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By O. Domenik. Florida Memorial College. 2018.

Up to 10% of the population does not effectively metabolize codeine to morphine order zenegra 100 mg with amex, resulting in poor pain control cheap zenegra 100mg with amex. To avoid the unpredictably variable analgesia and potential for toxicity, a simpler approach is to use morphine. Hydromorphone or oxycodone are alternatives for patients who cannot tolerate morphine because of adverse effects. An oral solution is available for doses other than 10 and 20 mg but is very unpalatable and should be given via feeding tube. Hold feeds before and after enteral administration as continuous feeds and formula may decrease bioavailability of oral products. Significantly increased free fraction in patients with hypoalbuminemia may result in underestimation of effective drug concentration and difficulty in interpretation of drug levels and toxicity may occur at “therapeutic” serum levels. Consider supplemental steroids at times of stress if patient has received long-term or frequent bursts of steroid therapy. Prolonged weakness may occur when corticosteroids are used concurrently with non- depolarizing neuromuscular blocking agents. Higher doses may be required if administered through a ventilator due to loss of drug in the circuit. Titrate dose to effect and/or adverse effects (tachycardia, tremor and hypokalemia). For most patients metered dose inhalers with a spacer device are the preferred method of drug delivery. Some patients, particularly those receiving opiates may require higher doses and/or more frequent administration. Use lower doses if there is no significant bleeding and patient will require warfarin in the future. They were developed taking into consideration services provided at different levels within the health system and resources available. These guidelines are intended to standardize care at both tertiary and secondary levels of service delivery across different socio- economic stratifcations of our society. The clinical conditions included in this manual were selected based on facility reports of high volume and high risk conditions treated in each specialty area. The guidelines were developed through extensive consultative work sessions, which included health experts and clinicians from different specialties. The work group brought together current evidence-based knowledge in an effort to provide the highest quality of healthcare to the public. It is my strong hope that the use of these guidelines will greatly contribute to improved diagnosis, management and treatment of patients. And, it is my sincere expectation that service providers will adhere to these guidelines/protocols. The Ministry of Health is grateful for the efforts of all those who contributed in various ways to the development, review and validation of the National Clinical Treatment Guidelines. We would like to thank our colleagues from district, referral and university teaching hospitals, and specialized departments within the Ministry of Health, our partners and private health practitioners. We also thank the Rwanda Professional Societies in their relevant areas of specialty for their contribution and technical review, which enriched the content of this document. Finally, we wish to express thanks to all those who contribute to improving the quality of health care of the Rwanda population. Weak / absent breathing Circulation Cold Hands with any of: Immediate transfer to emergency area: 1. Classifcation of pain severity - Self-reporting: use of number or faces scale - Observational: based on behaviors (crying, shaking, etc. Acute Gastroenteritis Defnition: Gastroenteritis is an infammation of the stomach and intestines that causes diarrhea, vomiting, nausea and other symptoms of digestive upset. Causes - Viral gastroenteritis: Rotaviruses are the most likely cause of infec- tious diarrhea in children under the age of 5 - Bacterial gastroenteritis : Campylobacter, Salmonella or E. Persistent Diarrhea Defnition: Persistent diarrhea is a diarrhea, with or without blood, which begins acutely and lasts for 14 days or longer.

Move the floss up and down between the teeth from the tops of the crowns to the gum 3 cheap zenegra 100mg on-line. A fracture 100mg zenegra with mastercard, the slipper or low back pan Advantage ⇒ Has a thinner rim than as standard bed pan ⇒ Is designed to be easily placed under a person’s buttocks Disadvantage ⇒ Easier to spill the contents of the fracture pan Basic Nursing Art 40 ⇒ Are useful for people who are a. The pediatric bedpan • Are small sized • Usually made of a plastic Offering and Removing Bed Pan • If the individual is weak or helpless, two peoples are needed to place and remove bed pans • If a person needs the bed pan for a longer time periodically remove and replace the pan to ease pressure and prevent tissue damage • Metal bed pans should be warmed before use by: o Running warm water inside the rim of the pan or over the pan o Covering with cloth • Semi-Fowler’s position relieves strain on the client’s back and permits a more normal position for elimination Improper placement of the bedpan can cause skin abrasion to the sacral area and spillage o Place a regular bed pan under the buttocks with the narrow end towards the foot of the bed and the buttocks resting on the smooth, rounded rim o Place a slipper (fracture) pan with the flat, low end under the client’s buttocks o Covering the bed pan after use reduces offensive odors and the clients embarrassment Basic Nursing Art 41 If the client is unable to achieve regular defecation help by attending to: 1. Timing – do not ignore the urge to defecate • A patient should be encouraged to defecate when the urge to defecate is recognized • The patient and the nurse can discuss when mass peristalsis normally occurs and provide time for defecation (the same time each day) 3. Nutrition and fluids For a constipated client: increase daily fluid intake, drink hot liquids and fruit juices etc For the client with diarrhea – encourage oral intake of foods and fluids For the client who has flatulence: limit carbonated beverages; avoid gas- forming foods 4. Exercise • Regular exercise helps clients develop a regular defecation pattern and normal feces 5. Positioning • Sitting position is preferred 3 Measures to assist the person to void include: • Running water in the sink so that the client can hear it • Warming the bed pan before use • Pouring water over the perineum slowly • Having the person assume a comfortable position by raising the head of the bed (men often prefer to stand) • Providing sufficient analgesia for pain Basic Nursing Art 42 • Having the person blow through a straw into a glass of water – relaxes the urinary sphincter Perineal Care (Perineal – Genital Care) Perineal Area: • Is located between the thighs and extends from the top of the pelvic bone (anterior) to the anus (posterior) • Contains sensitive anatomic structures related to sexuality, elimination and reproduction Perineal Care (Hygiene) • Is cleaning of the external genitalia and surrounding area • Always done in conjunction with general bathing Patients in special needs of perineal care • Post partum and surgical patients (surgery of the perineal area) • Non surgical patients who unable to care for themselves • Patients with catheter (particularly indwelling catheter) Other indications for perineal care are: 1. Excessive secretions or concentrated urine, causing skin irritation or excoriation 4. Care before and after some types of perineal surgery Purpose • To remove normal perineal secretions and odors • To prevent infection (e. Patient preparation • Give adequate explanation • Provide privacy • Fold the top bedding and pajamas (given to expose perineal area and drape using the top linen. Cleaning the genital area • Put on gloves For Female • Remove dressing or pad used • Inspect the perineal area for inflammation excoriation, swelling or any discharge. In case of post partum or surgical pt • Clean by cotton swabs, first the labia majora then the skin folds between the majora and minora by retracting the majora using gauze squares, clean from anterior to posterior direction using separate swab for Basic Nursing Art 44 each strokes. In case of non-surgical pts • Wash or clean the genital area with soapy water using the different quarters of the washcloth in the same manner. Female Perineum • Is made up of the vulva (external genitalia), including the mons pubis, prepuce, clitoris, urethral and vaginal orifices, and labia majora and minora • The skin of the vaginal orifice is normally moist • The secretion has a slight odor due to the cells and normal vaginal florae • The clitoris consists of erectile tissues and many nerves fibers. Is very sensitive to touch Care • Convenient for a woman to be on a bed pan to clean and rinse the vulva and perineum • Secretion collects on the inner surface of the labia • Use on hand to gently retract the labia • Use a separate section of wash cloth for each wipe in a downward motion (from urethra to back perineum) • Then clean the rectal area Note • Following genital or rectal surgery, sterile supplies may be required for cleaning the operative site, E. Hair care includes combing (brushing of hair), washing/shampooing of hair and pediculosis treatment. Equipments • Comb (which is large with open and long toothed) • Hand mirror • Towel • Lubricant/oils (if required) Procedure 1. Comb the hair by dividing the hair • Hold a section of hair 2-3 inches from the end and comb the end until it is free from tangles. Documentation Shampooing/Washing the Hair of Patient Confined to Bed Purpose • Stimulate blood circulation to the scalp through massaging • Clean the patients hair so it increase a sense of well-being to the pt Equipments • Comb and brush • Shampoo/soap in a dish • Shampoo basin • Plastic sheet • Two wash towels • Cotton balls • Water in basin and pitcher • Receptacle (bucket) to receive the used water • Lubricants/oil as required Procedure 1. Prepare the patient • Assist patient to move to the working side of the bed • Remove any hair accessories (e. Shampooing/washing the hair • Wet the hair thoroughly with water • Apply shampoo (soap) to the scalp. Documentation and reporting Pediculosis Treatment Purpose • To prevent transmission of some arthropod born diseases • To make patient comfortable Definition Pediculosis: infestation with lice Lice: • Are small, grayish white, parasitic insects that infest mammals • Are of three common kinds: ¾ Pediculose capitis: is found on the scalp and tends to stay hidden in the hairs ¾ Pediculose pubis: stay in pubic hair ¾ Pediculose corporis: tends to cling to clothing, suck blood from the person and lay their eggs the clothing suspect their presence in the clothing if: a. There are hemorrhagic spots in the skin where the lice have sucked blood Head and body lice lay their eggs on the hairs then eggs look like oval particles, similar to dandruff, clinging to the hair. Kerosene Oil mixed with equal parts of sweet oil • Destroys both adult lice and eggs of nits • From aesthetic point of view, kerosene causes foul smell and create discomfort to patient and the attendant Guidelines for Applying Pediculicides Hair: • Apply pediculicide shampoo to dry hair until hair is thoroughly saturated and work shampoo in to a lather • Allow product to remain on hair for stated period (varies with products) • Pin hair and allow to dry • Use a fine toothed comb to remove death lice and nits (comb should not be shared by other family members) • Repeat it in 8-10 days to remove any hatched nits • Apply pediculious lotion (or cream) to affected areas • Bath after 12 hrs and put on clean clothes 3. Oil of Sassafras • Is a kind of scented bark oil • Only destroy lice not nits • For complete elimination, the oil should be massaged again after 10 days when the nits hatch • Is used daily for a week with equal parts of Luke warm H2O then it should be repeated after a week 4. Gcmmaxine (Gamma Bengenhexa Chloride) Basic Nursing Art 51 • Emphasize the need for treatment of sexual partner • After complete bathing wash linen available as a cream, lotion, and a shampoo • 1. However, many peoples, because of weakness, immobility and/or one or both upper extremities are unable to feed themselves all or parts of the meal. Therefore, the nurse must be knowledgeable, sensitive and skillful in carrying out feeding procedures.

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Sclera Retina Anterior Choroid Chamber Cornea Fovea Optic nerve Pupil Lens Iris Suspensary ligament Ciliary body Optic nerve head Conjunctiva Vitreous body 1 buy cheap zenegra 100 mg line. Cornea - Is the main refractive media of the eye (75 % of refractory function of the eye) buy zenegra 100mg fast delivery. Iris - has central hole (pupil) through which light reaches the retina - consists of a vascular stroma covered by mesothelium anteriorly and by two pigmented layers of epithelium posteriorly. Its size is subject to various factors like aging, illumination, sleep, change of gaze, emotional status. Ciliary body - Triangular structure that is situated between the iris anteriorly and choroids posteriorly. Circulation of aqueous fluid Aqueous fluid is produced by ciliary process of ciliary body. It flows from the posterior Chamber along the pupillary opening to the anterior chamber. Finally it will be drained through the Canal of schlemn in the Trabecular meshwork to episcleral veins Stroma Endothelium Epithelium Trabecular meshwork Canal of Schlemn Iris Anterior Lens Chamber angle Posterior chamber Ciliary Processes Ciliary body Fig. The Choroids - It is network of blood vessels - The arteries and veins are located externally while capillaries are found internally. Have two layers I- Outer layer - Next to choroid, single layer of fragment epithelial cell. The electrical impulses produced by each rod or cone passes across synapses to the bipolar cell. Then the impulses are modified in various ways as they pass through the bipolar and ganglion cells. The nerve fibers from the ganglion cells travel in the nerve fibers layer on the surface of the retina to the optic disc and form the optic nerve. This is used to protect the macular cones from the dazzle of incident light, which occurs even with maximal pupillary constriction. Anterior chamber - Delineated anteriorly by the posterior corneal surface and posteriorly by iris. Posterior chamber - Limited anteriorly and laterally by the posterior iris surface and ciliary body and posterior by lens & vitreous body C. Vitreous space - Filled with vitreous humor - Transparent, roughly spherical and gelatinous structure occupying posterior 4/5 of the globe with volume of 4 ml. The lymphatic drainage of the medial eye lid is to sub mandibular lymph node and that of lateral one is to the superficial preauricular lymph nodes and then to deeper cervical lymph nodes. Ahmed 4 - Albert and Jakoboiec Principle and practice of ophthalmology 5 - Up to date - (C) 2001 - www. To give a clear idea about the approach to ophthalmic patients and specific examination techniques. At the end of the course the students are expected to know how to examine ophthalmic patients and use of certain ophthalmic instruments 2. Family history The main purpose of the history is to find out what exactly the patient is complaining. However it is always helpful to find out some background information about the patient e. Such information will indicate what vision the patient needs for work and for personal satisfaction. Major symptom of eye disease given • Disturbances of vision • Discomfort or pain in the eye • Eye discharge A. Disturbances of vision • The most common visual symptom • Can be sudden or gradual ¾ Blurring or reduction of vision ¾ Dazzling/glare/ – difficulty of seeing in bright light, may be caused by opacities in the cornea or lens ¾ Diplopia/ double vision/ ¾ Decreased peripheral vision – may be caused by various disorders in the retina, optic nerve or visual pathway pathology up to the visual cortex. Visual field Visual field is that portion of one’s surroundings that is visible at one time during central vision Not a routine test in all patients ¾ Important to do in any patients with suspected glaucoma, diseases of the optic nerves in visual pathways, and certain retinal diseases Confrontation test - Simple and no need of special equipment - Will detect serious visual field defects. To examine the front of the eye, this requires both a good light illumination with bright light, torch and magnifying lens(loupe).

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Thus order zenegra 100mg otc, the sternal angle and second rib are important landmarks for the identification and counting of the lower ribs purchase zenegra 100mg with amex. This small structure is cartilaginous early in life, but gradually becomes ossified starting during middle age. The ribs articulate posteriorly with the T1–T12 thoracic vertebrae, and most attach anteriorly via their costal cartilages to the sternum. Parts of a Typical Rib The posterior end of a typical rib is called the head of the rib (see Figure 7. This region articulates primarily with the costal facet located on the body of the same numbered thoracic vertebra and to a lesser degree, with the costal facet located on the body of the next higher vertebra. A small bump on the posterior rib surface is the tubercle of the rib, which articulates with the facet located on the transverse process of the same numbered vertebra. Just lateral to the tubercle is the angle of the rib, the point at which the rib has its greatest degree of curvature. A shallow costal groove for the passage of blood vessels and a nerve is found along the inferior margin of each rib. Most ribs are then attached, either directly or indirectly, to the sternum via their costal cartilage (see Figure 7. Thus, the cartilage of rib 10 attaches to the cartilage of rib 9, rib 9 then attaches to rib 8, and rib 8 is attached to rib 7. Instead, their small costal cartilages terminate within the musculature of the lateral abdominal wall. However, growth, remodeling, and ossification (bone formation) continue for several decades after birth before the adult skeleton is fully formed. Knowledge of the developmental processes that give rise to the skeleton is important for understanding the abnormalities that may arise in skeletal structures. Development of the Skull During the third week of embryonic development, a rod-like structure called the notochord develops dorsally along the length of the embryo. The tissue overlying the notochord enlarges and forms the neural tube, which will give rise to the brain and spinal cord. By the fourth week, mesoderm tissue located on either side of the notochord thickens and separates into a repeating series of block-like tissue structures, each of which is called a somite. The sclerotomes consist of an embryonic tissue called mesenchyme, which will give rise to the fibrous connective tissues, cartilages, and bones of the body. These cells then differentiate directly into bone producing cells, which form the skull bones through the process of intramembranous ossification. As the brain case bones grow in the fetal skull, they remain separated from each other by large areas of dense connective tissue, each of which is called a fontanelle (Figure 7. They are important during birth because these areas allow the skull to change shape as it squeezes through the birth canal. After birth, the fontanelles allow for continued growth and expansion of the skull as the brain enlarges. The largest fontanelle is located on the anterior head, at the junction of the frontal and parietal bones. However, the skull bones remained separated from each other at the sutures, which contain dense fibrous connective tissue that unites the adjacent bones. The connective tissue of the sutures allows for continued growth of the skull bones as the brain enlarges during childhood growth. The second mechanism for bone development in the skull produces the facial bones and floor of the brain case. However, these cells differentiate into cartilage cells, which produce a hyaline cartilage model of the future bone. As this cartilage model grows, it is gradually converted into bone through the process of endochondral ossification. This is a slow process and the cartilage is not completely converted to bone until the skull achieves its full adult size.

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