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- Associate Professor of Neurosurgery
Note: Thin-prep (liquid-based) Pap smears are collected in the same way with a spatula and a brush medicine website discount 750 mg levaquin with mastercard, but then both are swirled separately in a bottle of thin prep solution and sent to medications descriptions discount levaquin 750mg without prescription the laboratory medicine on airplane buy 750 mg levaquin amex. A watery discharge is normal for a few weeks after the procedure as the cervix heals medicine school trusted 250 mg levaquin. Guidelines regarding postoperative sexual activity, bathing, and other activities are provided by the nurse or the physician. The gynecologist excises a small amount of cervical tissue, and the pathologist examines the borders of the specimen to determine if they are free of disease. Do not obtain a Pap smear if the woman is menstruating or has other frank bleeding (exception: high suspicion of neoplasia). Place the longer end of the Ayre spatula in the cervical canal and rotate it in a full circle to obtain a sample from the exocervix. In women who have had a hysterectomy, use a cotton applicator moistened with saline solution to obtain a sampling of cells from the vaginal cuff or posterior vagina. Immediately spray the slide or, if a Thin-prep, swirl the brush and spatula in the solution. This obtains endocervical cells and may sample cells from the squamocolumnar junction if it is high in the canal. Saline solution prevents drying, which makes interpretation difficult for the cytologist and prevents absorption of cells into the cotton, increasing the yield on the slide. Usually, the procedure can be performed without anesthesia; however, a paracervical block or a small injection of lidocaine into the uterus is effective if required. The examiner may apply a tenaculum (a clamp-like instrument that stabilizes the uterus) after the pelvic examination and then inserts a thin, hollow, flexible suction tube (pipelle or sampler) through the cervix into the uterus. Endometrial biopsy is usually indicated in cases of midlife irregular bleeding, postmenopausal bleeding, and infertility (to identify changes in the uterine lining after ovulation). Findings on aspiration may include normal endometrial tissue, hyperplasia, or endometrial cancer. Simple hyperplasia is an overgrowth of the uterine lining and is usually treated with progesterone. Complex hyperplasia is a risk factor for uterine cancer and is treated with progesterone and careful follow-up. Women who are overweight, who are over 45, who have a history of nulliparity and infertility, and who have a family history of colon cancer seem to be at higher risk for hyperplasia (Farquhar, Lethaby, Sowter et al. A perineal pad is placed over the perineum after the procedure, and excessive bleeding is reported. If pelvic discomfort or low back pain occurs, mild analgesics usually provide relief. To reduce the risk of infection and bleeding, most physicians advise no vaginal penetration or use of tampons for 2 weeks. Laparoscopy may be used for diagnostic purposes (eg, in cases of pelvic pain when no cause can be found) or treatment. Laparoscopy also facilitates many surgical procedures, such as tubal sterilization, ovarian biopsy, myomectomy, and lysis of adhesions (scar tissue that can cause pelvic discomfort). A surgical instrument (intrauterine sound or cannula) may be positioned inside the uterus to permit manipulation or movement during laparoscopy, affording better visualization. The pelvic organs can be visualized after the injection of a prescribed amount of carbon dioxide intraperitoneally into the cavity. Called insufflation, this technique separates the intestines from the pelvic organs. If the patient is undergoing sterilization, the fallopian or uterine tubes may be electrocoagulated, sutured, or ligated and a segment removed for histologic verification (clips are an alternative device for occluding the tubes). After the laparoscopy is completed, the laparoscope is withdrawn, carbon dioxide is allowed to escape through the outer cannula, the small skin incision is closed with sutures or a clip, and the incision is covered with an adhesive bandage. The cervical canal is widened with a dilator and the uterine endometrium is scraped with a curette. The purpose of the procedure is to secure endometrial or endocervical tissue for cytologic examination, to control abnormal uterine bleeding, and as a therapeutic measure for incomplete abortion. Because this procedure is usually carried out under anesthesia and requires surgical asepsis, it is usually performed in the operating room. However, it may take place in the outpatient setting with the patient receiving a local anesthetic supplemented with diazepam (Valium), midazolam (Versed), or meperidine (Demerol). The patient who receives these medications is carefully monitored until she has fully recovered. The nurse provides an explanation of the procedure as well as physical and psychological preparation, informing the patient about what the procedure involves and what to expect in terms of postoperative discomfort and bleeding. The perineum is not shaved, but the patient is instructed to void before the procedure.
A rapid rise in body temperature is regarded as unfavorable because hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage medications or drugs order levaquin 250mg otc, a poor prognostic sign medicine grapefruit interaction discount levaquin 750mg otc. Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body medications quiz order levaquin 750 mg otc. Motor Function Motor function is assessed frequently by observing spontaneous movements medications related to the female reproductive system purchase levaquin online now, asking the patient to raise and lower the extremities, and comparing the strength and equality of the hand grasp and pedal push at periodic intervals. The presence or absence of spontaneous movement of each extremity is also noted, and speech and eye signs are assessed. If the patient does not demonstrate spontaneous movement, responses to painful stimuli are assessed. Peripheral stimulation may provide inaccurate assessment data because it may result in a reflex movement rather than a voluntary motor response. Abnormal responses (lack of motor response; extension responses) are associated with a poorer prognosis. A unilaterally dilated and poorly responding pupil may indicate a developing hematoma, with subsequent pressure on the third cranial nerve due to shifting of the brain. If both pupils become fixed and dilated, this indicates overwhelming injury and intrinsic damage to the upper brain stem and is a poor prognostic sign. The patient with a head injury may develop focal nerve palsies such as anosmia (lack of sense of smell) or eye movement abnormalities and focal neurologic deficits such as aphasia, memory deficits, and post-traumatic seizures or epilepsy. Patients may be left with residual organic psychological deficits (impulsiveness, emotional lability, or uninhibited, aggressive behaviors) and, as a consequence of the impairment, lack insight into their emotional responses (Davis, 2000). The brain is extremely sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxic. Therapy is directed toward maintaining optimal oxygenation to preserve cerebral function. Interventions to ensure an adequate exchange of air are discussed in Chapter 61 and include the following: · Keep the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure (Bader & Palmer, 2000). The goal is to keep blood gas values within the normal range to ensure adequate cerebral blood flow. The monitoring of serum electrolyte levels is important, especially in patients receiving osmotic diuretics, those with inappropriate antidiuretic hormone secretion, and those with post-traumatic diabetes insipidus. Serial studies of blood and urine electrolytes and osmolality are carried out because head injuries may be accompanied by disorders of sodium regulation. Hyponatremia is common following head injury due to shifts in extracellular fluid, electrolytes, and volume. Hyperglycemia, for example, may cause an increase in extracellular fluid that lowers sodium (Hickey, 2003). Hypernatremia may also occur due to sodium retention that may last several days, followed by sodium diuresis. Endocrine function is evaluated by monitoring serum electrolytes, blood glucose values, and intake and output. A record of daily weights is maintained, especially if the patient has hypothalamic involvement and is at risk for the development of diabetes insipidus. Early initiation of nutritional therapy has been shown to improve outcomes in head-injured patients (Bader & Palmer, 2000). Parenteral nutrition via a central line or enteral feedings administered via a nasogastric or nasojejunal feeding tube may be used. Laboratory values should be monitored closely in patients receiving parenteral nutrition. Elevating the head of the bed and aspirating the enteral tube for evidence of residual feeding before administering additional feedings can help prevent distention, regurgitation, and aspiration. A continuous-drip infusion or pump Chapter 63 may be used to regulate the feeding. Enteral or parenteral feedings are usually continued until the swallowing reflex returns and the patient can meet caloric requirements orally. The patient emerging from a coma may become increasingly agitated toward the end of the day. It may indicate injury to the brain but may also be a sign that the patient is regaining consciousness. Strategies to prevent injury include the following: Management of Patients With Neurologic Trauma 1921 · If incontinence occurs, consider use of an external sheath catheter on a male patient. Because prolonged use of an indwelling catheter inevitably produces infection, the patient may be placed on an intermittent catheterization schedule. If the temperature rises, efforts are undertaken to identify the cause and to control it using acetaminophen and cooling blankets as prescribed (Bader & Palmer, 2000). If infection is suspected, potential sites of infection are cultured and antibiotics are prescribed and administered. Prolonged pressure on the tissues will decrease circulation and lead to tissue necrosis. Potential areas of breakdown need to be identified early to avoid the development of pressure ulcers. Specific nursing measures include the following: · Assess the patient to ensure that oxygenation is adequate · and the bladder is not distended.
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Chest physical therapy medicine used for adhd buy 500mg levaquin free shipping, including postural drainage to treatment 11mm kidney stone levaquin 750mg free shipping mobilize secretions medications lisinopril discount levaquin online master card, and suctioning to treatment depression cheap 250 mg levaquin with amex remove secretions may have to be performed frequently. Educational topics for outpatient self-care include medication management, energy conservation, strategies to help with ocular manifestations, and prevention and management of complications. Understanding the action of the medications and taking them on schedule is emphasized, as are the consequences of delaying medication and the signs and symptoms of myasthenic and cholinergic crisis. The patient can determine the best times for daily dosing by keeping a diary to determine fluctuation of symptoms and to learn when the medication is wearing off. The medication schedule can then be manipulated to maximize strength throughout the day. To do this, the nurse helps the patient identify the best times for rest periods throughout the day. If the patient lives in a two-story home, the nurse can suggest that frequently used items such as hygiene products, cleaning products, and snacks be kept on each floor to minimize travel between floors. The patient is encouraged to apply for a handicapped license plate to minimize walking from parking spaces and to schedule activities to coincide with peak energy and strength levels. To minimize the risk of aspiration, mealtimes should coincide with the peak effects of anticholinesterase medication. The patient is advised to sit upright during meals with the neck slightly flexed to facilitate swallowing. Soft foods in gravy or sauces can be swallowed more easily; if choking occurs frequently, the nurse can suggest pureйing food to a pudding consistency. Suction should be available at home and the patient and family instructed in its use. Gastrostomy feedings may be necessary in some patients to ensure adequate nutrition. Impaired vision results from ptosis of one or both eyelids, decreased eye movement, or double vision. To prevent corneal damage when the eyelids do not close completely, the patient is instructed to tape the eyes closed for short intervals and regularly · Arterial blood gases, serum electrolytes, input and output, and daily weight are monitored. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias (numbness). In 66% of cases, there is a predisposing event, most often a respiratory or gastrointestinal infection, although vaccination, pregnancy, Chapter 64 Management of Patients With Neurologic Infections, Autoimmune Disorders, and Neuropathies 1959 and surgery have also been identified as antecedent events (Bella & Chad, 1998). Infection with Campylobacter jejuni (a relatively common gastrointestinal bacterial pathogen) precedes GuillainBarreй syndrome in a few cases (Ho & Griffin, 1999; Lindenbaum, Kissel & Mendel, 2001). Maximum weakness varies but usually includes neuromuscular respiratory failure and bulbar weakness. The duration of the symptoms is variable: complete functional recovery may take up to 2 years (Hickey, 2003). Residual deficits are most likely in patients with rapid disease progression, those who require mechanical ventilation, or those 60 years of age or older. Death occurs in 3% to 8% of cases, resulting from respiratory failure, autonomic dysfunction, sepsis, or pulmonary emboli (Bella & Chad, 1998). While the classic clinical features include areflexia and ascending weakness, variation in presentation occurs. There may be a sensory presentation, with progressive sensory symptoms, an atypical axonal destruction, and the Miller-Fisher variant, which includes paralysis of the ocular muscles, ataxia, and areflexia (Ho & Griffin, 1999). Assessment and Diagnostic Findings the patient presents with symmetric weakness, diminished reflexes, and upward progression of motor weakness. Changes in vital capacity and negative inspiratory force are assessed to identify impending neuromuscular respiratory failure. Evoked potential studies demonstrate a progressive loss of nerve conduction velocity (Bella & Chad, 1999). Medical Management Because of the possibility of rapid progression and neuromuscular respiratory failure, Guillain-Barrй is a medical emergency, requiring intensive care unit management. Careful assessment of changes in motor weakness and respiratory function alert the clinician to the physical and respiratory needs of the patient. Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation. The patient is weaned from mechanical ventilation when the respiratory muscles can again support spontaneous respiration and maintain adequate tissue oxygenation. These may include the use of anticoagulant agents and thigh-high elastic compression stockings or sequential compression boots to prevent thrombosis and pulmonary emboli. Both therapies decrease circulating antibody levels and reduce the amount of time the patient is immobilized and dependent on mechanical ventilation. Tachycardia and hypertension are treated with short-acting medications such as alpha-adrenergic blocking agents. The use of short-acting agents is important because autonomic dysfunction is very labile.
Prevention involves patient education regarding precipitating factors treatment 4 water purchase online levaquin, possible lifestyle or habit changes that may be helpful medicine x pop up order 250mg levaquin amex, and pharmacologic measures medicine that makes you throw up cheap levaquin generic. A migraine or a cluster headache in the early phase requires Medical Management Therapy for migraine headache is divided into abortive (symptomatic) and preventive approaches medicine keri hilson lyrics generic 750mg levaquin with visa. The abortive approach, best employed in patients who suffer less frequent attacks, is aimed at relieving or limiting a headache at the onset or while it is in progress. The preventive approach is used in patients who experience more frequent attacks at regular or predictable intervals and may have medical conditions that preclude the use of abortive therapies (Evans & Lipton, 2001). The triptans, serotonin receptor agonists, are the most specific antimigraine agents available. Some headaches may be prevented if the appropriate medications are taken before the onset of pain. Nursing care during a fully developed attack includes comfort measures such as a quiet, dark environment and elevation of the head of the bed to 30 degrees. In addition, symptomatic treatment such as antiemetics may be indicated (Goadsby et al. Symptomatic pain relief for tension headache may be obtained by application of local heat or massage. Additional strategies may include the use of analgesic agents, antidepressant medications, and muscle relaxants. Headaches, especially migraines, are more likely to occur when the patient is ill, overly tired, or stressed. Nonpharmacologic therapies are important and include patient education about the type of headache, its mechanism (if known), and appropriate changes in lifestyle to avoid triggers. Regular sleep, meals, exercise, avoidance of peaks and troughs of relaxation, and avoidance of dietary triggers may be helpful in avoiding headaches (Goadsby et al. The patient with tension headaches needs teaching and reassurance that the headache is not due to a brain tumor. Stress reduction techniques, such as biofeedback, exercise programs, and meditation, are examples of nonpharmacologic therapies that may prove helpful. Patients and their families need to be reminded of the importance of following the prescribed treatment regimen for headache and keeping follow-up appointments. In addition, they are reminded of the importance of participating in health promotion activities and recommended health screenings to promote a healthy lifestyle. The National Headache Foundation (see Resources at end of the chapter) provides a list of clinics in the United States and the names of physicians who specialize in headache and who are members of the American Association for the Study of Headache. Compare and contrast the possible characteristics, causes, prognoses, and nursing interventions for a) the patient who is unconscious, b) the patient in a persistent vegetative state, and c) the patient in coma. A patient is admitted to your unit after undergoing transsphenoidal surgery for a brain tumor. Describe the major complications to assess for, along with the signs and symptoms of each. How would you modify your teaching and discharge planning if the patient understands little English? You are caring for an 18-year-old patient admitted to the hospital to evaluate the recent onset of seizures and an episode of status epilepticus. How would your approach differ if the patient is a 28-year-old woman who is 6 months pregnant? Handbook of stress, coping, and health: Implications for nursing research theory and practice. Management of Patients With Neurologic Dysfunction 1885 Journals Asterisks indicate nursing research articles. Evaluation of portable bladder ultrasound: Accuracy and effect on nursing practice in an acute care neuroscience unit. Validity and reliability of the SjO2 catheter in neurologically impaired patients: A critical review of the literature. Factors known to raise intracranial pressure and the associated implications for nursing management. Effect of therapeutic hypothermia on the incidence and treatment of intracranial hypertension. Effect of backrest position on intracranial and cerebral perfusion pressures in traumatically brain-injured adults. Identifying patients "at risk" for alcohol withdrawal syndrome and a treatment protocol. New therapies in the management of acute or cluster seizures and seizure emergencies. Verbal communication: What do critical care nurses say to their unconscious or sedated patients? Identify the risk factors for cerebrovascular disorders and related measures for prevention. Compare the various types of cerebrovascular disorders: their causes, clinical manifestations, and medical management. Relate the principles of nursing management to the care of a patient in the acute stage of an ischemic stroke.
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