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C The clinical presentation and laboratory results in and the following laboratory data: this patient are indicative of cirrhosis of the liver generic 20 mg female cialis. Peripheral blood smear: macrocytosis buy female cialis 20 mg line, target cells 9 Most of the clotting factors are made in the liver. Conjugated bilirubin is excreted into the Tese clinical presentations and laboratory results intestines, where the bilirubin is then converted to are consistent with: urobilinogen and excreted into the stool. In vitro, blood clots result in the most appropriate first step to investigate the consumption of the clotting factors and therefore abnormal results? Report the result as obtained If the clotting factors have been activated but the B. Which of the following factors Heparin half-life is decreased in extended thrombosis, may be associated with the lack of response to and the anticoagulant activities of heparin change heparin therapy in this patient? In addition, the platelet count should be monitored regularly during heparin therapy, because Hemostasis/Correlate clinical and laboratory data/ a decrease of the platelet count to 50% below the Inhibitors/3 baseline value is significant and may be associated 11. Deep venous thrombosis was suspected, and the patient was started on heparin therapy. Which of the following is (are) the proper protocol to evaluate patients receiving heparin therapy? Monitor the platelet count daily and every other day after heparin therapy is completed D. Patient History: Tese clinical manifestations and laboratory results A 46-year-old female was admitted to the emergency are consistent with: department with complaints of headache, dizziness, A. Diagnostic Hemostasis/Correlate clinical and laboratory data/ procedures indicated recurrence of the carcinoma. The Hct 23% 37%–46% neurological symptoms in this patient are manifested by headache, dizziness, nausea, and vomiting. The platelet count, neutrophils performed on admission, was done on a hematology Band neutrophils 3 0%–10% analyzer and was falsely elevated because of the Lymphocytes 11 20%–50% presence of microcytes or fragmented red cells. Patient History Answer to Question 13 A 1-year-old infant was admitted to the hospital with recurrent epistaxis for the past 5 days. C These clinical manifestations and laboratory results past medical history revealed easy bruising and a are consistent with Glanzmann’s thrombasthenia. Te patient was Laboratory tests reveal a low hemoglobin level due transfused with 2 units of packed red cells upon to epistaxis. The Admission Laboratory Results bleeding time test evaluates in vivo platelet function Reference and number. Patient History: Answers to Questions 14–15 A 30-year-old female was referred to the hospital for evaluation for multiple spontaneous abortions 14. D These clinical manifestations and laboratory results and current complaint of pain and swelling in her are consistent with lupus anticoagulant. Anticardiolipin antibodies K is stored in the liver and is essential for activation of D. Vitamin K needs bile (secreted Hemostasis/Correlate clinical and laboratory data/ by the liver) for its absorption. Te biopsy was scheduled for recommend the following: Start the patient on 11:00 a. A fresh blood sample was sent to the laboratory at Answers to Questions 16–18 8:00 a. B Traditional anticoagulant drugs such as heparin instrument flags the result owing to failure of the and warfarin are well known. Several days later, the patient developed a massive clot in her left leg that necessitated amputation. A 50-year-old female was admitted to a hospital Answers to Questions 19–20 for hip replacement surgery. The low Hgb and Hct in this patient were due to What steps should be taken before releasing these severe bleeding during surgery. No follow-up steps are needed; report the results adjusted according to the following formula: as obtained (0. Report Hgb and Hct results, adjust the in mL; H = patient’s Hct; and C = volume of anticoagulant volume, and redraw a new sample anticoagulant in mL. B The lack of a positive family history in this patient indicates the presence of an acquired coagulopathy. Factor V no history of excessive bleeding during childbirth antibodies are the most common antibodies several years earlier nor during a tonsillectomy in among the clotting factors of the common pathway childhood. Acute bleeding episodes may be treated by platelet Mixing studies (patient transfusions. Hematology of Infancy Hemostasis/Correlate clinical and laboratory data/ and Childhood. From the following, identify a specific component Answers to Questions 1–4 of the adaptive immune system that is formed in response to antigenic stimulation: 1.

The patient and family must be informed about the technology and the goals of its use purchase 20 mg female cialis. Diabetes insipidus requires fluid and electrolyte replacement buy generic female cialis 20 mg online, along with the administration of vasopressin, to replace and slow the urine output. Assessing respiratory function is essential, because even a small degree of hypoxia can increase cerebral ischemia. The respiratory rate and pattern are monitored, and arterial blood gas values are assessed frequently. The nurse must be alert to the development of complications; all assessments are carried out with these problems in mind. Chart 61-2 provides an overview of the nursing management of the patient who has undergone intracranial surgery. Seizures are a potential complication, and any seizure activity is carefully recorded and reported. Restlessness may occur as the patient becomes more responsive, or restlessness may be caused by pain, confusion, hypoxia, or other stimuli. The endotracheal tube is left in place until the patient shows signs of awakening and has adequate spontaneous ventilation, as evaluated clinically and by arterial blood gas analysis. Some degree of cerebral edema occurs after brain surgery; it tends to peak 24 to 36 hours after surgery, producing decreased responsiveness on the second postoperative day. Intraventricular drainage is carefully monitored, using strict asepsis when any part of the system is handled. Overview of Nursing Management for the Patient after Intracranial Surgery Postoperative Interventions Nursing Diagnosis: Risk for ineffective breathing pattern related to postoperative cerebral edema Goal: Achievement of adequate respiratory function Establish proper respiratory exchange to eliminate systemic hypercapnia and hypoxia, which increase cerebral edema. Nursing Diagnosis: Risk for imbalanced fluid volume related to intracranial pressure or diuretics Goal: Attainment of fluid and electrolyte balance Monitor for polyuria, especially during first postoperative week; diabetes insipidus may develop in patients with lesions around the pituitary or hypothalamus. Nursing Diagnosis: Disturbed sensory perception (visual/auditory) related to periorbital edema and head dressings Goal: Compensate for sensory deprivation; prevent injury Perform supportive measures until the patient can care for self. Temperature control may be impaired in certain neurologic states, and fever increases the metabolic demands of the brain. Assess temperature of extremities, which may be cold and dry due to impaired heat-losing mechanisms (vasodilation and sweating). The patient is asked about the factors or events that may precipitate the seizures. The nurse determines whether the patient has an aura before an epileptic seizure, which may indicate the origin of the seizure (eg, seeing a flashing light may indicate that the seizure originated in the occipital lobe). Observation and assessment during and after a seizure assist in identifying the type of seizure and its management. Planning and Goals The major goals for the patient may include prevention of injury, control of seizures, achievement of a satisfactory psychosocial adjustment, acquisition of knowledge and understanding about the condition, and absence of complications. Nursing Interventions Preventing Injury Injury prevention for the patient with seizures is a priority. If the type of seizure the patient is having places him or her at risk for injury, the patient should be lowered gently to the floor (if not in bed), and any potentially harmful items nearby (eg, furniture) should be removed. Patients for whom seizure precautions are instituted should have pads applied to the side rails while in bed. Cooperation of the patient and family and their trust in the prescribed regimen are essential for control of seizures. The nurse emphasizes that the prescribed antiseizure medication must be taken on a continuing basis and that drug dependence or addiction does not occur. Periodic monitoring is necessary to ensure the adequacy of the treatment regimen, to prevent side effects, and to monitor for drug resistance (Rho et al. In an effort to control seizures, factors that may precipitate them are identified, such as emotional disturbances, new environmental stressors, onset of menstruation in female patients, or fever (Rho et al. The patient is encouraged to follow a regular and moderate routine in lifestyle, diet (avoiding excessive stimulants), exercise, and rest (sleep deprivation may lower the seizure threshold). An additional dietary intervention, referred to as the ketogenic diet, may be helpful for control of seizures in some patients (Stafstrom & Rho, 2004). This high-protein, low-carbohydrate diet is most effective in children whose seizures have not been controlled with two antiepileptic medications, but it is sometimes used for adults who have had poor seizure control (Stafstrom & Rho, 2004). Photic stimulation (bright flickering lights, television viewing) may precipitate seizures; wearing dark glasses or covering one eye may be preventive. Because seizures are known to occur with alcohol intake, alcoholic beverages should be avoided. Improving Coping Mechanisms The social, psychological, and behavioral problems that frequently accompany epilepsy can be more of a disability than the actual seizures. Epilepsy may be accompanied by feelings of stigmatization, alienation, depression, and uncertainty. The patient must cope with the constant fear of a seizure and the psychological consequences (Rho et al.

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The problem is resolved by imposing a drug-free period during each dosing interval of 24 hours cheap 10mg female cialis. Thus discount 20mg female cialis visa, presently, the patches are applied in the morning, after showering, and worn for 12–16 hours, with a “resting” or wash-out period overnight when patients are less susceptible (although not immune) to angina attacks. The drug has a relatively long half-life (6–20 h) and a modest clearance (13 L h−1). The rationale for the development of transdermal clonidine was to reduce side-effects and to improve patient compliance. The control of drug delivery over 7 days is impressive, and avoids the “peaks and valleys” of2 conventional (twice-a-day) oral administration (Figure 8. However, this system has not achieved as wide a success as first seemed likely because of skin sensitization. Clonidine itself, when administered transdermally on a chronic, repetitive basis, induces in a significant fraction of patients a classic immunologic skin reaction, and this has severely attenuated its use. Estmdiol Transdermal estradiol is indicated for postmenopausal hormone replacement therapy. Estradiol is a potent, high clearance (600– 800 L/hr) and short half-life (1 hr) drug. Due to the very high hepatic first-pass effect, conventional oral hormone replacement therapy results in an artificially elevated and, in the long 206 Figure 8. Transdermal delivery of estradiol, however, results in sustained plasma concentrations over several days (Figure 8. Pharmacologically, beneficial effects on the frequency of hot flushes, sleep disturbance, irritability and mental accuity have been documented. More recently, other simpler, and more elegant, monolithic systems have reached the market, and perform as well as, if not better than, the original system. Because the postmenopausal woman is usually treated concomitantly with an oral progestin (i. One of the first of these systems containing estradiol and levonorgestrel has recently been approved for marketing. Fentanyl This very powerful analgesic had been limited to parenteral use during and after surgery. Accurate dose titration is necessary because of the drug’s very narrow therapeutic window (1–2 ng mL−1). The potential of fentanyl, however, to significantly improve the treatment of acute post-operative pain and chronic cancer pain provoked the development of the now-approved Duragesic transdermal system. This reservoir system can be used for up to 3 days and is available in four “doses” (10, 20, 30 and 40 cm delivering, respectively, 25,2 50, 75 and 100 µg hr−1). Nicotine 207 Nicotine is generally believed to be the principal addictive component in tobacco. Patches containing nicotine are targeted at smoking cessation and compete with other nicotine-based systems, including chewing gum, lozenges and a nasal spray. Nicotine has a relatively short half-life (2 hr) and high clearance (78 L hr−1), which means that nicotine replacement via the gum, for example, requires almost constant chewing of about 10 pieces per day to match the bioavailability of the “drug” achieved by smoking one cigarette per hour. Transdermal delivery, therefore, was designed to provide sustained input over the course of 24 hours (or, in the case of one system, for ~16 hours—the argument being that not even the heaviest smoker lights up when asleep! Several patches reached the market (such as Nicotrol, Nicoderm, Prostep and Habitrol) representing examples of each of the basic system designs, and all of which are pharmacokinetically bioequivalent. There are differences, though, in the degree of irritation induced by the different patches and this seems to be related to the relative thermodynamic activity of nicotine in the different systems. Drug loading also varies appreciably between the different patches, as does the efficiency of drug usage. Short- term efficacy has been established by showing that the use of the patches reduces tobacco withdrawal symptoms and increases abstinence. Longer-term studies reveal that the patches can be effective but require supplemental pyschological and motivational aid and counseling to minimize the chances that a subject returns to smoking. Recently, in many countries, nicotine patches have become available “over the counter” without a prescription. Testosterone These patches (Testoderm, Testoderm with Adhesive, and Androderm) are approved for the treatment of hormonal insufficiency in diseases such as primary hypogonadism and hypogonadotropic hypogonadism. The systems are applied daily to mimic the endogenous profile of serum testosterone in the normal male. Testoderm (4 mg and 6 mg) and Testoderm with Adhesive (6 mg) release controlled amounts of testosterone upon daily application to scrotal skin. These systems have contact areas of 40 or 60 cm, and2 contain 10 and 15 mg of testosterone, respectively. The matrix system, Androderm, also provides continuous delivery of testosterone for 24 hours, but is applied to non-scrotal skin. Permeation enhancers are essential for this patch to ensure the efficient delivery of drug through skin sites which are less permeable than scrotal skin.

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Connecting Body Systems–Respiratory System The main function of the respiratory system is to provide oxygen to the entire body and expel car- bon dioxide from the body purchase 10 mg female cialis visa. Specific functional relationships between the respiratory system and other body systems are summarized below 10mg female cialis amex. Blood, lymph, and immune Digestive • Tonsils, adenoids, and other immune struc- • Respiratory system provides O2 needed tures in the respiratory tract protect for digestive functions. Musculoskeletal • Respiratory system provides O2 for Female reproductive muscle contraction. Medical Word Elements This section introduces combining forms, suffixes, and prefixes related to the respiratory system. Many disorders Pulmonary Disease of the respiratory system, including bronchitis and emphysema, begin as an acute problem but Chronic obstructive pulmonary disease become chronic over time. Their damag- duce a chronic partial obstruction of the air pas- ing effects are commonly irreversible. The patient finds it difficult to breath (dys- For diagnosis, treatment, and management of pnea) especially upon exertion and usually respiratory disorders, the medical services of a spe- exhibits a chronic cough. Chronic bronchitis Excess mucus production Distended Extra mucus bronchiole Inflamed Figure 7-3. Influenza Asthma produces spasms in the bronchial pas- type A epidemics occur about every 2 to 3 years. Both viruses undergo is commonly caused by exposure to allergens or antigenic changes; consequently, new vaccines must irritants. During recovery, coughing episodes pro- is a mild flu and is not associated with epidemics. Symptoms Over time, the epithelium of the bronchial pas- include fever, chills, headache, generalized muscle sages thickens, and breathing becomes more diffi- pain (myalgia), and loss of appetite, but recovery cult. If death occurs, it is usually the result that expand the bronchi (bronchodilators) by of a secondary pneumonia caused by bacteria or relaxing their smooth muscles. Children should not do not reverse the bronchospasms, the condition use aspirin for relief of symptoms caused by virus- is referred to as status asthmaticus. Chronic bronchitis is an inflammation of the bronchi caused mainly by smoking and air pollu- Pleural Effusions tion. Bronchitis is Any abnormal fluid in the pleural cavity, the space characterized by swelling of the mucosa and a between the visceral and parietal pleura, is called a heavy, productive cough, commonly accompanied pleural effusion. Patients usually seek medical help tains only a small amount of lubricating fluid. Two initial tech- and medications that aid in the removal of mucus niques used to diagnose pleural effusion are aus- (expectorants) help to widen air passages. Auscultation is the lis- may be prescribed if the disease progresses or tening of sounds made by organs of the body using becomes chronic. Percussion is the gentle tapping the chest with the fingers and listening to the resultant Emphysema sounds to determine the position, size, or consis- Emphysema is characterized by decreased elastic- tency of the underlying structures. A transudate is a noninflammatory fluid commonly occurs with another respiratory disor- that resembles serum but with slightly less pro- der, such as asthma, tuberculosis, or chronic bron- tein. Most emphysema sufferers find it easier to breathe Both of these conditions allow serum to leak when sitting upright or standing erect (orthop- from the vascular system and collect in the pleu- nea). Various types Influenza of pleural effusions include serum (hydrothorax), Influenza (flu) is an acute infectious respiratory pus (empyema or pyothorax), and blood (hemo- viral disease. Type A is of pri- effusion, air can enter the pleural space (pneu- mary concern because it is associated with world- mothorax), resulting in a partial or complete wide epidemics (pandemics) and its causative collapse of a lung. Parietal pleura Air Air Visceral pleura Parietal pleura Visceral pleura Pleural cavity Pneumothorax on Pneumothorax on inspiration expiration Figure 7-4. Treatment consists of correcting the underlying tious for 6 to 8 months outside the body. Often a surgical puncture of makes laboratory staining of this organism more the chest using a hollow-bore needle (thoracocen- challenging. It eventually produces typical inflammatory nodules (granulomas) called tubercles. Pathology 159 Ribs Lung Syringe with catheter Pleural removing pleural fluid effusion from around lung Visceral pleura Parietal pleura Collecting bottle Figure 7-5. Diagnosis relies on examination of biopsied lung tissue or bronchial Pneumonia washings (lavage). Pneumonia is any inflammatory disease of the lungs that may be caused by bacteria, viruses, or Cystic Fibrosis fungi. A type of pneumonia Cystic fibrosis is a hereditary disorder of the associated with influenza is sometimes fatal. This thickened from food or liquid inhalation (aspiration pneu- mucus clogs ducts of the pancreas and digestive monias). As a result, digestion is impaired and the the lung (lobar pneumonia), but some are more patient may suffer from malnutrition. Chest pain, muco- ducts of the sweat glands, causing the skin to purulent sputum, and spitting of blood (hemop- become highly “salty.

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