By R. Ernesto. Gordon-Conwell Theological Seminary.

Ultrastructurally order 20 mg feldene amex, tight junctions between the endothelial cell membranes seal the lining of brain capillaries – a major facet of the relatively impermeable blood-brain barrier generic feldene 20mg otc. Circulatory disorders of the venous system account for a small fraction of cerebrovascular disease and time does not permit a review of the superficial and deep draining pathways of intracranial blood 20mg feldene visa. Physiologic Considerations Hemodynamic as well as anatomic factors play an important role in the vulnerability of brain to disorders of the circulation cheap feldene 20 mg online. The brain comprises only two percent body weight purchase feldene 20mg without prescription, but it receives fifteen percent of the cardiac output. Blood flow is a function of perfusion pressure (the gradient between mean arterial pressure and venous pressure) and the resistance of the vascular bed (determined mainly at the arteriolar level). Increased intracranial pressure (see the section on Intracranial Hypertension in this syllabus) raises venous pressure and, unless compensated for, lowers the perfusion gradient and the flow of blood. Overall cerebral blood flow is relatively constant over a broad range of arterial pressure. Arteriolar tone is not mediated by the autonomic nervous system or endocrine influences. Cerebral blood flow is clearly affected by oxygen tension, pH, and carbon dioxide tension. But many observations suggest that additional factors, possible oligopeptide neurotransmitters among them, are important determinants of blood flow in the brain. Lack of information in this area is one of the impediments to major advances in cerebrovascular disease. The nerve cell is dependent on oxidative metabolism and a continuous supply of glucose and oxygen for survival. Neuronal function ceases seconds after circulatory arrest; irreversible structural damage follows a few minutes later. Recent work proposes that an excess of excitatory amino acid transmitters and an abnormal influx of calcium into the cell play a decisive role in the death of the nerve cell. Glial cells, especially astroglial and microglia, are more resistant to impaired circulation than nerve cells. The amount of damage and the survival of tissue at risk depends on a number of modifying factors, which include the duration of ischemia, availability of collateral circulation, and the magnitude and rapidity of the reduction of blood flow. Global cerebral ischemia occurs when there is a generalized reduction of cerebral perfusion, such as in cardiac arrest and severe hypotension. Focal cerebral ischemia occurs when there is a reduction or stoppage of blood flow to a localized area of the brain. The resultant localized lesion is referred to as an “infarct” and the pathological process as “infarction. These macrophages slowly leave the field – over a period of weeks and months – and vacated spaces (microcysts) gradually grow larger. The wall of the cavity, where nerve cells and oligodendrocytes may have succumbed but astrocytes survived the acute infarction, includes a network of elaborated astroglial cell processes (glial fibers) that make up the brain’s puny version of scar formation. This is the classical picture of total infarction of brain tissue, but encephalomalacia often stops short of cavitating necrosis. If only the most susceptible members of the neuronal population die while the majority of them survive, little more than a partial loss of nerve cells and astrocytosis may be detectable on microscopic examination. Bear in mind that in the nervous system there is always secondary degeneration of neuronal processes at a distance from the site of injury. Destruction of the motor cortex in the frontal lobe, therefore, leads to secondary degeneration of nerve fibers along the entire length of the lateral and ventral funiculi of the spinal cord (“Wallerian” or “secondary tract degeneration”). In addition, in a number of heavily interconnected neuronal systems of the brain, secondary degeneration occurs transynaptically, othogradely in some systems and retrogradely in others. Sometimes atherosclerotic plaque formation in major arteries is generalized and sometimes the cerebral arteries are affected – or spared – well out of proportion to the degree of involvement of the aortic or coronary systems. The internal carotid arteries at the bifurcation of the common carotid in the neck, the vertebral and basilar arteries, the supraclinoid segment of the internal cartoid artery, and the middle and posterior cerebral arteries are all frequently affected in the usual segmental and eccentric fashion. Involvement of the anterior cerebral artery beyond the anterior communicating artery is distinctly unusual. Otherwise, proximal segments of major branches from the circle of Willis are also affected, but once the arteries reach the cerebral convexities 24 they develop thickening of the intimal layer only in the most advanced cases of atherosclerosis. When stenosis of an internal carotid reaches a certain point, circulation through the ipsilateral middle and anterior cerebral arteries is critically compromised. In this situation, the overlapping areas of the brain bathed by the terminals of both arteries (a "watershed" or arterial border zone) are most vulnerable, e.

Transporting: During transportation cheap feldene 20mg with visa, food can be contaminated by people order 20mg feldene free shipping, storage containers and so on (6) feldene 20 mg line. Processing and storage: Food is liable for contamination during its processing and storage if stringent sanitation measures are not in place generic 20 mg feldene amex. Food preparation and consumption areas: Restaurants cafeterias discount 20 mg feldene free shipping, mess halls, kitchens, bars, dining rooms, service tables, and utensils etc. In principle the same flow scheme applies to both the food industry and to locally produced foods for private consumption (19) Hazards: Production of • Nutrients Raw Materials • Natural toxins • Microbial toxins • Environmental contaminants Food Processing Hazards: • Reaction products • Contaminants • Additives Storage and Transport Hazards: • Chemical contamination • Microbial contamination Hazards: Food Consumption • Chemical contamination • Microbial contamination Risks: • Intoxication by chemical contaminates Food Preparation • Food-borne infections • Food poisoning Fig. Major contamination sources are (7, 19,4): ¾ Water: water serves as a cleaning medium during sanitation operation and is an ingredient added in the formulation of various foods. If a safe water supply is not used it then becomes a source of contamination of the food (chemical or biological agents). Examples are microorganisms causing typhoid and paratyphoid fevers, dysentery, and infectious hepatitis. If raw sewage drains or flows into potable water lines, wells, rivers, lakes, and ocean bays the water and living organisms such as seafood are contaminated. This contamination can result from unclean air surrounding the food or from contamination through improper sanitary practices. The hands, hair, nose, and mouth harbor microorganisms that can be transferred to food during processing, packaging, preparation, and service by touching, breathing, coughing, or sneezing. This is because the human body is warm; microorganisms proliferate rapidly, especially in the absence of good hygienic practices. The amounts and types of these agents vary with place and method of harvesting, type of food ingredient, processing technique, 93 and handling. There could be hazards connected to these ingredients if there is lack of awareness of the incoming individual ingredients. These pests transfer contaminants to food through their waste products; mouth feet, and other body parts; and during regurgitation onto clean food. Like flies and cockroaches, they transfer filth from garbage dumps and sewers to food or food processing and food service areas. Meat of animals can get contaminated during slaughtering, cutting, processing, storage, and distribution. Other contamination can occur by contact of the carcass with the hide, feet, manure, dirt, and visceral contents. Like wise drugs used to prevent disease and promote growth in animals may also become potential risk for human health due to persisting of these drugs in the meat or milk products. There are two related models that illustrate the relationship among factors that cause food-borne diseases. Chain of infection: This is a series of related events or factors that must exist or materialized and be linked together before an infection will occur. Transmission of the causative agent from the environment in which the food is produced, processed, or prepared to the food itself. Moreover, the contaminated food must remain in a suitable temperature range for a sufficient time to permit growth to a level capable of causing infection or intoxication (7). The presence of the disease agent is indispensable, but all of the steps are essential in the designated sequence before food-bore diseases can result (see also figure 3. Web of causation: This is a complex flow chart that indicates the factors that affect the transmission of food-borne diseases. This presentation of disease causation attempts to incorporable all of the factors and their complex interrelationships (7). The major ones are (4,13): ¾ Preparation of food more than half a day in advance of needs ¾ Storage at ambient t temperature ¾ Inadequate cooling ¾ Inadequate reheating ¾ Use of contaminated processed food (cooked meats and poultry, and the like) ¾ Undercooking ¾ Cross contamination from raw to cooked food from utensils, and contamination from other food contact surfaces in kitchen environment ¾ Infected food handlers or poor personal hygiene of food handlers ¾ Unsanitary dishware, utensils and equipment ¾ Improper food handling procedures such as unnecessary use of the hands during preparation and serving of food ¾ Improper food storage that may lead to cross contamination by agents of diseases (micro-organisms, poisonous chemicals), or exposure to moisture that may facilitate microbial growth ¾ Insects and rodents 96 3. Food quality from a more scientific point of view includes a number of safety aspects such as the presence of environmental contaminants, pesticide residues, use of food additives, microbial contamination, and nutritional quality. In practical terms, safe food can be defined as food that, after being consumed, causes no adverse health effects (19). The government is responsible for the establishment of standards or codes of practice as well as the enforcement of laws and regulations. Furthermore, it should encourage the food industry to undertake voluntary measures to improve food safety. Consumers in turn should be well aware of the quality of the food they buy, prepare and consume and should adopt appropriate practices of food handling at home.

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The sibling who had having an elective caesarean at least two vaginal births was section were no different from three times more likely to report nulliparous controls cheap 20 mg feldene amex. Studies have shown performed after the onset of that there is a decreased collagen labour is less protective than an content in nulliparous women elective section discount feldene 20mg without prescription. In both age groups feldene 20mg line, however discount 20 mg feldene amex, the associations are There is thus no question that statistically signifcant discount feldene 20mg amex. The scientifc There is however controversy as to challenge is therefore to identify the role of the menopause. Posterior the only available intervention is compartment prolapse can lead caesarean section but the infuence to diffcult rectal emptying, due of this on subsequent pregnancies to herniation of the rectocele has to be accepted. A study looking studies, episiotomies contributed at 28,000 Danish nurses found an to third and fourth degree tears. Virtually all studies that address the relationship between aging 112 Obesity Collagen Synthesis Obesity increases the intra- Abnormalities abdominal pressure signifcantly As already stated above there and chronically. Two examples care facilities might play a role include an increase in posterior but quantitative and qualitative compartment prolapse after a histochemical differences in Burch colposuspension and a collagen and muscle tissue are greater number of cystocoeles awaited. There are also reports of prolapse of the vaginal vault after transection of the uterosacral ligaments for chronic pelvic pain. It This chapter shall focus on the has been shown on numerous impact of childbirth and delivery occasions, that one of the main factors on the development of causes of female pelvic foor pelvic foor dysfunction. The potential a thorough overview of this impact space in the female pelvis is limited on the pelvic foor. Human evolution theory, Neuromuscular function of the postulates that the fetal head pelvic foor is dependent on the has enlarged signifcantly over integrity of the nervous system. The while Homo sapiens now has a pudendal nerve is particularly cranial capacity of approximately prone to damage where it curves 1800 cm3. It is therefore not around the ischial spine and surprising that the structures of enters the pudendal canal. Ample the pelvic foor are damaged due evidence links neurologic injury to pregnancy as well as childbirth. Another The most important muscles of the study found evidence of pudendal pelvic foor are the puborectalis, nerve denervation in 80% of pubococcygeus and anal sphincter women after vaginal delivery. The genital hiatus in mechanism of injury is most likely nulliparous women measures 6-36 to be a combination of direct cm2 during valsalva while the trauma and traction injury during surface area of the fetal head is 70- delivery. Partial shown in both the levator ani levator avulsion has been shown muscle and the external anal to occur in 15% of women during sphincter after vaginal delivery. These women This is the result of a combination are at an increased risk for severe of loss of total motor units as well pelvic organ prolapse, urinary as asynchronous activity in those incontinence and even recurrent that remained. This did not identify any levator ani will be clinically most evident defects in nulliparous women, in in the anal canal, with its many contrast to the fndings in 20% afferent nerve endings, resulting of primiparous women, who had in anal incontinence or faecal a visible defect in the levator ani urgency. These defects were usually been shown to be protective, but in the pubovisceral portion of the only in women who delivered levator ani muscle. Pelvic foor muscle Anatomical and functional changes strength has been also been shown to the pelvic foor can develop to decrease by 25-35% following secondary to pelvic foor distension vaginal delivery compared to during descent of the fetal head caesarean section. Interestingly, 115 6-10 weeks postpartum there is Figure 2: Two-dimensional however no signifcant difference endoanal ultrasound image of anal from antenatal values, excepting sphincter disruption secondary to for a lower intravaginal pressure in obstetric injury. Injury to the anal sphincter during Connective tissue trauma childbirth occurs either as a result Pelvic organ support essentially of direct disruption of the muscles consists of or relies on the or due to injury to the pudendal endopelvic fascia and the nerves. The incidence of anal condensations of this fascia that sphincter damage varies between forms the ligaments (uterosacral, 0. The use of endoanal occurs as a consequence of ultrasound has demonstrated a weakness of these supports. It is far much higher incidence of anal more common in parous women sphincter injuries (Figure 2) in (50%), compared to nulliparous asymptomatic women, the so- women (2%). During vaginal called occult injuries with as many delivery, the mechanism is most as 35% of primiparous and up to likely due to mechanical trauma of 44% of multiparous women having these supporting structures with evidence of sphincter disruption. Risk factors for both the overt and Spontaneous healing might also occult sphincter injuries include lead to weaker collagen and so forceps delivery, prolonged second predispose to incontinence and stage, large birth weight, midline prolapse. Figure 1: Levator avulsion injury on ultrasound, the vagina reaching the pelvic sidewall (arrow) with no intervening muscle, unlike the healthy contralateral side. The protective effect of and has been reported in up caesarean delivery and nulliparity to 85% of women. The use of forceps is been reported to strongly predict the single independent risk factor postpartum incontinence. The frst vaginal delivery the vaginal delivery that is the has been suggested to be the risk factor for developing urinary most signifcant event leading incontinence.

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Administration of cool drinks 2) Application of cold compress and ice bags 3) Cold sponging and cold packs 4) Cold bath 5) Ice cold lavages and enemas 6) Use of hypothermic blankets of mattresses When surface cooling is used treatment is directed at not only cooling the body but also prevent­ ing shivering cheap feldene 20mg amex. Shivering must be prevented because it increases metabolic activity discount 20mg feldene overnight delivery, produces heat safe feldene 20mg, in­ creases the oxygen usage markedly buy feldene 20 mg on line, increases circulation cheap feldene 20mg fast delivery, may cause hyperventilation and respiratory alkalosis. It takes longer time to reduce body temperature in a shivering patient 2) Meeting the nutritional need: The cellular metabolism is greatly increased during fever. The oxygen consumption in the body tissues approximately 13 percent for each centigrade degree of rise in 114 temperature of 7 percent for each Fahrenheit degree, Therefore a high caloric diet is indicated in fevers. Unless it is contraindicated, the fluid intake is increased to 3000ml in 24 hours to prevent dehy­ dration and to eliminate the waste products Care in rigor: Rigor is characterized by three stages: 1) The first stage or cold stages: the patient shivers uncontrollably. The temperature may continue to rise During the second stage, remove all the blankets and hot appliances. Pulse is rhythmic fluctuation of fluid pressure against the arterial wall created by the pumping action of the heart muscle by placing fingers over an artery particularly at the location where it cross the bond Sites for checking pulse: 1) Temporal artery 2) Carotid artery 3) Brachial artery 4) Radial artery 5) Femoral artery 6) Popliteal artery 7) Dorsalis pedis 8) Posterior tibial artery Apical pulse Auscultated in adult Apical pulse is palpated to count pulse rate in infants Characteristics of pulse 1) Rate: It is number of pulse beats in a minute. Normal rate in adult is 80 to 100 per minute 2) Rhythm: It refers to regularity of the beats, beats are spaced at regular intervals they are said to be regular. Interval varies between the beats it is called irregular 115 3) Strength: The strength/ amplitude of a pulse reflects the volume of blood ejected against the arterial wall 4) Volume: It refers to the fullness of the artery it is the force of the blood felt at each beat 5) Tension: It is the degree of compressibility 6) Equality: It refers to assess both radial pulses and compare the characteristics of both 7) Principles: Exercise, emotion and anxiety will cause increased pulse rate, finger tips sensitive to touch will fell the pulsation. Moderate pressure allow one to feel superficial radical artery characteristics of the pulse vary with individuals Factors involved in pulse 1) Age: The heart rhythm in infants and children often varies markedly with respiration 2) Autonomic nervous system: Stimulation of the pare sympathetic nervous system results in decreas­ ing in the pulse rate. If more than this quantity of air passes out in and out of the lungs the respiration is said to be deep Rhythm: In normal respiration rhythm is normal Various sites of respiration 1) Chest 2) Abdomen Factors involved in respiration: 1) Age: Normal growth from infancy to adulthood results in a larger lung capacity as lung capacity increases the respiratory rate decreases. Medications narcotic decreases respiratory rate and depth 2) Stress: Stress increases the rate and depth of respiration 3) Exercise: It increases rate and depth of the air decreases to meet the body’s need for additional oxygen 4) Altitude: The oxygen content of the air decreases as the altitude increases 5) Gender: Men normally have larger lung capacity than woman 6) Body position;A straight erect position promotes full chest expansion. When the ventricles are contraction the pressure is at its highest this is known as the ‘Systolic Pressure’ ‘Diastolic Pressure’ is when the ventricles are relaxing and the blood pressure is at its lowest Hypertension: when the systolic pressure is above the normal level Hypotension: when the systolic pressure is below the normal range Purposes: (1) To acquire a base line. Characteristics of pain : 1) Severity :Ranges from no pain to excruciating pain 2) Timing :duration and onset of pain 3) Location: body area involved. Factors increasing and decreasing pain: age, gender, activity, rest, sleep, diet, culture, home rem­ edies, drugs, alcohol, diversional activities like listening to music, watching T. Pain Assessment: Pain intensity scale 117 Simple Descriptive Pain Intensity Scale No pain Mild pain Moderate Severe Very Worst pain pain Severe pain 0­10 Numeric Pain Intensity Scale 0 1 2 3 4 5 6 7 8 9 10 Visual Analog Scale No pain pain as bad as it could be possible or unbarrable pain Faces Pain Scale­ Revised: This instrument has 6 faces depicting expressions that range from con­ tented to obvious distress. The patient is asked to point to the face that most closely resembles the intensity of his or her pain. Bleeding from the kidneys or ureters causes urine to become dark red, bleeding from the bladder or urethra causes bright red urine. Urine that stands several, minutes in a container becomes cloudy renal disease many appear cloudy or foamy because of high protein concen­ trations. The stronger the odour 118 Characteristics of Normal Urine: 1) Volume: One to two litres in 24 hours but varies 2) Color: Yellow or amber but varies. The type of test deter­ mines the method of collection Specimen collection: The nurse collects random. Urinalysis: The laboratory performs a urinalysis on a specimen obtained by any of the previously described methods. Specific gravity: The specific gravity is the weight or degree of concentration of a substance com­ pared with an equal volume of water Urine culture: A urine culture requires a sterile or clean voided sample of urine. Urine test Purposes of Sugar test: Testing the urine for the persons and the amount of sugar provides the doctors with information about the amount of insulin needed by the patient. Purpose of Acetone test: Acetone is an abnormal finding that indicates that the body has begun to break down stored fats to use for energy, since it is not able to use the sugar. Purpose of Albumin test: High albumin excretion is a prognostic of renal failure and complications such as myocardial infarction. Albuminuria is presently the most reliable early indicator of adverse renal and cardiovascular events in diabetic patients. The most accurate method is to obtain a double voided urine specimen in which the first voided is set aside and the patient is asked to void a short time later. This second voiding consists of the most recently produced urine from the kidney and is the best indicator of the amount of sugar being excreted at that moment not of urine that may have been in the bladder for hours. If the patient has a Foley’s catheter the urine specimen should be taken from the tubing, which contains the latest formed urine not from the drainage bag. Preparation of articles Correct collection and preparation of urinary specimens for diagnostic testing contributes to ac­ curate test results.

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