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By F. Joey. Lutheran Theological Seminary at Gettysburg. 2018.

The coracoclavicu- associated with radial shortening and malalignment at the lar distance may be assessed by comparison to the oppo- distal radial ulnar joint cheap finast 5mg with mastercard. This combination is referred to as site side with both sides included on a crosswise AP im- the Essex-Lopresti fracture purchase 5mg finast visa. These may be associated with fractures of the Fractures of the coronoid process of the ulna are an- greater tuberosity or with compression fractures of the other common fracture at the elbow buy 5mg finast otc. These are almost al- posterolateral aspect of the humeral head (Hill-Sachs de- ways seen in association with or following posterior dis- formity) finast 5 mg otc. Fractures of the olecranon are of- (bony Bankart deformity) may also be identified; these ten displaced and readily identified cheap finast 5mg on-line, but some olecranon are best seen on axillary views of the shoulder. Knowledge of the normal rela- ly missed; it is estimated that nearly half are missed on tionship of the anterior cortex of the humerus to the the initial evaluation. A line drawn along the ante- illary view, or scapular-Y view facilitates diagnosis. On the in- sects the anterior third of the condyle, there may be a pos- ternal and external views, a clue may arise from the fact teriorly displaced supracondylar fracture. Fractures of the that the technologist is unable to obtain images in exter- lateral condyle and medial epicondyle are also common. Compression fractures of the anteromedial The most common dislocation of the adult elbow is the aspect of the humeral head are found in association with posterior dislocation. These are usually quite obvious and posterior dislocations, analogous to the Hill-Sachs defect not difficult to diagnose. These compression de- the Monteggia fracture-dislocation, in which an angulat- formities of the anteromedial aspect of the humeral head ed or displaced fracture of the proximal ulna is associat- present as a trough in the humeral head and are often best ed with a radial head dislocation. When doubt exists concerning overlap of the radial head on the capitellum on the AP im- the presence of a posterior dislocation, CT may be ex- age should indicate the presence of a dislocation. A line tremely valuable to determine that a dislocation is present drawn along the long axis of the radial neck should in- and to assess fracture of the humeral head. The history tersect the capitellum in every projection (radio-capitel- may be helpful in patients with posterior dislocations, lar line). Dislocations at the wrist include perilunate and lu- Radiographic examination of the wrist usually consists of nate dislocations. Perilunate dislocations are frequently three views: PA, lateral, and pronation-oblique projec- associated with fractures through the scaphoid waist (a tions. Additional views, including angle views of the trans-scaphoid perilunate dislocation). Virtually all per- scaphoid (with ulnar deviation), a “clenched fist” view, ilunate dislocations are dorsal. Lunate dislocations, in and carpal tunnel views, may be helpful in specific situ- contrast, are virtually all volar in direction and are rarely ations. Recently, a semisupinated oblique view was rec- seen in association with other fractures at the wrist. Scapho-lunate dissociation (rotary subluxation of the The most common fracture at the wrist in the adult scaphoid) results in abnormal rotation of the scaphoid population is the Colles fracture, which is much more fre- and is due to a disruption in the scapho-lunate and volar quent in elderly women than in men. This may occur alone or be part of oth- is a resultant dorsal tilt to the distal radial articular sur- er more complex injuries about the lunate axis. Subtle injuries may be difficult to detect when dis- The Galeazzi fracture is a fracture is of the distal radi- placement is minimal; these may be recognized only by al shaft associated with a dislocation at the distal radial the loss of the normal volar tilt to the distal radial artic- ulnar joint (i. Fractures of the distal radius are frequently Isolated dislocations at the distal radioulnar joint are ex- associated with injuries to the ulnar side of the wrist, in- tremely difficult to diagnose because slight degrees of ro- cluding tears of the triangular fibrocartilage, dislocation tation of the wrist from the lateral projection may cause of the distal radio-ulnar joint and fractures of the ulnar difficulty. Such injuries often give rise to ulnar-sided wrist bility of distal radioulnar dislocations, CT is the recom- pain with instability and the ulnar abutment syndrome, mended technique for evaluation. In the carpus, fracture of the scaphoid is by far the Less common injuries at the wrist include fractures of most common fracture, accounting for approximately the hook of the hamate and of the pisiform or capitate. A scaphoid CT may be needed to demonstrate these fractures; refor- fracture may be virtually impossible to detect on conven- matted images in coronal and sagittal planes should be a tional imaging but clinically suspected due to pain in the part of the examination. If there is a strong Hands suspicion and an immediate diagnosis is necessary, MRI is an expensive but highly accurate method of diagnosis. Conventional imaging of the hand should include PA, a At least one author stated that MRI is cost effective in pa- lateral view, and pronation oblique views. The internal tients with negative X-rays in whom there is a strong clin- oblique view may detect fractures that were overlooked or ical suspicion of a scaphoid fracture. The diagnosis significantly underestimated on standard views of the can be made with a brief limited examination. While most of these fractures are identified mon the complications of osteonecrosis and non-union.

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In MS discount finast 5mg visa, involuntary bowel or fecal incontinence is the result of interruption in the neural pathways and impaired cortical awareness of the urge to defecate finast 5 mg with visa. Questions to ask include the use of medications that influence bowel activity purchase finast 5mg mastercard, such as diuretics finast 5mg online, antacids buy finast 5mg overnight delivery, nonsteroidal anti-inflammatory agents, anticholinergics, antidepressants, antibiotics, laxatives, and enemas. Fluid and dietary history should include fluid intake, daily intake of fiber, and type of food or snacks eaten. Objective assessment of the abdomen should include aus- cultation, palpation, and percussion. Assessment should include patient’s functional ability to ambulate and transfer, the use of assistive devices, the ability to remove clothing, and the accessibility of toilet facilities. Goals of bowel training program include: normalizing stool consistency establishing a regular pattern for defecation stimulating rectal emptying on a routine basis avoiding complications of diarrhea, constipation, or incontinence improving the patient’s quality of life C. Constipation should be first treated with nonpharmacologic interventions: 1. The use of stool softeners or bulk formers with fluids and fiber may help. Oral stimulants provide a chemical stimulation and a localized mechanical stimulation and lubrication to promote elimination of stool. Dulcolax® suppositories and Therevac® mini enemas con- tain medications that stimulate strong, involuntary, wavelike movement that facilitates the elimination of stool. Regular use of enemas should be avoided to minimize the risk of dependency. Fecal impaction is a complication of chronic constipation: manual disimpaction or soap suds enemas are the options for immediate treatment, but long-term management with the above is the appropriate option. An episode of fecal impaction is an indication for the need for an aggressive bowel program. Adequate bulk and fiber is important for maintenance of stool consistency. Patients should be instructed to avoid overly spicy and gas-forming foods. Planned times for bowel evacuation and the use of supposi- tories to stimulate rectal emptying allows for more bowel control. Encourage the patient to sit on a toilet or commode for 25 to 30 minutes after consuming a hot beverage. The following strategies may help: sit comfortably on the toilet and try to “bear down” rocking back and forth and massaging the abdomen can promote bowel activity if the bowels do not move within 10 minutes, leave the bathroom and try again later when another “urge” is present E. Chapter 15 The Nurse’s Role in Advanced Multiple Sclerosis Objectives: Upon completion of this chapter, the learner will: Describe key issues of concern in advanced MS Discuss nursing implications in progressive disease Cite specific strategies in avoiding complications of this advanced conditionAdvanced MS A. Caregivers are faced with ongoing tasks and special needs in this population C. The nurse is challenged as both a caregiver and educator of the patient, family, and responsible others in the patient’s lifeNutrition A. A well-balanced diet is important throughout one’s lifetime—sick or well. Good nutrition is characterized by a well-developed body with ideal weight, healthy hair and skin, and mental alertness. Department of Agriculture are guidelines for health professionals and patients. Recommendations include servings in bread and cereal group, vegetable and fruit groups, limiting fat intake, and adequate intake of water and fluids. There is no conclusive evidence that any nutritional therapy affects the course of MS. The nurse is in an excellent position to educate patients and families about nutrition. Tremor, weakness, paralysis, and dysphagia can interfere with nutrition. A registered dietitian can determine caloric needs based on activity level. A person with skin breakdown will need increased calories and protein to promote healing.

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Type Ia axons are larger in di- the status of muscle length and tension order 5mg finast free shipping. Alpha motor neurons innervate shaped endings that wrap around the middle of the intra- the extrafusal muscle fibers purchase 5 mg finast, and gamma motor neurons in- fusal muscle fiber (see Fig buy finast 5 mg without a prescription. Cells bodies of both alpha and clear chain fibers are innervated by type Ia axons trusted finast 5mg. Type II gamma motor neurons reside in the ventral horns of the axons innervate mainly nuclear chain fibers and have nerve spinal cord and in nuclei of the cranial motor nerves discount 5mg finast with mastercard. This high number reflects the com- ings of both primary and secondary sensory axons of the plex role of the spindles in motor system control. Intrafusal muscle spindles respond to stretch by generating action po- muscle fibers likewise constitute a significant portion of the tentials that convey information to the central nervous sys- total number of muscle cells, yet they contribute little or tem about changes in muscle length and the velocity of nothing to the total force generated when the muscle con- 94 PART II NEUROPHYSIOLOGY A R Ia Response Passive stretch of muscle fibers from resting length Tension Wt. T Passive stretch B Ia response ceases R Stimulate alpha Ia Response motor neuron Tension Wt. T Stimulate C Ia responsiveness is maintained Stimulate alpha R and Ia Response gamma motor neurons Tension Wt. A, The Ia C, Concurrent alpha and gamma motor neuron activation, as oc- sensory endings from the muscle spindles discharge at a slow rate curs in normal, voluntary muscle contraction, shortens the muscle when the muscle is at its resting length and show an increased fir- spindle along with the extrafusal fibers, maintaining the spindle’s ing rate when the muscle is stretched. Rather, the contractions of intrafusal fibers play a spindle were reinstituted, the Ia nerve endings would re- modulating role in sensation, as they alter the length and, sume their sensitivity to stretch. This is accomplished by coordinated activation discharge of action potentials. Contraction of the muscle of the alpha and gamma motor neurons during muscle con- increases the firing rate in type Ib axons from Golgi tendon traction (see Fig. Ia endings report both the velocity and the length of stretch, type Ia endings show a greater firing rate increase, while muscle stretch; type II endings report length. B, With the release CHAPTER 5 The Motor System 95 types of endings, each located distal to the sensory endings on the striated poles of the spindle’s muscle fibers (see Fig. The nerve terminals are either plate endings or trail endings; each intrafusal fiber has only one of these two types of endings. Plate endings occur predominantly on bag1 fibers (dynamic), whereas trail endings, primarily on chain fibers, are also seen on bag2 (static) fibers. This arrangement allows for largely independent control of the nuclear bag and nuclear chain fibers in the spindle. Gamma motor neurons with plate endings are designated dynamic and those with trail endings are designated static. This functional distinction is based on experimental find- ings showing that stimulation of gamma neurons with plate endings enhanced the response of type Ia sensory axons to stretch, but only during the dynamic (muscle length chang- ing) phase of a muscle stretch. During the static phase of the stretch (muscle length increase maintained) stimulation of the gamma neurons with trail endings enhanced the re- sponse of type II sensory axons. Static gamma neurons can affect the responses of both types Ia and II sensory axons; dynamic gamma neurons affect the response of only type Ia axons. These differences suggest that the motor system has the ability to monitor muscle length more precisely in some muscles and the speed of contraction in others. THE SPINAL CORD IN THE CONTROL OF MOVEMENT Muscles interact extensively in the maintenance of posture and the production of coordinated movement. The circuitry of the spinal cord automatically controls much of this inter- FIGURE 5. Sensory feedback from muscles reaches motor neu- rons controlling axial, girdle, and limb muscles rons of related muscles and, to a lesser degree, of more dis- are grouped in pools oriented in a medial-to-lateral fashion. In addition to activating local circuits, muscles flexor and extensor motor neurons also segregate into pools. This information is processed and can be re- layed back to influence spinal cord circuits. A zone between the medial and lateral pools contains in- The Structural Arrangement of Spinal terneurons that project to limb motor neuron pools ipsilat- Motor Systems Correlates With Function erally and axial pools bilaterally. Between the spinal cord’s The cell bodies of the spinal cord motor neurons are dorsal and ventral horns lies the intermediate zone, which grouped into pools in the ventral horns. A pool consists of contains an extensive network of interneurons that inter- the motor neurons that serve a particular muscle. Some interneu- ber of motor neurons that control a muscle varies in direct rons make connections in their own cord segment; others proportion to the delicacy of control required. The motor have longer axon projections that travel in the white mat- neurons are organized so that those innervating the axial ter to terminate in other segments of the spinal cord.

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