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By: F. Koraz, M.B.A., M.B.B.S., M.H.S.

Clinical Director, University of Texas at Tyler

A lack of focus on the individual patient birth control 3 day period buy 3.03mg drospirenone with amex, the family birth control comparison order 3.03mg drospirenone with amex, and the environment by some health care providers has created feelings of disillusionment and depersonalization in many patients birth control definition buy cheap drospirenone 3.03 mg. The cost of illness birth control pills 84 days cheap drospirenone, especially chronic illness care, continues to escalate and accounts for an increasing percentage of health care dollars. At the same time, patient satisfaction with the health care received has decreased. Active participation of the patient and family in promoting health supports the self-care model historically embraced by the nursing profession. This model is congruent with the philosophy that seeks to balance and integrate the use of crisis medicine and advanced technology with the influence of the mind and spirit on healing. A holistic approach to health reconnects the traditionally separate approaches to mind and body. Factors such as the physical environment, economic conditions, sociocultural issues, emotional state, interpersonal relationships, and support systems can work together or alone to influence health. The connections among physical health, emotional health, and spiritual well-being must be understood and considered when providing health care. One focus of brain research has been to identify and integrate traditional medical and psychiatric knowledge with new psychobiologic and psychoneuroimmunologic data. Researchers in the field of psychobiology study the biologic basis of mental disturbances and have established some relationships between mental disorders and changes in the structure and function of the brain. Researchers in the field of psychoneuroimmunology study the connections between the emotions, the central nervous system, the neuroendocrine system, and the immune system and have established compelling evidence that psychosocial variables can affect the functioning of the immune system. As this neuroscientific research continues, data about neurotransmitters and the functioning of the brain will augment existing understanding of emotions, intelligence, memory, and many aspects of general body functioning. In the future, an accepted definition of mental illness may well include biologic information. By enhancing the biologic knowledge base about the brain and nervous system, scientists establish the foundation for breakthroughs in the treatment of both symptoms and illnesses. These findings suggest that the health care community ought to place as much emphasis on emotional health as it places on physiologic health and ought to recognize how biologic, emotional, and societal problems combine to affect individual patients, families, and communities. Some problems that nurses and other health care providers must address include substance abuse, homelessness, family violence, eating disorders, trauma, and chronic mental health conditions such as anxiety and depression. Department of Health and Human Services initiated a mental health agenda for the nation in the document entitled Healthy People 2010 (U. Nurses in all settings encounter patients with mental health problems and have an integral role in helping to achieve the national goals by recognizing and treating emotional distress and promoting emotional health. Typically, people who are mentally healthy are satisfied with themselves and their life situations. In the usual course of living, emotionally healthy people focus on activities geared to meet their needs and attempt to accomplish personal goals while concurrently managing everyday challenges and problems. Often, people must work hard to balance their feelings, thoughts, and behaviors to alleviate emotional distress, and much energy is used to change, adapt, or manage the obstacles inherent in daily living. Emotional health is also manifested by having moral and humanistic values and beliefs, having satisfying interpersonal relationships, doing productive work, and maintaining a realistic sense of hope (Chart 7-3). When people have unmet emotional needs or distress, they experience an overall feeling of unhappiness. How different people respond to these troublesome situations reflects their level of coping and maturity. Emotionally healthy people endeavor to meet the demands of distressing situations while still facing the typical issues that emerge in their lives. The ways in which people respond to uncomfortable stimuli reflect their exposure to various biologic, emotional, and sociocultural experiences. The use of ineffective and unhealthy methods of coping is manifested by dysfunctional behaviors, thoughts, and feelings. These behaviors are aimed at relieving the overwhelming stress, even though they may cause further problems. Coping ability is strongly influenced by biologic or genetic factors, physical and emotional growth and development, family and childhood experiences, and learning. Typically, a person reverts to the strategies observed early in life that were used by family Chart 7-2 · Major Mental Health Objectives for Healthy People in the Year 2010 · Increase the number of persons in primary care who receive mental health screening and assessment. Reduce the proportion of adults with disabilities who report feelings such as sadness, unhappiness, or depression that prevent them from being active Increase the proportion of adults with disabilities reporting sufficient emotional support.

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The importance of keeping scheduled appointments for assessing the stability of the fixation appliance is emphasized birth control breast cancer drospirenone 3.03mg with amex. Consultation with a dietitian may be indicated so that the patient and family can learn about foods that are high in essential nutrients and ways in which these foods can be prepared so that they can be consumed through a straw or spoon birth control pills zovia discount 3.03 mg drospirenone free shipping, while remaining palatable birth control 3 day period buy drospirenone discount. Salivary gland ultrasonography or sialography (x-ray studies filmed after the injection of a radiopaque substance into the duct) may be required to demonstrate obstruction of the duct by stenosis birth control pills 832 discount drospirenone 3.03 mg visa. If located within the gland, the calculi are irregular and vary in diameter from 3 to 30 mm. On physical assessment, the gland is swollen and quite tender, the stone itself can be palpable, and its shadow may be seen on x-ray films. Sometimes, enlargement of the ductal orifice permits the stone to pass spontaneously. Occasionally lithotripsy, a procedure that uses shock waves to disintegrate the stone, may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Surgery may be necessary to remove the gland if symptoms and calculi recur repeatedly. Chronic irritation by a warm pipestem or prolonged exposure to the sun and wind may predispose a person to lip cancer. Predisposing factors for other oral cancers are exposure to tobacco (including smokeless tobacco), ingestion of alcohol, dietary deficiency, and ingestion of smoked meats. Pathophysiology Malignancies of the oral cavity are usually squamous cell cancers. Any area of the oropharynx can be a site for malignant growths, but the lips, the lateral aspects of the tongue, and the floor of the mouth are most commonly affected. Clinical Manifestations Many oral cancers produce few or no symptoms in the early stages. A typical lesion in oral cancer is a painless indurated (hardened) ulcer with raised edges. Tissue from any ulcer of the oral cavity that does not heal in 2 weeks should be examined through biopsy. As the cancer progresses, the patient may complain of tenderness; difficulty in chewing, swallowing, or speaking; coughing of blood-tinged sputum; or enlarged cervical lymph nodes. Diagnosis is based on the health history and physical examination and the results of fine needle aspiration biopsy. Management of salivary gland tumors evokes controversy, but the common procedure involves partial excision of the gland, along with all of the tumor and a wide margin of surrounding tissue. Dissection is carefully performed to preserve the seventh cranial nerve (facial nerve), although it may not be possible to preserve the nerve if the tumor is extensive. Radiation therapy alone may be a treatment choice for tumors that are thought to be contained or if there is risk of facial nerve damage from surgical intervention. Local recurrences are common, and the recurrent growth usually is more aggressive than the original. It has also been observed that patients with salivary gland tumors have an increased incidence of second primary cancers (Bull, 2001). Assessment and Diagnostic Findings Diagnostic evaluation consists of an oral examination as well as an assessment of the cervical lymph nodes to detect possible metastases. Biopsies are performed on suspicious lesions (those that have not healed in 2 weeks). High-risk areas include the buccal mucosa and gingiva for people who use snuff or smoke cigars or pipes. For those who smoke cigarettes and drink alcohol, high-risk areas include the floor of the mouth, the ventrolateral tongue, and the soft palate complex (soft palate, anterior and posterior tonsillar area, uvula, and the area behind the molar and tongue junction). Medical Management Management varies with the nature of the lesion, the preference of the physician, and patient choice. Surgical resection, radiation therapy, chemotherapy, or a combination of these therapies may be effective. In cancer of the lip, small lesions are usually excised liberally; larger lesions involving more than one third of the lip may be more appropriately treated by radiation therapy because of superior cosmetic results.

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Severe hyperkalemia causes skeletal muscle weakness and even paralysis birth control pills hypertension 3.03mg drospirenone amex, related to a depolarization block in muscle birth control for women lyrics buy line drospirenone. Although hyperkalemia has marked effects on the peripheral nervous system birth control zero copay cheap drospirenone express, it has little effect on the central nervous system birth control for women yoga buy drospirenone with a mastercard. Rapidly ascending muscular weakness leading to flaccid quadriplegia has been reported in patients with very high serum potassium levels. Arterial blood gas analysis may reveal metabolic acidosis; in many cases, hyperkalemia occurs with acidosis. Nursing Management Patients at risk for potassium excess, for example those with renal failure, should be identified so they can be monitored closely for signs of hyperkalemia. To avoid false reports of hyperkalemia, prolonged use of a tourniquet while drawing the blood sample is avoided, and the patient is cautioned not to exercise the extremity immediately before the blood sample is obtained. The blood sample is delivered to the laboratory as soon as possible, because hemolysis of the sample results in a falsely elevated serum potassium level. Potassium-rich foods to be avoided include coffee, cocoa, tea, dried fruits, dried beans, and wholegrain breads. Conversely, foods with minimal potassium content include butter, margarine, cranberry juice or sauce, ginger ale, gumdrops or jellybeans, hard candy, root beer, sugar, and honey. When potassium is added to parenteral solutions, the potassium is mixed with the fluid by inverting the bottle several times. Potassium chloride should never be added to a hanging bottle because the potassium might be administered as a bolus (potassium chloride is heavy and settles to the bottom of the container). It is important to caution patients to use salt substitutes sparingly if they are taking other supplementary forms of potassium or potassium-conserving diuretics. Also, potassium-conserving diuretics, such as spironolactone (Aldactone), triamterene (Dyrenium), and amiloride (Midamor); potassium supplements; and salt substitutes should not be administered to patients with renal dysfunction. Calcium is absorbed from foods in the presence of normal gastric acidity and vitamin D. It briefly inhibits calcium reabsorption from bone and decreases the serum calcium concentration. A patient may have a total body calcium deficit (as in osteoporosis) but a normal serum calcium level. Elderly people with osteoporosis, who spend an increased amount of time in bed, are at increased risk for hypocalcemia as bed rest increases bone resorption. Primary hypoparathyroidism results in this disturbance, as does surgical hypoparathyroidism. Not only is hypocalcemia associated with thyroid and parathyroid surgery, but it can also occur after radical neck dissection and is most likely in the first 24 to 48 hours after surgery. Transient hypocalcemia can occur with massive administration of citrated blood (as in exchange transfusions in newborns), because citrate can combine with ionized calcium and temporarily remove it from the circulation. It is thought that calcium ions combine with the fatty acids released by lipolysis, forming soaps. It has also been suggested that hypocalcemia might be related to excessive secretion of glucagon from the inflamed pancreas, resulting in increased secretion of calcitonin (a hormone that lowers serum calcium). Hypocalcemia is common in patients with renal failure because these patients frequently have elevated serum phosphate levels. Other causes of hypocalcemia include inadequate vitamin D consumption, magnesium deficiency, medullary thyroid carcinoma, low serum albumin levels, alkalosis, and alcohol abuse. Medications predisposing to hypocalcemia include aluminum-containing antacids, aminoglycosides, caffeine, cisplatin, corticosteroids, mithramycin, phosphates, isoniazid, and loop diuretics. Osteoporosis is associated with prolonged low intake of calcium and represents a total body calcium deficit, even though serum calcium levels are usually normal. This disorder occurs in millions of Americans and is most common in postmenopausal women. It is characterized by loss of bone mass, causing bones to become porous and brittle and therefore susceptible to fracture. About 1% of skeletal calcium is rapidly exchangeable with blood calcium; the rest is more stable and only slowly exchanged. The small amount of calcium located outside the bone circulates in the serum, partly bound to protein and partly ionized. Calcium plays a major role in transmitting nerve impulses and helps to regulate muscle contraction and relaxation, including cardiac muscle. Calcium is instrumental in activating enzymes that stimulate many essential chemical reactions in the body, and it also plays a role in blood coagulation.

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Because of the decreased amount of bile in the intestinal tract birth control for women 99 buy 3.03mg drospirenone, the stools become light or clay-colored birth control pill womens liberation order 3.03mg drospirenone amex. Dyspepsia and intolerance to fatty foods may develop because of impaired fat digestion in the absence of intestinal bile birth control for women how are stis drospirenone 3.03 mg on-line. Loss of fluid into the peritoneal space causes further sodium and water retention by the kidney in an effort to maintain the vascular fluid volume birth control kelnor proven 3.03mg drospirenone, and the process becomes self-perpetuating. As a result of liver damage, large amounts of albumin-rich fluid, 15 L or more, may accumulate in the peritoneal cavity as ascites. With the movement of albumin from the serum to the peritoneal cavity, the osmotic pressure of the serum decreases. This, combined with increased portal pressure, results in movement of fluid into the peritoneal cavity. Clinical Manifestations Increased abdominal girth and rapid weight gain are common presenting symptoms of ascites. The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall. Hereditary Hyperbilirubinemia Increased serum bilirubin levels (hyperbilirubinemia) resulting from several inherited disorders can also produce jaundice. Although serum bilirubin levels are increased, liver histology and liver function test results are normal, and there is no hemolysis. Assessment and Diagnostic Evaluation the presence and extent of ascites are assessed by percussion of the abdomen. When fluid has accumulated in the peritoneal cavity, the flanks bulge when the patient assumes a supine position. The presence of fluid can be confirmed either by percussing for shifting dullness or by detecting a fluid wave. Although portal hypertension is commonly associated with hepatic cirrhosis, it can also occur with noncirrhotic liver disease. While splenomegaly (enlarged spleen) with possible hypersplenism is a common manifestation of portal hypertension, two major consequences of portal hypertension are ascites and varices. Although ascites is often a result of liver damage, it may also occur with disorders such as cancer, kidney disease, and heart failure. Varices are varicosities that develop from elevated pressures transmitted to all of the veins that drain into the portal system. In addition, blood clotting abnormalities, often seen in patients with severe liver disease, increase the likelihood of bleeding. Portal hypertension and the resulting increase in capillary pressure and obstruction of venous blood flow through the damaged liver are contributing factors. The failure of the liver to metabolize aldosterone increases sodium and water retention by the kidney. Chapter 39 Assessment and Management of Patients With Hepatic Disorders 1083 blocking agent, is most often the first-line therapy in patients with ascites from cirrhosis. Oral diuretics such as furosemide (Lasix) may be added but should be used cautiously because with long-term use they may also induce severe sodium depletion (hyponatremia). Ammonium chloride and acetazolamide (Diamox) are contraindicated because of the possibility of precipitating hepatic coma. Fluid restriction is not attempted unless the serum sodium concentration is very low. Possible complications of diuretic therapy include fluid and electrolyte disturbances (including hypovolemia, hypokalemia, hyponatremia, and hypochloremic alkalosis) and encephalopathy. Also, when potassium stores are depleted, the amount of ammonia in the systemic circulation increases, which may cause impaired cerebral functioning and encephalopathy. This results in reduced renal glomerular filtration and sodium excretion and a decreased response to loop diuretics. Bed rest may be a useful therapy, especially for patients whose condition is refractory to diuretics.

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