MR. ABU BAKAR

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PICNIC

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. Read More ..

Cognitive Impairment

What is cognitive impairment?

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. 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.

What other symptoms might occur with cognitive impairment?

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

Headache

Malaise or lethargy

Muscle twitching, spasms or seizures

Nausea with or without vomiting

Rash

Stiff or rigid neck

Metabolic symptoms that may occur along with cognitive impairment

Cognitive impairment may accompany other symptoms related to metabolic disorders including:

Abdominal pain

Abnormal heart rhythm such as rapid heart rate (tachycardia) or slow heart rate (bradycardia)

Changes in skin

Confusion or loss of consciousness for even a brief moment

Difficulty breathing or rapid breathing Nausea with or without vomiting

Fatigue

Feeling very thirsty

Frequent urination or decrease in urine output

Fruity breath

Muscle weakness

Other symptoms that may occur along with cognitive impairment

Cognitive impairment may accompany symptoms related to other problems, such as injury, stroke or dementia. These symptoms may include:

Change in sleep patterns

Changes in mood, personality or behavior

Confusion or loss of consciousness for even a brief moment

Difficulty with memory, thinking, talking, comprehension, writing or reading

Impaired balance and coordination

Loss of vision or changes in vision

Nausea with or without vomiting

Numbness, weakness or paralysis

Seizure

Severe headache

Serious symptoms that might indicate a life-threatening condition

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:

Change in level of consciousness or alertness such as passing out or unresponsiveness

Change in mental status or sudden behavior change such as confusion, delirium, lethargy, hallucinations or delusions

Garbled or slurred speech or inability to speak

High fever (higher than 101 degrees Fahrenheit)

High-pitched, shrill cries in an infant or small child

Paralysis or inability to move a body part

Poor feeding, unusual sleepiness, or irritability in a child or infant

Seizure

Stiff or rigid neck

Sudden change in vision, loss of vision, or eye pain

Trauma to the head

Worst headache of your life

What causes cognitive impairment?

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:

Chromosomal abnormalities such as Down syndrome, fragile X syndrome, cri du chat syndrome, Prader-Willi syndrome, and others

Congenital hypothyroidism (underactive thyroid)

Genetic abnormalities such as phenylketonuria, Tay-Sachs disease, galactosemia, Hunter syndrome, Hurler syndrome, adrenoleukodystrophy, and others

Intrauterine growth retardation (poor growth of fetus)

Prenatal drug or alcohol exposure

Prenatal infections

Birth-related causes of cognitive impairment Cognitive impairment can also be caused by complications related to delivery including:

Infection

Lack of oxygen during labor or birth Preterm birth or its complications such as intracranial hemorrhage (uncontrolled bleeding in the brain)

Causes of cognitive impairment that occur after birth or during childhood and adolescence

Cognitive impairment can also be caused by conditions that occur after birth or during childhood and adolescence including:

Autism (abnormal development of communication and social skills)

Head injury

Heavy metal poisoning such as lead poisoning

Infection

Kidney disease (which includes any type of kidney problem such as kidney stones, kidney failure, and kidney anomalies)

Malnutrition

Metabolic conditions

Neonatal jaundice (yellowing of the skin and whites of the eyes occurring after birth)

Side effects of cancer therapy

Systemic lupus erythematosus (a disorder in which the body attacks its own healthy cells and tissues)

Causes of cognitive impairment that occur in adults

Cognitive impairment can also be caused by conditions that occur in adulthood including:

Alcohol or drug abuse

Brain or spinal cord injury

Certain vitamin deficiencies

Congestive heart failure (deterioration of the heart’s ability to pump blood)

Dementia

Infections

Kidney disease (which includes any type of kidney problem such as kidney stones, kidney failure, and kidney anomalies)

Liver disease (which includes any type of liver problem such as hepatitis, cirrhosis, and liver failure)

Medication side effects

Serious or life-threatening causes of cognitive impairment

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:

Brain tumor

Encephalitis (inflammation and swelling of the brain due to a viral infection or other causes)

Heat stroke

Kidney failure

Meningitis (infection of the membranes that cover the brain and spinal cord)

Profound dehydration

Sepsis (severe infection of the bloodstream)

Spinal cord injury or tumor

Stroke

Traumatic head injury

Questions for diagnosing the cause of cognitive impairment

To diagnose your condition, your doctor or licensed health care practitioner will ask you several questions related to your cognitive impairment including:

When did you first notice symptoms of cognitive impairment?

What specific symptoms have you noticed?

Did anything such as an injury or illness precede the symptoms?

Were there any prenatal complications or complications of birth?

Do you have any other medical conditions?

What medications are you taking? Are you taking any new medications?

Have you taken any street drugs?

Do you drink alcohol?

What are the potential complications of cognitive impairment?

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:

Developmental delays and failure to thrive

Learning disability

Paralysis or inability to move a body part

Permanent cognitive impairment

Permanent loss of sensation

Personality changes

Physical disability

Reference : http://www.localhealth.com/article/cognitive-impairment Read More ..

9 PATIENT SAFETY SOLUTIONS

LOOK ALIKE SOUND ALIKE (LASA)

Separate location for placing Look Alike Sound Alike medication

Arrange Look Alike Sound Alike medication in non-alphabetical orders

Reading the label before handling and preparing Look Alike Sound Alike medication and should be placed in labeled shelves

Tall man lettering, color difference and bold face technique are used to be easily differentiate Look Alike Sound Alike medications

MEDICATION RECONCILIATION

History of current treatment should be taken by the doctor from the patient, relatives or from medical record if available

Compare the current treatment with the new added treatment and document it in the reconciliation list

CONTROLLED OF CONCENTRATED ELECTROLYTES

“MUST BE DILLUTED”

CAN KILLED……..!!!!!!

Check and verify doctors order

A proper computation of dilution is needed and asks about double checking

Note all the things you have done

Keep on monitoring patient status

Identification of patient is a must when starting the infusion

Label the prepared solution to avoid confusion

Learn doing proper handover all the time

PATIENT HANDOVER

Use SBAR

Situation : chief complaint, current status

Background : previous history

Assessment : result of assessment, vital signs, investigations and symptoms

Recommendation : suggested and anticipated changes, complications, critical monitoring

AVOIDING CATHETER & TUBING MISCONECTION

Doctor’s order must be checked and verified

Re-check all lines and tubes before and after each shift

Avoid positioning of the functionally similar tube close to each other as much as possible

Stick label on high risk catheter (e.g. arterial, epidural & intrathecal)

Encourage patient and relatives to inform the healthcare providers on duty when they notice any problems on changes on the line or tubes

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

PATIENT I.D BRACELET

please….WEAR ME

Write complete patient information clearly

Ensure that 2 identifiers are available (e.g. full 3 names and birth date)

Apply the bracelet to an appropriate limb within one hour

Replace the bracelet if any part of the patient’s information has become not clear

Make sure that you must ask patient name rather than telling his/her name

Each time care is provided, patient identification must be done by healthcare provider

CORRECT PROCEDURE AT CORRECT BODY SITE

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

A written consent should be obtained after discussion with the patient

Establish the performance of correct procedure at correct body site as a safety priority

Relevant and complete documentation is needed during and after the procedure

Check the equipment’s needed for the procedure must be checked if it correct and functioning properly

SINGLE USE OF INJECTION

Remember the ten rights when you give patient medication

Always use the single injection as safety priority

Recapping should not be done to avoid needle stick or pick

Hand hygiene and proper protection must be applied before giving the medication

Waste management procedure, rules and regulation practices should be identified and implemented in a safe way

IMPROVED HAND HYGIENE

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5 MOMENTS FOR HAND HYGIENE

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HANDS WASHING

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ISOLATION TECHNIQUE

Definition

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.

Purpose

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.

Precautions

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.

Description

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.
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.
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.

Standard precautions

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:
• Blood
• Body fluids
• Secretions, such as phlegm
• Excretions, such as urine and feces (not including sweat) whether or not they contain visible blood
• Nonintact skin, such as an open wound
• Mucous membranes, such as the mouth cavity.
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:
• Handwashing, the most important infection control method
• Use of latex or other protective gloves
• Masks, eye protection and/or face shield
• Gowns
• Proper handling of soiled patient care equipment
• Proper environmental cleaning
• Minimal handling of soiled linen
• Proper disposal of needles and other sharp equipment such as scalpels
• Placement in a private room for patients who cannot maintain appropriate cleanliness or contain body fluids.

Transmission based precautions

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.

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.
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.

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).
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.

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:
• Antibiotic-resistant bacteria
• Hepatitis A
• Scabies
• Impetigo
• Lice.
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.
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.

Types of Isolation :
 Strict isolation.
 Contact isolation.
 Respiratory isolation
 Tuberculosis or acid-fast bacillus (AFB) isolation.
 Enteric precautions
 Drainage/secretion precautions
1. Strict Isolation
 Designed for highly contagious infections that are spread by both airborne droplet nuclei and contact transmission.
 Examples include:
 varicella,
 Disseminated herpes zoster,
 Viral hemorrhagic fevers.
Technique
 Private room.
 With negative airflow.
 The use of masks, gowns, and gloves for all persons entering the room.
2. Contact isolation
 designed for highly transmissible infections that are not spread by airborne droplet nuclei but are transmitted primarily by close and direct contact.
 Examples
 viral respiratory infections in children, such as respiratory syncytial virus (RSV)
 Patients with large draining wounds require contact precautions.
Technique
 Technique includes :
 Private room,
 Masks for those personnel providing close direct care to the patient,
 Gowns if soiling is likely,
 Gloves for touching infective material.
3. Respiratory Isolation
 designed to prevent transmission of diseases spread over short distances through the air (droplet transmission).
Examples include :
 children with Haemophilus influenza,
 epiglottitis,
 meningitis,
 pneumonia.
 patients with serious meningococcal disease;
 mumps and pertussis.
Technique
 Technique includes.
 Private room.
 Or cohering patients with the same organism.
 And masks for those personnel providing close direct care to the patient.
4. Tuberculosis or Acid-fast Bacillus (AFB)
 isolation—designed for patients suspected or known to have pulmonary or laryngeal tuberculosis.
 technique includes a private room with negative airflow
 and the use of appropriate respiratory protection (see tuberculosis).
5. Enteric precautions
 designed to prevent infections that are transmitted by direct or indirect contact with fecal material,
 such as Salmonella gastroenteritis.
Technique
 private room only if the patient has poor hygiene and is likely to contaminate the environment,
 gowns if soiling is likely,
 and gloves for touching infective material.
Drainage/secretion precautions
 designed to prevent infections transmitted by direct or indirect contact with purulent material or other drainage from an infected body site.
 Technique includes :
 gowns if soiling is likely
 and gloves for touching infective material.



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Insertion of Suprapubic Catheter

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

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

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

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

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

Technique


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

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

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

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

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

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

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

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

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

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

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

How to Help People with post-power syndrome

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

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

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

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

Insomnia Overview

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

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

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

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

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

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

Statistics on Insomnia

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

Insomnia Causes

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

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

* Jet lag

* Changes in shift work

* Excessive or unpleasant noise

* Uncomfortable room temperature (too hot or too cold)

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

* Presence of an acute medical or surgical illness or hospitalization

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

* Insomnia related to high altitude (mountains)

Chronic or long-term insomnia

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

Psychological related insomnia

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

* anxiety,

* stress,

* schizophrenia,

* mania (bipolar disorder), and

* depression.

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

Physiological related insomnia

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

* Chronic pain syndromes

* Chronic fatigue syndrome

* Congestive heart failure

* Night time angina (chest pain) from heart disease

* Acid reflux disease (GERD)

* Chronic obstructive pulmonary disease (COPD)

* Nocturnal asthma (asthma with night time breathing symptoms)

* Obstructive sleep apnea

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

* Brain tumors, strokes, or trauma to the brain

High risk groups for insomnia

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

* travelers

* shift workers with frequent changing of shifts

* seniors

* adolescent or young adult students

* pregnant women, and

* menopausal women

Medication related insomnia

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

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

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

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

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

Other causes of insomnia

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

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

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

Primary Sleep Disorders

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

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

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

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

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

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

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

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

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

Insomnia Symptoms

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

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

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

o Poor concentration and focus

o Difficulty with memory

o Impaired motor coordination (being uncoordinated)

o Irritability and impaired social interaction

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

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

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

o Others have tried nonprescription sleep aids.

When to Seek Medical Care

When to call the doctor

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

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

When to go to the hospital

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

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

Exams and Tests

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

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

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

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

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

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

Insomnia Treatment

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

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

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

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

Non-medical treatment and behavioral therapy

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

Sleep hygiene

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

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

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

* Avoid forcing yourself to sleep.

* Keep a regular sleep and awakening schedule.

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

* Do not smoke, especially in the evening.

* Do not go to bed hungry.

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

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

Relaxation therapy

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

Stimulus control

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

* Go to bed when you feel sleepy.

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

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

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

* Avoid taking long naps in the daytime.

Sleep restriction

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

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

* Avoid large meals and excessive fluids before bedtime

* Control your environment.

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

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

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

Medications and Medical Therapies

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

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

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

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

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

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

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

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

Follow-up

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

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

Prevention

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

Insomnia from jet lag

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

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

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

Insomnia from shift changes

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

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

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

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

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

o Discuss the use of naps with a doctor.

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

Insomnia from acute stresses

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

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

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

General recommendations include the following:

* Work to improve your sleep habits.

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

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

o Establish a bedtime routine. Fix wake time.

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

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

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

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

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

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Huntington's disease

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

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

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

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

Early symptoms include:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Definition

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

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

Precautions

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

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

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

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

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

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

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

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

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

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

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

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

There are no complications associated with these tests.
Results

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

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

Health care team roles

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

Definition

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

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

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

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

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

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

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

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

Description

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Results

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

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

Health care team roles

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

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

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

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

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Definition

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.

Purpose

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.

* 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).
* 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.
* To strictly monitor the urinary output and fluid balance of critically ill patients.

Indwelling catheterization is:

* 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.
* 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.
* 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.

Precautions

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.

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.

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.
Infection control

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.

The extended portion of the catheter should be washed with a mild soap and warm water to keep it free of accumulated debris.

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.
Description

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.

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.
Preparation

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.

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.

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.
Catheter choices

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.

There are also additional types of catheters:

* PTFE-coated latex Foley catheters
* hydrogel-coated latex Foley catheters
* pure silicone Foley catheters
* silicone-coated latex Foley catheter

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.

LENGTH. Female adult patients should be given the choice of a short, female length or a standard length catheter for urethral catheterization.

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.

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.
Procedure

The standard technique for catheter insertion is:

* Explain the procedure to the patient, position the patient and ensure privacy and good lighting.
* 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.
* 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.
* 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.
* 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.

Aftercare

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.

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.

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.
Complications

Complications that are liable to occur include:

* Trauma and/or introduction of bacteria into the urinary system, leading to infection and, rarely, septicemia.
* 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.
* Bypassing of urine around the catheter. Inserting a smaller catheter size can minimize this problem.

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.
Results

Urinary catheterization should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long-term catheterization.

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.
Health care team roles
Observation

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.

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.
Patient education

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.

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.
KEY TERMS

Catheterization—A procedure of inserting a catheter through the urethra into the bladder to remove urine.

Catheter—A tube for evacuating or injecting fluid.

Contaminate—To make an item unsterile or unclean by direct contact.

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.

Intermittent catheterization—Periodic catheterization to facilitate urine flow. The catheter is removed when the bladder is sufficiently empty.

Perineal area—The genital area between the vulva and anus in a woman.

Urinary incontinence—The inability to retain urine or control one's urine flow.

Urinary retention—The inability to void (urinate) to discharge urine.

Urethritis—Inflammation of the urinary bladder.
Resources
BOOKS

Nettina, Sandra M. Lippincott Manual of Nursing Practice. 7th edition. Philadelphia: Lippincott, 2001, pp.692-697.
PERIODICALS

Colley, Wendy. RGN, DNCret. FETC. "Know How." Nursing Times (July 2, 1997).

Cravens, David D., Steven Zweig. "Urinary Catheter Management." American Family Physicians 61, no. 2 (January 15, 2000): 369.

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.

Aliene S. Linwood, B.S.N., RN, D.P.A., FACHE


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