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The anterior and lateral columns are composed of many different groups of axons of both ascending and descending tracts—the latter carrying motor commands down from the brain to the spinal cord to control output to the periphery effexor xr 75mg without a prescription. Basal Nuclei Parkinson’s disease is a disorder of the basal nuclei cheap 37.5mg effexor xr with amex, specifically of the substantia nigra effexor xr 75mg free shipping, that demonstrates the effects of the direct and indirect pathways purchase effexor xr 75 mg online. Without that modulatory influence discount 150mg effexor xr, the basal nuclei are stuck in the indirect pathway, without the direct pathway being activated. The increased activity of the indirect pathway results in the hypokinetic disorder of Parkinson’s disease. Parkinson’s disease is neurodegenerative, meaning that neurons die that cannot be replaced, so there is no cure for the disorder. With levels of the precursor elevated, the remaining cells of the substantia nigra pars compacta can make more neurotransmitter and have a greater effect. According to one hypothesis about the expansion of brain size, what tissue might have been sacrificed so energy was available to grow our larger brain? Based on what you know about that tissue and nervous tissue, why would there be a trade-off between them in terms of energy use? To protect this region from the toxins and pathogens that may be traveling through the blood stream, there is strict control over what can move out of the general systems and into the brain and spinal cord. The next branches give rise to the common carotid arteries, which further branch into the internal carotid arteries. The bases of the common carotids contain stretch receptors that immediately respond to the drop in blood pressure upon standing. The orthostatic reflex is a reaction to this change in body position, so that blood pressure is maintained against the increasing effect of gravity (orthostatic means “standing up”). Heart rate increases—a reflex of the sympathetic division of the autonomic nervous system—and this raises blood pressure. Branches off the left and right vertebral arteries merge into the anterior spinal artery supplying the anterior aspect of the spinal cord, found along the anterior median fissure. The two vertebral arteries then merge into the basilar artery, which gives rise to branches to the brain stem and cerebellum. The left and right internal carotid arteries and branches of the basilar artery all become the circle of Willis, a confluence of arteries that can maintain perfusion of the brain even if narrowing or a blockage limits flow through one part (Figure 13. The circle of Willis is a specialized arrangement of arteries that ensure constant perfusion of the cerebrum even in the event of a blockage of one of the arteries in the circle. The animation shows the normal direction of flow through the circle of Willis to the middle cerebral artery. Where would the blood come from if there were a blockage just posterior to the middle cerebral artery on the left? The superior sagittal sinus drains to the confluence of sinuses, along with the occipital sinuses and straight sinus, to then drain into the transverse sinuses. The dura mater is a thick fibrous layer and a strong protective sheath over the entire brain and spinal cord. Beneath the arachnoid is a thin, filamentous mesh called the arachnoid trabeculae, which looks like a spider web, giving this layer its name. It is directly attached to the inner surface of the bones of the cranium and to the very end of the vertebral cavity. Two infoldings go through the midline separations of the cerebrum and cerebellum; one forms a shelf-like tent between the occipital lobes of the cerebrum and the cerebellum, and the other surrounds the pituitary gland. Arachnoid Mater The middle layer of the meninges is the arachnoid, named for the spider-web–like trabeculae between it and the pia mater. The name pia mater comes from the Latin for “tender mother,” suggesting the thin membrane is a gentle covering for the brain. This procedure is called a lumbar puncture and avoids the risk of damaging the central tissue of the spinal cord. Blood vessels that are nourishing the central nervous tissue are between the pia mater and the nervous tissue. The particular pathogens are not special to meningitis; it is just an inflammation of that specific set of tissues from what might be a broader infection. Bacterial meningitis can be caused by Streptococcus, Staphylococcus, or the tuberculosis pathogen, among many others. Viral meningitis is usually the result of common enteroviruses (such as those that cause intestinal disorders), but may be the result of the herpes virus or West Nile virus.

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As scientific research evolves buy discount effexor xr 150 mg, it is hoped that the gaps in our understanding will be filled proven effexor xr 75mg, and better 16 strategies for prophylaxis and treatment will become available order effexor xr 37.5 mg otc. The following is a summary of our current understanding of the pathoge- netic maze of rheumatic carditis discount 150mg effexor xr free shipping. Initial streptococcal infection in a genetically predisposed host in a susceptible environment leads to the activation of T-cell and B-cell lymphocytes by streptococcal antigens and superantigens discount effexor xr 150mg with amex, which re- sults in the production of cytokines and antibodies directed against streptococcal carbohydrate and myosin. A break in the endothelial continuity of a heart valve would expose subendothelial structures (vimentin, laminin and valvu- lar interstitial cells) and lead to a “chain reaction” of valvular destruc- tion. Once valve leaflets are inflamed through the valvular surface endothelium and new vascularization occurs, the newly formed mi- crovasculature allows T-cells to infiltrate and perpetuate the cycle of valvular damage. The presence of T-cell infiltration, even in old min- eralized lesions, is indicative of persistent and progressive disease in the valves. Valvular interstitial cells and other valvular constituents under the influence of inflammatory cytokines perpetuate aberrant repair. Although the foregoing offers a very feasible explanation of the ex- perimental data, questions remain that have significant implications for choosing streptococcal vaccines (22–24). For example, there is no direct and conclusive evidence for a pathogenetic role of cross-reac- tive antibodies in vivo and there is no exact animal model of rheu- matic fever for study. The need for a better understanding of the epidemiology of streptococci is underscored by a report that one group A streptococcal serotype can be rapidly and completely re- placed by another serotype in a stable population with adequate access to health care (25). This serotype change still has not been adequately explained and it raises questions about the efficacy of any type-specific streptococcal vaccine that is synthesized by combining M-protein sequences from virulent streptococcal serotypes. Identification and characterization of novel superantigens from Streptococcus pyogenes. European Journal of Clinical Microbiology and Infectious Diseases, 1991, 10:55–57. VirR and Mry are homologous trans-acting regulators of M protein and C5a peptidase expression in group A streptococci. Interactions of fibronectin with streptococci: the role of fibronectin as a receptor for Streptococcus pyogenes. Genetic variability of the emm-related gene of the large vir regulon of group A streptococci: potential intra- and intergenomic recombination events. Protection against a heterologous M serotype with shared C repeat region epitopes. Treatment of streptococcal pharyngotonsillitis: reports of penicillin’s demise are premature. Antibody-mediated autoimmune myocarditis depends on genetically determined target organ sensitivity. Dynamic epidemiology of group A streptococcal serotypes associated with pharyngitis. Major manifestations were least likely to lead to an improper diagno- sis and included carditis, joint symptoms, subcutaneous nodules, and chorea. Modified in part from reference (45) 20 two minor, manifestations offered reasonable clinical evidence of rheumatic activity. Although the Jones criteria have been revised repeatedly, the modi- fications were often made without prospective studies and were based on the perceived effects of previous revision(s). The prophylactic and prognostic stakes clearly underscore the importance of correctly identifying carditis. A diagnosis of recurring carditis requires the demonstration of valvular damage or involvement, with or without pericardial or myocardial involvement (11). Such clinical findings include a documented change in a previous murmur to a new murmur or pericardial rub, or an obvious radiographic increase in cardiac size, respectively. Further, recurrences of the disease are common in developing coun- tries, owing to gaps in the detection and secondary prevention of disease caused by a lack of health-care facilities. It is prudent to consider them as cases of “probable rheumatic fever” (once other diagnoses are excluded) and advise regular secondary prophylaxis. This cautious approach is particularly suitable for patients in vulnerable age groups in high incidence settings. However, an echo-Doppler examination should be per- formed if the facilities are available. Subcutaneous nodules are almost always associated with cardiac involvement and are found more commonly in patients with severe carditis.

Collecting Blood Specimen 101 Basic Clinical Nursing Skills The hospital laboratory technicians obtain most routine blood specimens order effexor xr 150mg on-line. Patient preparation 102 Basic Clinical Nursing Skills • Instruct the pt what to expect and for fasting (if required) • Position the pt comfortably 2 buy 150 mg effexor xr with mastercard. Obtain specimen of the venous to blood • Adjust the syringe and needles • Clean/disinfect the area with alcohol swab effexor xr 150 mg otc, dry with sterile cotton swab • Puncture the vein sites • Release the tourniquet when you are sure in the vein • Withdraw the required amount of venous blood specimen 103 Basic Clinical Nursing Skills • Withdraw the needle and hold the sites with dry cotton (to apply pressure) • Put the blood into the specimen container • Made sure not to contaminate outer part of the container and not to distract the blood cells while putting it into the container 4 effexor xr 75mg low cost. Care of the specimen and the equipment • Label the container • Shake gently (if indicated to mix) • Send immediately to laboratory discount effexor xr 150 mg with amex, accompanying the request • Give care of used equipments 6. Chart Definition: it is a written record of history, examination, tests, diagnosis, and prognosis response to therapy Purpose of Patients Chart a. For diagnosis or treatment of a patient while in the hospital (find after discharge) if patient returns for treatment in the future time b. For serving an information in the education of health personnel (medical students, interns, nurses, dietitians, etc) e. For promoting public health General Rules for Charting • Spelling Make certain you spell correctly 105 Basic Clinical Nursing Skills • Accuracy Records must be correct in all ways, be honest • Completeness No omission, avoid unnecessary words or statement • Exactness Do not use a word you are not sure of • Objective information Record what you see avoid saying (condition better) • Legibility Print/write plainly and distinctively as possible • Neatness No wrinkles, proper speaking of items Place all abbreviation, and at end of statement • Composition / arrangement Chart carefully consult if in doubt avoid using of chemical formulas • Sentences need to be complete and clear, avoid repetition • Don’t overwrite • Don’t leave empty spaces in between • Time of charting Specific time and date • Color of ink Black or blue (red for transfusion, days of surgery) 106 Basic Clinical Nursing Skills It should be recorded on the graphic sheet All orders should be written and signed. Verbal or telephone orders should be taken only in emergency verbal orders should be written in the order sheet and signed on the next visit. Laboratory and other diagnostic reports • Patients or relatives and friends of patients are not allowed to read the chart when necessary but can have access if allowed by patient. Purpose: • To replace fluid losses 107 Basic Clinical Nursing Skills • To provide maintenance requirements • To check for retention of body fluid Fluid balance sheet ♦ 24 hrs the intake out put should be compared and the balance is recorded ¾ Positive balance if intake >output Negative balance if out put >intake Study Questions 1. Closed bed: is a smooth, comfortable and clean bed, which is prepared for a new patient • In closed bed: the top sheet, blanket and bed spread are drawn up to the top of the bed and under the pillows. Open bed: is one which is made for an ambulatory patient are made in the same way but the top covers of an open bed are folded back to make it easier of a client to get in. To conserve patient’s energy and maintain current health status 110 Basic Clinical Nursing Skills Anesthetic bed: is a bed prepared for a patient recovering from anesthesia ⇒ Purpose: to facilitate easy transfer of the patient from stretcher to bed Amputation bed: a regular bed with a bed cradle and sand bags ⇒ Purpose: to leave the amputated part easy for observation Fracture bed: a bed board under normal bed and cradle ⇒ Purpose: to provide a flat, unyielding surface to support a fracture part Cardiac bed: is one prepared for a patient with heart problem ⇒ Purpose: to ease difficulty in breathing General Instructions 1. Linen for one client is never (even momentarily) placed on another client’s bed 111 Basic Clinical Nursing Skills 5. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered for disposal 6. Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on the other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Vertical - make a fold in the sheet 5-10 cm 1 to the foot Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot 10. Bed spread Note • Pillow should not be used for babies • The mattress should be turned as often as necessary to prevent sagging, which will cause discomfort to the patient. Closed Bed • It is a smooth, comfortable, and clean bed that is prepared for a new patient Essential Equipment: • Two large sheets • Rubber draw sheet • Draw sheet • Blankets • Pillow cases • Bed spread Procedure: • Wash hands and collect necessary materials • Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed 113 Basic Clinical Nursing Skills • Tuck sheet under mattress at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck sheet on the sides and foot of bed, mitering the corners • Tuck sheets smoothly under the mattress, there should be no wrinkles • Place rubber draw at the center of the bed and tuck smoothly and tightly • Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely • Place top sheet with wrong side up, center fold of sheet on center of bed and wide hem at head of bed • Tuck sheet of foot of bed, mitering the corner • Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the corner • Fold top sheet over blanket • Place bed spread with right side up and tuck it • Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothening out all wrinkles, put pillow case on pillow and place on bed • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands 114 Basic Clinical Nursing Skills B. Occupied Bed Purpose: to provide comfort, cleanliness and facilitate position of the patients Essential equipment: • Two large sheets • Draw sheet • Pillow case • Pajamas or gown, if necessary Procedure: • If a full bath is not given at this time, the patient’s back should be washed and cared for • Wash hands and collect equipment • Explain procedure to the patient • Carry all equipment to the bed and arrange in the order it is to be used • Make sure the windows and doors are closed • Make the bed flat, if possible • Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow cases on the chair for receiving dirty linen • Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder and the shoulder hand over the patient’s knees, turn the patient towards you 115 Basic Clinical Nursing Skills • Never turn a helpless patient away from you, as this may cause him/her to fall out bed • When you have made the patient comfortable and secure as near to the edge of the bed as possible, to go the other side carrying your equipment with you • Loosen the bedding on that side • Fold, the bed spread half way down from the head • Fold the bedding neatly up over patient • Roll dirty bottom sheet close to patient • Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half close to the patient, tucking top and bottom ends tightly and mitering the corner • Put on rubber sheet and draw sheet if needed • Turn patient towards you on to the clean sheets and make comfortable on the edge of bed • Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back care • Remove dirty sheet gently and place in dirty pillow case, but not on the floor • Remove dirty bottom sheet and unroll clean linen • Tuck in tightly at ends and miter corners • Turn patient and make position comfortable • Back rub should be given before the patient is turned on his /her back • Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious 116 Basic Clinical Nursing Skills • Go to foot of bed and pull the dirty top sheet out • Replace the blanket and bed spread • Miter the corners • Tuck in along sides for low beds • Leave sides hanging on high beds • Turn the top of the bed spread under the blanket • Turn top sheet back over the blanket and bed spread • Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s toes and chest • Be sure the patient is comfortable • Clean bedside table • Remove dirty linen, leaving room in order Wash hands Bed Making Making a post operative bed o The entire bed need clean linen. Fanfold the top linens to the side so that they lay opposite from where you will place the client’s stretcher. Rational: A pillow may be contraindicated for a client, usually the physician or charge nurse will determine when it is safe for the client to have one. Mouth Care Purpose • To remove food particles from around and between the teeth • To remove dental plaque to prevent dental caries • To increase appetite • To enhance the client’s feelings of well-being • To prevent sores and infections of the oral tissue • To prevent bad odor or halitosis Equipments • Toothbrush (use the person’s private item.

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