition - National Kidney Foundation. New York: Academic Press, 1999.<br />PERIODICALS<br /><br />Andreucci, M., Federico, S., and Andreucci, V.E. "Edema and Acute Renal Failure." Seminars in Nephrology 21, 3(May 2001): 251-6.<br /><br />Forbes, J.M., Hewitson, T.D., Becker, G.J., and Jones, C.L. "Simultaneous Blockade of Endothelin A and B Receptors in Ischemic Acute Renal Failure is Detrimental to Long-term Kidney Function." Kidney International 59, 4(April 2001): 1333-41.<br /><br />Gruberg, L., Mehran, R., Dangas, G., Mintz, G.S., Waksman, R., Kent, K.M., Pichard, A.D., Satler, L.F., Wu, H., and Leon, M.B. "Acute Renal Failure Requiring Dialysis After Percutaneous Coronary Interventions." Catheter Cardiovascular Interventions 59, 4(April 2001): 409-16.<br /><br />Knoll, T., Schult, S., Birck, R., Braun, C., Michel, M.S., Bross, S., Juenemann, K.P., Kirchengast, M., and Rohmeiss, P. "Therapeutic Administration of an Endothelin-A Receptor Antagonist After Acute Ischemic Renal Failure Dose-Dependently Improves Recovery of Renal Function." Journal of Cardiovascular Pharmacology 37, 4(April 2001): 483-8.<br /><br />Rana, A., Sathyanarayana, P., and Lieberthal, W. "Role of Apoptosis of Renal Tubular Cells in Acute Renal Failure: Therapeutic Implications." Apoptosis 6,1-2(February-April 2001): 83-102<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-71228868955476612902009-12-29T08:13:00.000-08:002009-12-29T08:15:03.577-08:00Airway Managementenotes.com,<br /><br />Definition<br /><br />Airway management involves ensuring that the patient has a patent airway through which effective ventilation can take place.<br /><br />Purpose<br /><br />An obstructed airway means that the body is deprived of oxygen. If ventilation is not reestablished, brain death will occur within minutes. The primary purpose of airway management is to provide a continuously open airway along with a continuous source of oxygen. When a patient is critically ill and requires an artificial airway and mechanical ventilation, it is the responsibility of the healthcare professionals caring for the patient to ensure that the airway is secure.<br /><span class="fullpost"><br />Another goal of airway management is to provide an artificial airway that is as close to the patient's natural airway as possible. This may mean mechanically performing physiological functions such as humidifying inspired air and removing secretions.<br />Precautions<br /><br />Airway management is a necessity for any patient who has an artificial airway. If the patient is restless or agitated, it is recommended that activities such as suctioning or endotracheal tube care be postponed until either the patient is calm or a sedative has been given. This is to avoid inadvertent removal of the airway. However, if the patient's respiratory status is unstable, suctioning or repositioning the endotracheal tube should be done if it will stabilize the patient.<br />Description<br /><br />Airway management consists of much more than just keeping the breathing tube in the correct position. The tube must be managed so that it allows optimal ventilation with the fewest complications.<br />Humidification<br /><br />Humidification of inspired air normally takes place in the upper respiratory tract. When this area is bypassed by an artificial airway (such as an endotracheal or tracheostomy tube), humidification must be performed out-side the body. If supplemental oxygen is used, it will require humidification to prevent drying and irritation of the respiratory tract and to facilitate removal of secretions. There are humidification devices available that can be attached to oxygen flow meters or ventilators.<br />Suctioning<br /><br />Suctioning consists of inserting a sterile catheter into the endotracheal or tracheostomy tube in order to remove secretions. This is an extremely important part of caring for a patient with an artificial airway, since the reflex of coughing, which would normally remove these secretions, is not effective. The patient will experience respiratory distress if the tube is obstructed by sputum. Suctioning should be performed only when the patient<br /><br />needs it; however, the need should be assessed at least every two hours.<br /><br />A number of studies have been done to find ways to minimize the complications of suctioning. Equipment should be sterilized to decrease the risk of infection. There are now closed suction systems available that are attached to the ventilator tubing on one end and to the artificial airway on the other. The catheter remains protected inside a sterile plastic sleeve that is changed every 24 hours. This system limits the amount of times the tubing must be disconnected from the airway, thus reducing exposure of the trachea to environmental contaminants.<br /><br />Suctioning causes oxygen deprivation for the time that the suction is applied. Hypoxemia can be minimized by preoxygenating the patient with 100% oxygen prior to suctioning and between each pass of the suction catheter. (This can be done by either pushing the 100% oxygen button on the ventilator or by using a bag-valve-mask device.) The patient's pulse oximetry should be monitored while suctioning. The duration of each suction pass should be limited to 10 seconds and the number of passes should be limited to three or less if possible. This decreases hypoxemia and airway trauma. Studies have shown that using intermittent suction is no more beneficial than continuous suction.<br /><br />Installation of a small amount of saline prior to suctioning was a common procedure in the past. It was thought that saline helped to loosen secretions and to facilitate their removal, but studies have shown this is not the case. On the contrary, saline installation has been shown to increase infection rates and to cause decreased oxygen levels for longer periods than suctioning without saline use. This procedure is no longer regarded as beneficial.<br />Preparation<br /><br />Preparation for airway management includes explaining all procedures that will be performed to the patient. Often, patients who are receiving mechanical ventilation are kept sedated or even paralyzed to facilitate optimal ventilation. The level of sedation should be assessed. If patients are not receiving continuous infusions of a sedating drug, they may have a physician's order for sedation as needed. If they are agitated, they should be given the prescribed dose of sedation prior to performing any airway-related procedures, to ensure that the airway is not inadvertently removed.<br /><br />Patients receiving mechanical ventilation also often have bilateral soft wrist restraints applied to prevent accidental removal of the artificial airway. It is recommended that these be securely fastened before starting an airway-related procedure, or that another healthcare professional be at the bedside to help calm and hold the patient. Also, all needed supplies should be at the bedside prior to starting a procedure, so as to not cause excess discomfort or stress for the patient.<br />Aftercare<br /><br />After the procedure is finished, the patient should be reassured if necessary and their respiratory status should be reassessed. The insertion point of the airway should be confirmed to be at the same place as prior to the procedure, unless the purpose was to change the depth of the tube. If the airway has been manipulated since suctioning, the patient may require suctioning again. Any waste should be disposed of in the garbage or in a biohazard container if there is a large amount of blood. Prior to the healthcare professional leaving the room, the patient should be made comfortable, further sedation or pain medication should be administered as needed and the patient should be confirmed to be stable.<br />Complications<br /><br />The greatest risk of airway management is that the airway may be inadvertently removed, causing the patient to have respiratory distress. Procedures that require manipulating the airway may cause fear or agitation for patients if they feel that they do not have control over their breathing. If the patient becomes combative, it can be very difficult to finish the procedure without disturbing the airway.<br />Results<br /><br />The anticipated outcomes of airway management are a continuously open airway through which effective ventilation can take place, and prevention of infection.<br />Health care team roles<br /><br />The nurse and respiratory therapist are equally responsible for monitoring and managing artificial airways. Both perform sterile suctioning and both document their assessment of the patient's respiratory status. The respiratory therapist is generally responsible for managing the ventilator, adding humidification, and changing ventilator tubing.<br /><br />If the patient is accidentally extubated (the airway is removed), both the nurse and respiratory therapist must assist in reinsertion. This is usually done by an anesthesiologist, a certified registered nurse anesthetist (CRNA), a medical resident, or another physician. The respiratory therapist is generally responsible for ventilating the patient with a bag-valve-mask device until reintubation (reinsertion of the airway), while the nurse gathers equipment, administers medications, and monitors the patient's pulse oximetry, vital signs, and cardiac rhythm.<br /><br />The nurse and respiratory therapist are also responsible for finding alternative means for the patient to communicate. Artificial airways are inserted through the vocal cords, making speaking impossible. The patient should be encouraged to try alternative methods such as mouthing words, writing, or pointing to letters, words, or pictures on a communication board. Communicating with these patients takes great patience and creativity, as well as dedication to helping them feel like their needs are being met.<br />KEY TERMS<br /><br />Bag-valve-mask device—Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.<br /><br />Endotracheal tube—Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.<br /><br />Hypoxemia—Abnormal deficiency of oxygen in the arterial blood.<br /><br />Oxygen flow meter—Meter attached to a oxygen source that controls the amount of supplemental oxygen the patient receives.<br /><br />Pulse oximeter—Noninvasive machine that measures the amount of hemoglobin that is saturated with oxygen.<br /><br />Tracheostomy tube—Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires long-term ventilatory assistance.<br /><br />Ventilator (mechanical ventilation)—Device used to provide assisted respiration and positive pressure breathing.<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-20543152966542383292009-12-29T08:10:00.000-08:002009-12-29T08:12:28.075-08:00Activities of Daily Living Evaluationenotes.com,<br /><br />Definition<br /><br />An activities of daily living (ADL) evaluation is an assessment of an individual's physical and sometimes mental skills. In the area of physical or occupational therapy, it reflects how well a disabled patient or someone recovering from disease or accident can function in daily life. It is also used to determine how well patients relate to and participate in their environment.<br /><span class="fullpost"><br />Purpose<br /><br />ADL evaluations help practitioners determine how independent patients are and what skills they can accomplish on their own, as well as to gauge how independent each individual can become after intervention by a health professional. The goal of practitioners performing ADL evaluations is to help patients become as independent as possible, using appropriate adaptations if needed.<br />Description<br /><br />Many ADL indexes exist, such as the Katz Index, Revised Kenny Self-Care Evaluation, and the Barthel Index. These indexes typically evaluate patients on their self-care skills and rate each individual according to how functional they are. Scoring is based on how independently a task can be performed and whether supervision or assistance is needed in performing the task.<br />Basic ADL versus Instrumental ADL<br /><br />Basic activities of daily living are those skills needed in typical daily self care. An evaluation would, in part, consist of bathing, dressing, feeding, and toileting. The evaluator would examine various activities in each category to determine the patient's skill. Afterward it can be determined what, if any, changes will be necessary to allow the patient to function as independently as possible.<br /><br />Instrumental activities of daily living refer to skills beyond basic self care that evaluate how individuals function within their homes, workplaces, and social environments. Instrumental ADLs may include typical domestic tasks, such as driving, cleaning, cooking, and shopping, as well as other less physically demanding tasks such as operating electronic appliances and handling budgets. In the work environment, an ADL evaluation assesses the qualities necessary to perform a job, such as strength, endurance, manual dexterity, and pain management.<br /><br />If a person is being treated following an injury or disorder diagnosis, whether an intervention is needed depends upon how severe his or her functional ability has been affected. If an individual's ADL function is not restored, a health care professional will perform an intervention, which entails helping the individual adapt to permanent dysfunction or regain meaningful function. How well an individual must be able to perform these tasks depends upon the living setting he or she is returning to, whether it is a full custodial facility, assisted living community, or living at home on his or her own.<br />Complications<br /><br />Returning a client to full meaningful function can be problematic for individuals who do not have the motivation to do so. A holistic approach to treatment is most important in cases such as these, and physical and occupation therapists are trained to evaluate not only the physical disability or dysfunction of an individual, but also the person's mental health and well-being. Occupational therapists can address mental health issues resulting from injury or disorder diagnosis, such as depression. However, in cases where a patient has sustained a permanent cognitive disability and is learning-impaired, it is more effective and appropriate for the occupational therapist to teach family members or a caretaker how to perform daily tasks for the patient.<br />Results<br /><br />Interventions implemented to increase function include adaptations and home modification. Adaptations are devices that can enhance the usability of everyday items for individuals who have a limited range of motion. Home modification involves the process of making one's living environment more functional for ADL.<br />Adaptations<br /><br />There are several ways that adaptations can be used to make common household items more functional. For example, patients commonly have a weakened grasp that is insufficient to hold heavy or small objects, so enhancements such as easily gripped handles could be added to small objects, such as eating utensils or personal grooming items. Other adaptations may involve the use of unique tools to facilitate tasks, such as using a long rod with a hook at one end, known as a dressing stick, to pull on pants or socks. Adaptations may involve altering the environment to aid in other tasks, such as providing adequate lighting or magnifying lenses to compensate for a vision impairment.<br />Home modifications<br /><br />Home modification has become a major area for occupational therapists to practice. In order for patients to return home or go to a group setting, the physical environment of the house or facility may have to be altered to make ADL function better. Common examples of home modifications include the installation of grab bars in the shower, toilet area and hallways; lower kitchen counters for easier access to wheelchair-bound individuals; and the elimination of potential trip points, such as loose throw rugs and slight changes in floor elevation.<br />Health care team roles<br /><br />Occupational therapists and physical therapists are the two primary disciplines most qualified to assess ADL function and recommend the appropriate intervention and modifications in one's home and work environment. Physical therapists might focus primarily on a patient's mobility and ambulation, while the occupational therapist might focus on more specific tasks described above.<br />KEY TERMS<br /><br />Adaptation—Altering a tool used in performing a task so that the patient is better able to function independently or with minimal assistance.<br /><br />Dressing stick—A long rod with a hook attached to the end that a patient uses in place of the hands. Typically a dressing rod would be used to pull on a pair of pants or socks.<br /><br />Home modification—Altering the physical environment of the home so as to remove hazards and provide an environment that is more functional for the patient. Examples of home modification include installing grab bars and no-slip foot mats in the bathroom to prevent falls.<br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-65918862777633890612009-12-29T08:07:00.000-08:002009-12-29T08:09:59.359-08:00Cervical Spondylosis and Spondylotic Cervical Myelopathymerck.com,<br />Cervical spondylosis is osteoarthritis of the cervical spine causing stenosis of the canal and sometimes cervical myelopathy due to encroachment of bony osteoarthritic growths (osteophytes) on the lower cervical spinal cord, sometimes with involvement of lower cervical nerve roots (radiculomyelopathy).<br /><span class="fullpost"><br />Cervical spondylosis due to osteoarthritis is common. Occasionally, particularly when the spinal canal is congenitally narrow (< 10 mm), osteoarthritis leads to stenosis of the canal and bony impingement on the cord, causing compression and myelopathy (functional disturbance of the spinal cord). Hypertrophy of the ligamentum flavum can aggravate this effect. Osteophytes in the neural foramina, most commonly between C5 and C6 or C6 and C7, can cause radiculopathy (a nerve root disorder—see also Peripheral Nervous System and Motor Unit Disorders: Nerve Root Disorders). Manifestations vary according to the neural structures involved but commonly include pain.<br /><br />Symptoms and Signs<br /><br />Cord compression commonly causes gradual spastic paresis, paresthesias, or both in the hands and feet and may cause hyperreflexia. Neurologic deficits may be asymmetric, nonsegmental, and aggravated by cough or Valsalva maneuvers. After trauma, people with cervical spondylosis may develop central cord syndrome. Eventually, muscle atrophy and flaccid paresis may develop in the upper extremities at the level of the lesion, with spasticity below the level of the lesion.<br /><br />Nerve root compression commonly causes early radicular pain; later there may be weakness, hyporeflexia, and muscle atrophy.<br /><br />Diagnosis<br /><br /> *<br /> MRI or CT<br /><br />Cervical spondylosis is suspected when characteristic neurologic deficits occur in patients who are elderly, have osteoarthritis, or have radicular pain at the C5 or C6 levels. Diagnosis is by MRI or CT.<br /><br />Treatment<br /><br /> * For radiculopathy only, NSAIDS and soft cervical collar<br /> * For cord involvement or refractory radiculopathy, cervical laminectomy<br /><br />For patients with cord involvement, cervical laminectomy is usually needed; a posterior approach can relieve the compression but leaves anterior compressive osteophytes and may result in spinal instability and kyphosis. Thus, an anterior approach with spinal fusion is generally preferred. Patients with only radiculopathy may try nonsurgical treatment with NSAIDs and a soft cervical collar; if this approach is ineffective, surgical decompression may be required.<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-8687841799341551382009-12-18T07:46:00.000-08:002009-12-18T07:47:25.690-08:00Administration of Medicationwww.enotes.com<br /><br />Purpose<br /><br />The administration of medication is often a chief responsibility of the nurse. The practice of administering medication involves providing the patient with a substance prescribed and intended for the diagnosis, treatment, or prevention of a medical illness or condition.<br /><span class="fullpost"><br />Description<br /><br />The central action of medication administration involves actual and complete conveyance of a medication to the patient. However, there is a wider set of practices required to achieve safe, effective patient outcomes and to prepare for and evaluate the outcome of medication administration.<br /><br />Laws regarding medication administration vary from state to state. Doctors, physicians, physician assistants, nurse practitioners, and nurses are generally trained and authorized to administer medication, while other medical disciplines may have a limited responsibility in this area. In certain circumstances, unlicensed personnel may be trained and authorized to administer medication in residential care settings. State and federal laws also restrict the distribution of and access to medications that can be abused (called controlled substances). Responsibility for controlled substances includes accountability for any discarded substances, double-locked storage, and counting of medication supply at regular intervals by clinician teams.<br /><br />Preparation for medication administration begins with the order for medication, in most circumstances written by the physician. Nurse practitioners and physician assistants are also often authorized to write prescriptions. State laws vary regarding these privileges. A record of orders for medication and other treatments is kept in the medical chart. Universally accepted safe clinical practice guidelines and state laws govern the components of medication orders in order to ensure consistency and patient safety. All orders should contain the patient's name, the date and time when the order is written, and the signature of the ordering clinician. Caregivers administering medication are responsible for checking that these components are present and clear. The name of the medication is accompanied by the dosage, or how much of the drug should be given; the route of administration, or how the medication should be given (ie, intramuscular injection); and frequency, or how often the drug is to be given. Common routes of administration are discussed below.<br /><br />The most common route of administration is the oral route, or swallowing of medication. This is the easiest and safest route. The physical position and swallowing abilities of the patient should be evaluated to avoid choking. Patients may also receive medication by the buccal route (through the inner cheek or gum) or the sublingual route (under the tongue).<br /><br />Administration involving a needle or syringe occurs with several drug routes. These routes are referred to as parenteral. Care must be taken to maintain asepsis with all injections and injection sites. Intramuscular medications are injected into the muscle. A special injection technique called Z-track can be used when administering intramuscular medications that can be damaging to the tissue. All intramuscular injections involve the practice of landmarking, or identifying anatomical markers that indicate the correct injection site and avoid damage to bone or nerves. Subcutaneous injections are administered under the skin. Insulin is a common medication that is usually given subcutaneously. Intradermal medications are used much less frequently than subcutaneous or intramuscular injections. They are injected into the skin. Intravenous medications are given through an intravenous line into the vein. These medications may be mixed with a large amount of solution that is being infused, given in a small solution through a port in the intravenous tubing (bolus), or attached in smaller infusion containers to the larger infusion (piggyback). In all cases of administration with a needle or syringe, rotation of injection sites is required to prevent damage to tissue. It is also important that the size of the needle is selected based on the thickness of the medication to be given and the depth of the injection, while maximizing the patients level of comfort during insertion. Needle sticks with contaminated needles are a hazard to both health professional and patient. Care is taken to dispose of needles and syringes rapidly in impervious containers. Protective systems that sheath the needle after use are commonly used to prevent inadvertent needle sticks.<br /><br />Medication can also be instilled via the mucous membranes. Asepsis must be used to avoid introduction of infection. Rectal or vaginal medications are most often given in suppository form and must be introduced gently to avoid tearing or bleeding of tissue. Nasal medications are often instilled via spray or drops and often involve closing one nostril and asking the patient to inhale gently. The head should be tilted back to avoid aspiration. Ear or otic medications are given in liquid form. The patient's head is tilted to the side. Instruments should never enter the ear. If the medication is not instilled correctly, the patient may experience nausea or vertigo. Eye or ophthalmic medications may be given via drops or ointment. The container for the medication should not touch the eye, and drops are introduced into the inner canthus or corner of the eye.<br /><br />Inhalational medications are inhaled via the respiratory tract, most often to treat respiratory conditions. Metered dose inhalers (MDI) are often used. MDIs involve pressing a specially designed canister to release a mist.<br /><br />Topical medications are applied to the surface of the skin. The skin needs to be cleansed and assessed for breaks before administering topical medications. Topical patches that gradually release medication need to be labeled with date and time in case a second patch is inadvertently applied without removal of the first. Ointments are applied evenly. The clinician should avoid touching the topical medication, as medications that are absorbed into the system via the skin, such as nitroglycerin paste, may affect the clinician. As with all medication techniques, asepsis must be maintained to avoid introduction of microorganisms.<br /><br />Frequency of administration is most often ordered on a repeating schedule (ie, every 8 hours). At times the order may be written as a STAT (give right away) order, a one-time order (give just once) or a prn (give as needed) order. Standing orders are routine hospital orders that doctors in specialized areas prescribe on admission.<br /><br />Many abbreviations are used in writing medication orders. Other common abbreviations include:<br /><br /> * p.o.: by mouth<br /> * IM: intramuscular injection<br /> * SC: subcutaneous injection<br /> * IV: intravenous<br /> * PR: per rectum<br /> * h.s.: at hour of sleep (bedtime)<br /> * ac: before meals<br /> * pc: after meals<br /> * q: every, ie, q 8 h means every 8 hours<br /> * q.d.: every day<br /> * b.i.d.: twice/day<br /> * t.i.d.: three times/day<br /> * q.i.d.: four times/day<br /> * q.o.d.: every other day<br /><br />Some examples of medication orders using these abbreviations are:<br /><br /> * digoxin 0.25 mg p.o. q.d.<br /> * diphenhydramine 25 mg p.o. q h.s. prn.<br /><br />If orders are illegible, ambiguous, or confusing, the author of the order should be consulted to clarify the order before any medication administration occurs. When the order is clear, it often needs to be transcribed to another document reserved for recording administration of medications. Health care institutions have specific policies regarding methods with which to check medication orders and ensure proper transcription. Policies also dictate parameters for order renewal or medication discontinuation. Poor penmanship, misunderstanding of penmanship, and errors in transcription often contribute to medication errors. It is increasingly common for medical facilities to use a computerized system that lowers the risk of error by reducing steps in the process and validating information automatically.<br /><br />Once the order has been read and verified, the care-giver needs to evaluate the order in the context of the individual patient. Some factors to consider include:<br /><br /> * pharmacodynamics: how the drug works in the body<br /> * interactions: possible effects of other medication or food on the ordered medication<br /> * allergies: patient history of hypersensitivity to drug or drug class<br /> * contraindications: medical conditions that preclude the use of the ordered drug<br /> * side effects: potential adverse reactions to the drug<br /> * toxic effects: dangerous effects that often occur due to build up of drug in body or impaired metabolism<br /> * tolerance: certain drugs require increasing doses over time to achieve the same effect<br /> * physiological variables: sex, age, size, and physical condition may alter how a drug is processed in the body<br /> * diet: certain foods, liquids, or nutritional states may alter the drug's effect on the body<br /><br />Due to the large number of medications available and the large body of information required for appropriate drug administration, it is important to have access to a current medication reference such as the Physician's Desk Reference or other reference handbooks about medication. The package insert that comes with every medication is also a good resource. Pharmacists are knowledgeable resources and can answer many questions regarding medication. It is important to be familiar with the medication ordered before attempting to administer it. Procedural manuals by the institution or medical reference publishers detail the step-by-step techniques for administering various types of medication.<br /><br />The patient should be notified of the order for the drug and provided with education about the medication they are to receive. Before administration, five factors often referred to as the "five rights" should be addressed. Medication records should be on hand at time of administration to ensure safe administration.<br /><br />Right patient. Identify patient by name badge or bracelet. Avoid simply asking patient's name or checking the name on the door as miscommunications can sometimes occur.<br /><br />Right drug. Check record for name of drug and compare with drug on hand. As many drugs have similar spellings, this needs to be checked carefully. For prevention of error, it is often recommended that three checks of the drug to be administered are made: when reaching for the package that contains the drug, when opening the drug, and when returning the packaging to its storage area. It is also recommended that clinicians only administer drugs that they have prepared, versus those prepared by another clinician.<br /><br />Right route. Check medication record for how to administer the drug and check labeling of drug to ensure it matches prescribed route.<br /><br />Right dose. Compare ordered dose to dose on hand. At times, calculations may need to be performed to ascertain the correct dose. For example, a scored tablet, or one that is designed and intended for dividing, may need to be halved or quartered in order to administer the correct oral dose. This requires simple division. Common situations requiring calculation include calculation of intravenous infusion rates and the conversion of measurement units, for example, determining how many milliliters (mL) are required to give the ordered number of milligrams.<br /><br />The formula for this calculation can be applied to many situations:<br /><br /> * dose ordered/dose on hand × amount on hand = amount to administer<br /><br />Using the above medication question, 25 mg/100 mg × 2 ml = 0.5 ml (amount to administer)<br /><br />Intravenous medications also require frequent calculation. For example, an intravenous anticoagulant such as heparin may be ordered as "1000 units per hour," and the clinician may need to calculate how many drops are needed per minute or hour based on how the intravenous solution is prepared. These calculations may vary according to the infusion equipment used, for example, varying drop factor ratings or use of a device called a buretrol that carefully measures infused medication. Often a mechanical pump is used to control intravenous infusion rates.<br /><br />Right time. Verify that frequency or time ordered matches current time.<br /><br />All medications should be handled to ensure that they do not come into contact with potentially contaminated objects or surfaces. Medications of any sort should not be left unattended, and patients should be observed taking the medication. This avoids the disposal, hoarding, abuse, or misuse of the medication, and assures the safety of the patient.<br /><br />Documentation of medication administration is an important responsibility. The medication record tells the story of what substances the patient has received and when. Like other health care records, it is also a legal document. Various institutions have policies and procedures regarding documentation. The initials of the administering nurse or other health care provider and the time and date should be documented on the record next to the appropriate order. Other information may be required, such as location and severity of pain when administering a pain medicine (analgesic) or pulse rate when administering certain heart medications (i.e., digoxin). Patient refusals of medication also need to be documented, and the prescribing clinician should be informed.<br /><br />Medication errors need to be documented as well. The prescribing clinician should be notified of errors. Institutional policies usually require filing a separate form to document errors. Errors can include administering the wrong drug, wrong dose, at the wrong time, or via the wrong route. Omissions of medication are also considered errors.<br /><br />It is important to evaluate the patient following medication administration and document effect. For example, many hospitals dictate that a note be written regarding pain relief within several hours after analgesic administration. Any adverse effects from medication should be reported.<br />Preparation<br /><br />Preparation for safe medication administration requires a background of education and hands-on training. New nurses and other professionals should be supervised until they demonstrate an appropriate level of knowledge and competent skills for independent medication administration.<br />Aftercare<br /><br />The patient should be monitored to make sure the medication has had the desired effect.<br />Health care team roles<br /><br />In addition to the clinician who administers medication, other members of the health care team play vital roles surrounding the medication administration process. Doctors or other prescribing clinicians are responsible for writing clear, legible orders and for monitoring the response of the patient to medication. They are also responsible for responding to potential adverse effects and concerns by the patient or other clinicians. Pharmacists are responsible for evaluating the medication order for potential problems, correctly filling the order, and monitoring the medication supply. All health care professionals are responsible for complying with medication-related policies designed to protect the patient and/or staff and for maintaining current knowledge regarding medication and medication administration.<br />Resources<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-6611760676636780662009-12-18T07:43:00.000-08:002009-12-18T07:45:04.752-08:00Abdominal Ultrasoundenotes.com<br /><br />Definition<br /><br />Abdominal ultrasound uses high frequency sound waves to produce two-dimensional images of the body's soft tissues, which are used for a variety of clinical applications, including diagnosis and guidance of treatment procedures. Ultrasound does not use ionizing radiation to produce images, and in comparison to other diagnostic imaging modalities, it is low cost, safe, fast, and versatile.<br /><br /><span class="fullpost"><br />Purpose<br /><br />Abdominal ultrasound is used in the hospital radiology department and emergency department, as well as in physician offices for a number of clinical applications. Ultrasound has a great advantage over x-ray imaging technologies in that it does not damage tissues with ionizing radiation. Ultrasound is also generally far better than plain x-rays at distinguishing the subtle variations of soft tissue structures, and can be used in any of several modes, depending on the area of interest.<br /><br />As an imaging tool, abdominal ultrasound generally is indicated for patients afflicted with chronic or acute abdominal pain; abdominal trauma; an obvious or suspected abdominal mass; symptoms of liver disease, pancreatic disease, gallstones, spleen disease, kidney disease and urinary blockage; or symptoms of an abdominal aortic aneurysm.<br /><br />Specifically:<br /><br /> * Abdominal pain. Whether acute or chronic, pain can signal a serious problem—from organ malfunction or injury to the presence of malignant growths. Ultrasound scanning can help doctors quickly sort through potential causes when presented with general or ambiguous symptoms. All of the major abdominal organs can be studied for signs of disease that appear as changes in size, shape, and internal structure.<br /> * Abdominal trauma. After a serious accident, such as a car crash or a fall, internal bleeding from injured abdominal organs is often the most serious threat to survival. Neither the injuries nor the bleeding may be immediately apparent. Ultrasound is very useful as an initial scan when abdominal trauma is suspected, and it can be used to pinpoint the location, cause, and severity of hemorrhaging. In the case of puncture wounds, from a bullet for example, ultrasound can locate the foreign object and provide a preliminary survey of the damage. (CT scans are sometimes used in trauma settings.)<br /> * Abdominal mass. Abnormal growths—tumors, cysts, abscesses, scar tissue, and accessory organs—can be located and tentatively identified with ultrasound. In particular, potentially malignant solid tumors can be distinguished from benign fluid-filled cysts. Masses and malformations in any organ or part of the abdomen can be found.<br /> * Liver disease. The types and underlying causes of liver disease are numerous, though jaundice tends to be a general symptom. Ultrasound can differentiate between many of the types and causes of liver malfunction, and is particularly good at identifying obstruction of the bile ducts and cirrhosis, which is characterized by abnormal fibrous growths and reduced blood flow.<br /> * Pancreatic disease. Inflammation and malformation of the pancreas are readily identified by ultrasound, as are pancreatic stones (calculi), which can disrupt proper functioning.<br /> * Gallstones. Gallstones are an extremely common cause of hospital admissions. These calculi can cause painful inflammation of the gallbladder and also obstruct the bile ducts that carry digestive enzymes from the gall-bladder bladder and liver to the intestines. Gallstones are readily identifiable with ultrasound.<br /> * Spleen disease. The spleen is particularly prone to injury during abdominal trauma. It may also become painfully inflamed when infected or cancerous.<br /> * Kidney disease. The kidneys are also prone to traumatic injury and are the organs most likely to form calculi, which can block the flow of urine and cause further systemic problems. A variety of diseases causing distinct changes in kidney morphology can also lead to complete kidney failure. Ultrasound imaging has proven extremely useful in diagnosing kidney disorders, including blockage or obstruction.<br /> * Abdominal aortic aneurysm. This is a bulging weak spot in the abdominal aorta, which supplies blood directly from the heart to the entire lower body. A ruptured aortic aneurysm is imminently life-threatening. However, it can be readily identified and monitored with ultrasound before acute complications result.<br /> * Appendicitis. Ultrasound is useful in diagnosing appendicitis, which causes abdominal pain.<br /><br />Ultrasound technology can also be used for treatment purposes, most frequently as a visual aid during surgical procedures—such as guiding needle placement to drain fluid from a cyst, or to guide biopsies.<br />Precautions<br /><br />Ultrasound waves of appropriate frequency and intensity are not known to cause or aggravate any medical condition.<br /><br />The value of ultrasound imaging as a medical tool, however, depends greatly on the quality of the equipment used and the skill of the medical personnel operating it. More accurate results are obtained when ultrasound is performed by a clinician skilled in sonography. Basic ultrasound equipment is relatively inexpensive to obtain, and any physician with the equipment can perform the procedure whether specifically trained in ultrasound scanning and interpretation or not. Patients should not hesitate to verify the credentials of technologists and physicians performing ultrasound scanning, as well as the quality of the equipment used and the benefits of the proposed procedure.<br /><br />In cases where ultrasound is used as a treatment tool, patients should educate themselves about the proposed procedure with the help of their doctors—as is appropriate before any surgical procedure. Also, any abdominal ultrasound procedure, diagnostic or therapeutic, may be hampered by a patient's body type or other factors, such as the presence of excessive bowel gas (which is opaque to ultrasound). In particular, very obese people are often not good candidates for abdominal ultrasound.<br />Description<br /><br />Ultrasound includes all sound waves above the frequency of human hearing—about 20 thousand hertz, or cycles per second. Medical ultrasound generally uses frequencies between one and 10 megahertz (1-10 MHz). Higher frequency ultrasound waves produce more detailed images, but are also more readily absorbed and so cannot penetrate as deeply into the body. Abdominal ultrasound imaging is generally performed at frequencies between 2-5 MHz.<br /><br />An ultrasound scanner consists of two parts: the transducer and the data processing unit. The transducer both produces the sound waves that penetrate the body and receives the reflected echoes. Transducers are built around piezoelectric ceramic chips. (Piezoelectric refers to electricity that is produced when you put pressure on certain crystals such as quartz.) These ceramic chips react to electric pulses by producing sound waves (they are transmitting waves) and react to sound waves by producing electric pulses (receiving). Bursts of high-frequency electric pulses supplied to the transducer cause it to produce the scanning sound waves. The transducer then receives the returning echoes, translates them back into electric pulses, and sends them to the data processing unit—a computer that organizes the data into an image on a television screen.<br /><br />Because sound waves travel through all the body's tissues at nearly the same speed—about 3,400 miles per hour—the microseconds it takes for each echo to be received can be plotted on the screen as a distance into the body. The relative strength of each echo, a function of the specific tissue or organ boundary that produced it, can be plotted as a point of varying brightness. In this way, the echoes are translated into an image.<br /><br />Four different modes of ultrasound are used in medical imaging:<br /><br /> * A-mode. This is the simplest type of ultrasound in which a single transducer scans a line through the body with the echoes plotted on screen as a function of depth. This method is used to measure distances within the body and the size of internal organs.<br /> * B-mode. In B-mode ultrasound, a linear array of transducers simultaneously scans a plane through the body that can be viewed as a two-dimensional image on screen.<br /> * M-Mode. The M stands for motion. A rapid sequence of B-mode scans whose images follow each other in sequence on screen enables doctors to see and measure range of motion, as the organ boundaries that produce reflections move relative to the probe. M-mode ultrasound has been put to particular use in studying heart motion.<br /><br /> * Doppler mode. Doppler ultrasonography includes the capability of accurately measuring velocities of moving material, such as blood in arteries and veins. The principle is the same as that used in radar guns that measure the speed of a car on the highway. Doppler capability is most often combined with B-mode scanning to produce images of blood vessels from which blood flow can be directly measured. This technique is used extensively to investigate valve defects, arteriosclerosis, and hypertension, particularly in the heart, but also in the abdominal aorta and the portal vein of the liver.<br /><br />The actual procedure for a patient undergoing an abdominal ultrasound is relatively simple, regardless of the type of scan or its purpose. Fasting for at least eight hours prior to the procedure ensures that the stomach is empty and as small as possible, and that the intestines and bowels are relatively inactive. This also helps the gallbladder become more visible. Prior to scanning, an acoustic gel is applied to the skin of the patient's abdomen to allow the ultrasound probe to glide easily across the skin and also to better transmit and receive ultrasonic pulses. The probe is moved around the abdomen's surface to obtain different views of the target areas. The patient will likely be asked to change positions from side to side and to hold the breath as necessary to obtain the desired views. Usually, a scan will take from 20 to 45 minutes, depending on the patient's condition and anatomical area being scanned.<br /><br />Ultrasound scanners are available in different configurations, with different scanning features. Portable units, which weigh only a few pounds and can be carried by hand, are available for bedside use, office use, or use outside the hospital, such as at sporting events and in ambulances. Portable scanners range in cost from $10,000 to $50,000. Mobile ultrasound scanners, which can be pushed to the patient bedside and between hospital departments, are the most common comfiguration and range in cost from $100,000 to over $250,000, depending on the scanning features purchased.<br />Preparation<br /><br />A patient undergoing abdominal ultrasound will be advised by the physician about what to expect and how to prepare. As mentioned above, preparations generally include fasting.<br />Aftercare<br /><br />In general, no aftercare related to the abdominal ultrasound procedure itself is required. Discomfort during the procedure is minimal.<br />Complications<br /><br />Properly performed, ultrasound imaging is virtually without risk or side effects. Some patients report feeling a slight tingling and/or warmth while being scanned, but most feel nothing at all.<br />Results<br /><br />As a diagnostic imaging technique, a normal abdominal ultrasound is one that indicates the absence of the suspected condition that prompted the scan. For example, symptoms such as abdominal pain radiating to the back suggest the possibility of, among other things, an abdominal aortic aneurysm. An ultrasound scan that indicates the absence of an aneurysm would rule out this life-threatening condition and point to other, less serious causes.<br /><br />Because abdominal ultrasound imaging is generally undertaken to confirm a suspected condition, the results of a scan often will confirm the diagnosis, be it kidney stones, cirrhosis of the liver, or an aortic aneurysm. At that point, appropriate medical treatment as prescribed by a patient's physician is in order.<br />Health care team roles<br /><br />Ultrasound scanning should be performed by a registered and trained ultrasonographer, either a technologist and/or a physician (radiologist, obstetrician/gynecologist). Ultrasound scanning in the emergency department may be performed by an emergency medicine physician, who should have appropriate training and experience in ultrasonography.<br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0tag:blogger.com,1999:blog-784726309009680790.post-11766954912240261562009-12-18T07:38:00.000-08:002009-12-18T07:39:51.734-08:00Nephrostomy Tube Careenotes.com<br /><br />Definition<br /><br />A percutaneous nephrostomy tube (PNT) is a urinary diversion system comprised of a collection bag, a nephrostomy tube at an exit site (usually in the skin over the flank area), and a nephrostomy tube that enters and ends in the renal pelvis of the kidney. This allows for direct drainage of urine from the kidney when normal urinary flow is impeded. The PNT is most often used for a urinary obstruction such as a calculus.<br /><span class="fullpost"><br />Purpose<br /><br />The purpose of PNT care is to prevent complications when a PNT is in use.<br />Precautions<br /><br />Aspiration of fluid from the nephrostomy tube is prohibited as such action will damage the renal pelvis. Gravity drainage is used to collect specimens, and the nurse should never use force when irrigating the tube. A tube should never be irrigated with more than 5 ml of solution, since the capacity of the renal pelvis is between 4 and 8 ml. The nurse must avoid dislodging the tube while removing the dressing.<br />Preparation<br /><br />The nurse should wash hands prior to beginning the procedure, then assemble all of the following equipment:<br /><br /> * disposable underpad<br /> * clean gloves<br /> * measuring tape<br /> * sterile gloves<br /> * sterile cotton tip applicators (4)<br /> * sterile 0.9% NaCl or povidone-iodine solution or sponges<br /> * sterile 4×4 pad or transparent dressing<br /> * sterile 2×2 pads<br /> * tape<br /> * pouch belt<br /><br />Description<br /><br />The nurse should provide privacy for the patient in preparation for the procedure. He or she should position the patient on the side opposite the tube site with the nephrostomy site up. This provides better viewing of the tube and allows an easier dressing change.<br /><br />The nurse should put on clean gloves and place a disposable underpad beneath to the patient to absorb any drainage. To minimize tension at the site and to prevent dislodging, the nephrostomy tube should be anchored with a small piece of tape. The collection bag must be emptied. The old dressing can be removed by carefully loosening the edges, and then moving to the center of dressing. Care should be taken to avoid dislodging the tube while removing the dressing. A sterile cotton-tip applicator placed on the catheter will help stabilize the catheter while removing the dressing. The site is then assessed for signs of infection, any moisture, or other drainage. The PNT is then measured from exit site to tip. If the PNT length is longer than the measurement at time of insertion, the catheter may have migrated out, and the physician should be notified at that point. The nurse should remove the soiled gloves at this time and replace with sterile ones. The exit site should be cleansed with the agent of choice (0.9% saline or povidone-iodine solution), using sterile 2×2 pads. Each pad can only be used once. Cleansing should start at the exit site and work outward in a circular motion; this action should be repeated twice. If there is any crusted matter at the site, this must be loosened and removed by using a cotton-tip applicator moistened with 0.9% saline. Then, sterile dressing should be applied. After removing the old tape, the tube must be secured with new tape to the skin below the dressing, approximately 2.5 inches (6.5 cm) from the exit site. The patient will need to be assisted in the application of the pouch belt. Anchoring the PNT with tape reduces trauma and minimizes the possibility of dislodging or kinking the tubing; adding the belt further secures the PNT. The nurse may remove gloves at this point and wash hands. The patient's dressing needs to be dated and initialed, and will need to be changed daily, or more often if necessary.<br />Aftercare<br /><br />The used equipment needs to be disposed of properly. Upon completion of the procedure, the nurse should again wash hands. Then the nurse will need to document observations and the techniques used, including the assessment of the site, the external catheter length, the type of dressing applied, and the devices used to secure the PNT.<br />Complications<br /><br />There is an increased risk of infection because the PNT provides a direct pathway to the kidney. There is also a risk for dislodging the PNT during this procedure.<br />Patient education<br /><br />The patient may shower 48 hours post-insertion. The patient should be given all of the following instructions:<br /><br /> * Cover the dressing and exit site with a waterproof covering before showering.<br /> * Empty the collection bag prior to showering.<br /><br /> * Securely tape the PNT at the exit site and use a belt for the collection bag in the shower to prevent tube migration.<br /> * Generally, after 14 days, if there are no complications, the site may be left uncovered when showering.<br /><br />The patient should notify the doctor if any problems arise such as:<br /><br /> * signs of infection at the exit site of the PNT, including warmth, redness, swelling, tenderness, and discharge<br /> * drainage from the PNT<br /> * decreased urine output<br /> * inability to flush the PNT<br /> * presence of any bleeding, clots, stones, sediment, and odor<br /> * incontinence or inadequate bladder emptying<br /> * inadequate pain control, nausea, or vomiting<br /> * fever<br /> * accidental dislodgement of the PNT, or suspected migration of the PNT<br /><br />Results<br /><br />The site should not display any signs of infection. PNT measurement should be consistent with the baseline value. Abnormal findings are signs of infection, suspected migration, or a dislodged PNT. In the collection bag, any bleeding, clots, stones, sediment, and odor are all abnormal findings.<br />Health care team roles<br /><br />Registered nurses (RNs) and licensed practical nurses (LPNs) may perform this procedure. After returning home, the patient may simply cleanse the insertion site with soap and water, and change the dressing daily. In an inpatient setting, an aseptic technique must be maintained.<br /><br />Nurses are responsible for:<br /><br /> * dressing changes<br /> * proper disposal of equipment<br /> * documentation of the procedure<br /> * patient education<br /><br /></span>PHYSICAL MEDICINE & REHABILITATION HOSPITALhttp://www.blogger.com/profile/00721279445028648761noreply@blogger.com0