By W. Orknarok. Simmons College.

C Complementary Supplements Calcium and magnesium: Essential for proper muscle contractions and blood vessel health buy discount elimite 30 gm line. Fish oils: Over 30 studies have shown that the omega-3 fatty acids in fish oil can help lower blood pressure 30 gm elimite with visa, reduce atherosclerosis, and protect against heart attack. Garlic: Helps lower blood pressure and cholesterol, reduces clotting, and prevents plaque formation in the arteries. Most of the research showing benefits has been done on aged garlic extract (Kyolic). L-taurine: An amino acid that helps increase the force and effectiveness of heart-muscle contractions. Natural relaxants: Hops, lemon balm, passionflower, and valerian are herbs that can help promote calming, which can help those under stress. Lactium (milk protein extract) and Suntheanine (green tea extract) are also effective in promoting calming, reducing stress, and improving sleep. Most people experience an occasional change in bowel habits; when it is persistent, it is referred to as chronic constipation. During the digestive process, food passes from the stomach to the intestine where nutrients and water are absorbed into the body. The waste products of digestion create a stool, which travels through the intestines with muscle contractions. Anything that slows the passage of stools through the intestines or increases the amount of water absorbed by the body—such as a lack of fibre, fluids, or physical activity; medication; or ignoring the urge to def- ecate—can lead to constipation. Chronic constipation affects 31 percent of people between 19 and 65 years, and approximately 45 percent of people over 65 years. This can be a debilitating and uncom- fortable problem, but there are a number of lifestyle recommendations that can help. Note: See your doctor if you notice blood in your stool or have black stools, as this could signify a serious problem. Ex- amples include Dulcolax (bisacodyl), Senokot (senna), castor oil, and cascara. These drugs work quickly (overnight), but may cause abdominal cramping and are recom- mended for short-term (a few days) use only. Bulk-forming laxatives add bulk and water to the stools, which improves passage through the intestines. They are taken daily with plenty of fluids, and it may take a week to notice benefits. Stool softeners, such as Colace (docusate) cause water and fats to penetrate the stool, easing movement through intestines. Mineral oil makes the stool slippery to facilitate pas- sage; however, it should not be used regularly, as it can reduce the absorption of fat-soluble vitamins (A, D, E, and K). Those who take laxatives for a long time may need to go off them slowly to allow the bowels to return to normal function. Eat whole-grain breads and cereals (made with wheat bran, whole oats, rye, and flaxseed), fresh fruits (especially strawberries, apples, and rhubarb), dried fruits, vegetables, and legumes. Foods to avoid: • Refined and processed foods are high in sugar and contain little fibre. In one study, two-thirds of the infants had constipation that was relieved when cow’s milk was removed from their diet. Lifestyle Suggestions C • Increase physical activity, as exercise helps stimulate intestinal and bowel contractions. The longer you delay going to the toilet once you feel the urge, the more water that is absorbed from the stool and the harder it becomes. Top Recommended Supplements Fibre supplements: Products containing psyllium husks, flaxseed, oat bran, guar gum, glucommannan, and fenugreek are effective and can be taken regularly. Start with a small amount (one tablespoonful daily) and gradually increase to allow your bowels to adjust. Probiotics: Supplements containing these “friendly bacteria” help to restore the normal gut flora and have been shown in studies to relieve constipation. Complementary Supplements Aloe vera juice: Aids bowel movements by working as a stimulant and improving intestinal contractions. Magnesium: Aids intestinal function and helps stool retain water; may be deficient in those with constipation. These diseases affect the digestive system and cause the intestinal tissue to become inflamed, develop sores, and bleed. These diseases can be painful and debilitating and may lead to life-threatening complications, especially if untreated. Crohn’s disease and ulcerative colitis are very similar in that they both inflame the lining of your digestive tract and can cause severe bouts of watery or bloody C diarrhea and abdominal pain. Where they differ is that Crohn’s disease can occur anywhere in your digestive tract, often spreading deep into the layers of affected tis- sues whereas ulcerative colitis usually affects only the innermost lining of your large intestine (colon) and rectum.

Some patients cheap elimite 30 gm line, who have been told to take one aspirin tablet a day and do not recognise the difference between tablet strengths discount 30gm elimite, take one 300-mg tablet each day. Aspirin (and other platelet inhibitors) may offer most cardiac protection when taken in the evening, ensuring maximum effectiveness when platelets are stickiest. Isosorbide dinitrate can be given sublingually, enabling ready access and quick absorption. It may be given long term to reduce reocclusion (Weston 1996), and Hockings and Donovan (1997) recommended heparin for 6–12 hours following thrombolysis. A recent revival of interest in hirudin (leech extract), a thrombin inhibitor which, unlike heparin, is not neutralised by activated platelets, has proved disappointing; one trial was stopped due to adverse outcomes (Galvani et al. Thrombolysis Thrombolytics are best given within six hours (and preferably earlier) following infarction, although later use (e. Nearly one-third of patients receiving thrombolytics suffer reocclusion within three months (Weston 1996). It activates plasminogen into plasmin (Ganong 1995), causing lysis for 12–24 hours. Being a streptococcal product, it can cause anaphylaxis; this is rare with first doses as antibodies develop after 4 days, but subsequent doses may be problematic, and so repeat doses should be avoided after 4 days (Kynman 1997). Due to possible anaphylaxis, patients should be given information sheets informing them (and other healthcare workers) when second doses may be safely given. Unfortunately, repeat times are disputed: ■ Thompson (1990): avoid second doses between one week and 6 months; ■ McDonald (1997): a one-year interval between doses; ■ Hockings and Donovan (1997) cite 1996 Task Force of the European Society of Cardiology: two years; ■ Kynman (1997): antibodies may survive for between 4 and 54 months; re- administration may prove ineffective and cause a fatal delay in giving other drugs that might be more effective. Hospitals may have local policies or guidelines for when/if repeat streptokinase may be given (often five years), but nurses should also be guided by evidence-based practice. Anaphylaxis may occur with any second dose, so that hydrocortisone, antihistamines and adrenaline should be readily available whenever streptokinase is given. Reperfusion initially is more rapid than streptokinase (62 per cent at 90 minutes, compared with 31 per cent for streptokinase), but by 24 hours reperfusion rates are comparable (Weston 1996). Quicker reperfusion should salvage more myocardium, but this is unsupported by trials (Weston 1996). Its short half-life enables cannulation within half-an-hour after administration (Thompson 1990). As it is genetically engineered, alteplase is much more expensive than streptokinase, and this limits its use. Alteplase may be used if repeat doses of streptokinase are contraindicated (Weston 1996; McDonald 1997), such as following heparin. Although thrombolysis has reduced complications during recovery, following thrombolysis nurses should observe for: ■ allergic reaction/hypotension ■ haemorrhage Revascularisation dysrhythmias (especially ventricular) are common but usually benign, one-half of all patients experiencing a degree of left ventricular failure (Thompson 1990); reperfusion injury may progress to ventricular fibrillation, and 5 per cent of patients develop cardiogenic shock (Thompson 1990. The risk of major haemorrhage following thrombolysis is small (less than 5 per cent), but triples if patients have had previous vascular/cardiac procedures (deBono 1990), and so intramuscular injections should be avoided with all patients. Rest Rest, with bedrest for 48 hours (Hockings & Donovan 1997), promotes recovery. Rest and adequate sleep (quality as well as quantity) promote physical and psychological healing (see Chapter 3): planned care should include minimal interventions overnight and rest periods during the day, with active assessment of benefits. Prognosis Within the first weeks, up to one-tenth of patients suffer a second infarction (Hockings & Donovan 1997), while only one-tenth recover without further complications (Nowak & Handford 1994). Oedema may subside, enabling reperfusion and recovery, or progress to further infarction. The British Heart Foundation produces a range of useful booklets that are available in most hospitals. Nursing care of patients with myocardial infarctions should focus on prevention and close monitoring of further complications. Medical material can usefully be supplemented by whatever current textbooks readers have access to. Clinical scenario Howard Gray is a 52-year-old insurance broker with a history of angina. Review your role in administering and monitoring the effectiveness of this therapy (note frequency and type of investigation/assessment, identification of potential adverse effects). Chapter 25 Shock Fundamental knowledge Cellular pathology (see also Chapter 23) Pericardial anatomy Baroreceptors and chemoreceptors Renin-angiotensin-aldosterone cascade Normal inflammatory responses (increased capillary permeability, leucocyte migration, vasoactive mediators release) Introduction Traditional labels of shock, by causal mechanisms, have some value: resolving the cause should relieve problems. However caused, shock impairs tissue oxygen delivery, and causes microcirculatory maldistribution and metabolic complications (Shoemaker & Beez 1996), with life-threatening cellular hypoxia progressing to whole system dysfunction. Urgent microcirculatory resuscitation is needed to prevent the complications of shock. Perfusion pressure (mean arterial pressure) is the sum of: ■ total capacity of blood vessels ■ total blood volume ■ local factors (e. Prolonged hypoperfusion damages tissues, with shock becoming irreversible once reperfusion is unachievable. Renal hypotension causes renin release, increasing systemic pressure via the renin-angiotensin-aldosterone cascade. Cellular dysfunction aggravates electrolyte imbalances (especially hypercalcaemia and hyperkalaemia), impairing cardiac conduction, so causing dysrhythmias. Anaerobic metabolism and metabolic acidosis (from systemic hypoperfusion) stimulates tachypnoea.

In 1950 Ackerman wrote a book on anti-Semitism in collaboration with Marie Jahoda purchase 30gm elimite with visa. Sponsored by the American Jewish Com- mittee discount 30gm elimite fast delivery, Anti-Semitism and Emotional Disorder, a Psycho- analytic Interpretation examines and analyzes the phe- Nathan Ward Ackerman nomenon and offers possible solutions. He went on to 1908-1971 write many books during his career, including The Psy- Psychologist and educator noted for his work as a chodynamics of Family Life (1958) and Treating the Trou- family therapist, particularly for his ability to look bled Family (1966). He coauthored several books, includ- beyond the traditional assessment of families and to accurately assess the way that family members ing Exploring the Base for Family Therapy and published relate to each other. Ackerman is widely acknowledged as a pioneer in Nathan Ward Ackerman was born in Bessarabia, his field and credited with developing the concept of Russia on November 22, 1908. He believed that the mental or physical disposition of one family member would affect other family mem- A progressive, degenerative disease involving sev- bers, and that often the best way to treat the individual eral major organ systems, including the immune system and central nervous system. He received the Rudolph Meyer award from and conditions, it has been difficult to arrive at a formal the Association for Improvement to Mental Health in definition. Eventually, In 1960, Ackerman opened the Institute for Family similar symptoms were found among intravenous drug Studies and Treatment, a nonprofit organization devoted users, hemophiliacs, and other recipients of blood trans- to promoting family mental health. Ackerman developed a program for research that greatly furthered the effectiveness of the Institute. This journal remains a principal reference for other since 1985 has drastically reduced the risk of transfu- professionals in the field. Children may be infected in utero or is considered perhaps the finest facility for family psy- by exposure to blood and vaginal secretions during chology in the world. The child of an infected mother has a 25 to 35 percent chance of acquiring the virus. Within three to six weeks after infection they may tion of Psychoanalytic Medicine, as well as a member of exhibit flu-like symptoms that last up to three weeks and the Academy of Child Psychiatry, the American Psy- resolve spontaneously. New York: Avon Books, illness is challenging for friends, family, and others 1994. Originally thought of as a “gay men’s dis- as a wave of changing electrical charge. If the test is posi- During an action potential, there is a change in voltage tive, a more specific test, the Western blot assay, is ad- across the nerve cell membrane of about 120 millivolts, ministered. This is followed by progression of the disease, particularly the suppression the movement of potassium ions, which also carry a pos- of the immune system. New York: Mc- nence (especially among young people) and the use of Graw-Hill, 1993. Adaptation is crucial to the trol disorders, such as overeating, constitute a specific process of natural selection. Ethologists, scientists who type of compulsive behavior that provides short-term study the behavior of animals in their natural habitats gratification but is harmful in the long run. In contrast to from an evolutionary perspective, have documented two these various types of potentially addictive behavior, main types of adaptive behavior. Some behaviors, known physical addiction involves dependence on a habit-form- as “closed programs,” transmit from one generation to the ing substance characterized by tolerance and well-de- next relatively unchanged. In spite of the variety of activities that can be con- Adaptation occurs in individual organisms as well as sidered addictive, people who engage in them tend to in species. Sensory adaptation consists of physical have certain attitudes and types of behavior in common. Examples include the adjustment eyes ety or blocking out other types of uncomfortable feel- make when going from broad daylight into a darkened ings. To a greater or lesser extent, people engaged in ad- room and the way bodies adjust to the temperature of dictive behavior tend to plan their lives around it; in ex- cold water after an initial plunge. Once a steady level of treme cases they will do almost anything to obtain the stimulation (such as light, sound, or odor) is established, substance or engage in the behavior. When confronted, dangers called the “fight or flight” syndrome (including they generally deny that they have a problem, although rapid breathing, increased heart rate, and sweating) can privately they regret their addictive behavior, which in also be considered a form of adaptation. The psychologi- many cases they have tried without success to discontin- cal responses involved in classical and operant condi- ue. They tend to rationalize engaging in the behavior and tioning, which involve learned behaviors motivated by tell themselves they can stop whenever they want. They either positive reinforcement or fear of punishment, may also blame others for their addiction and often expe- can also be considered adaptation. Substance abuse and dependence (substance-related Further Reading disorders) are among the psychological disorders in the Bateson, P. Perspectives in Ethology: Behavior and Evolu- list of major clinical syndromes (Axis I) found in the tion. The Beak of the Finch: A Story of Evolution is classified as a depressant, is probably the most fre- in Our Time. Alcohol abuse and dependence affects over 20 million Americans— about 13 percent of the adult population.

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