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For those who have already sustained a stroke generic silagra 50 mg without a prescription erectile dysfunction causes cancer, rapid availability of appropriate imaging and access to a specialist acute stroke team are recommendations which are emphasised generic 50 mg silagra mastercard erectile dysfunction treatment protocol. The guideline recognises that not all patients need the most aggressive management, but that it is vital to identify swiftly those who may benefit. The decision not to address the later stages within this guideline was taken partly because this would increase the size of the task, but mainly because we knew that the Intercollegiate Stroke Working Party were updating their own excellent guideline which covers the later part of the patient pathway. The two guideline groups have collaborated extensively throughout development, and their separate pieces of guidance complement each other. They have been a pleasure to work with, both knowledgeable and committed, and I believe they have produced an excellent guideline. Stroke medicine is now such an active field that there will doubtless be further improvements to add in the near future. For the moment however, implementing this guideline across the country should be of real and immediate benefit to all patients with this once neglected problem. It can present with the sudden onset of any neurological disturbance, including limb weakness or numbness, speech disturbance, visual loss or disturbance of balance. Over the last two decades, a growing body of evidence has overturned the traditional perception that stroke is simply a consequence of aging which inevitably results in death or severe disability. Evidence is accumulating for more effective primary and secondary prevention strategies, better recognition of people at highest risk and thus most in need of active intervention, interventions that are effective soon after the onset of symptoms, and an under- standing of the processes of care that contribute to a better outcome. In addition, there is now good evidence to support interventions and care processes in stroke rehabilitation. In order for evidence from research studies to improve outcomes for patients, it needs to be put into practice. National guidelines provide clinicians, managers and service users with summaries of evidence and recommendations for clinical practice. Implementation of guidelines in practice, supported by regular audit, improves the processes of care and clinical outcome. Most of the evidence considered relates to interventions in the first 48 hours after onset of symptoms, although some interventions of up to 2 weeks are covered as well. This guideline is a stand-alone document, but is designed to be read alongside the Intercollegiate Stroke Working Party guideline ‘National clinical guideline for stroke’* which considers evidence for interventions from the acute stage into rehabilitation and life after stroke. The Intercollegiate Stroke Working Party guideline is an update of the 2004 2nd edition and includes all the recommendations contained within this guideline. Stroke has a sudden and sometimes devastating impact on the patient and their family who need continuing information and support. Clinicians dealing with acute care need to be mindful of the rehabilitation and secondary care needs of patients with stroke to ensure a seamless transition across the different phases of care. All aspects of care must be patient-centred and where possible based on full discussion with the patient and/or carer, for example some aspects of the guideline may not be appropriate for patients who are dying or who have other severe comorbidities. Healthcare professionals should also follow a code of practice accompanying the Mental Capacity Act 2005 (summary available from www. It accounted for over 56,000 deaths in England and Wales in 1999, which represent 11% of all deaths. More than 900,000 people in England are living with the effects of stroke, with half of these being dependent on other people for help with everyday activities. Many of the studies had a small sample size and were consequently statistically under-powered. Furthermore, the different diagnostic tests, interventions and outcomes often precluded any meaningful comparison across studies. In addition, the health economist searched for additional papers providing economic evidence or to inform detailed health economic work (for example, modelling). Conference paper abstracts and non-English language papers were excluded from the searches. Each clinical question dictated the appropriate study design that was prioritised in the search strategy but the strategy was not limited solely to these study types. The research fellow or health economist identified titles and abstracts from the search results that appeared to be relevant to the question. However, there were ad hoc occasions when this was required in order to clarify specific details. The health economist performed supplemental literature searches to obtain additional data for modelling. High-quality case-control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal. For each section, the layout is similar and contains: q Clinical introduction sets a succinct background and describes the current clinical context. The rationale for not citing all statistical outcomes in the text is to try to provide a ‘user friendly’ readable guideline balanced with statistical evidence where this is thought to be of interest to the reader. These describe comprehensive details of the primary evidence that was considered during the writing of each section including all statistical outcomes. The guideline was then submitted for a formal public and stakeholder consultation prior to publication. Future guideline updates will consider evidence published after this cut-off date. If not, the guideline will be considered for update approximately four years after publication. The recommendations cited here are a guide and may not be appropriate for use in all situations. The decision to adopt any of the recommendations cited here must be made by the practitioner in light of individual patient circumstances, the wishes of the patient, clinical expertise and resources. All people with suspected stroke should be admitted directly to a specialist acute stroke unit following initial assessment either from the community or accident & emergency (A&E) department. Brain imaging should be performed immediately* for people with acute stroke if any of the following apply: q indications for thrombolysis or early anticoagulation treatment (see sections 8. On admission, people with acute stroke should have their swallowing screened by an appropriately trained healthcare professional before being given any oral food, fluid or medication. Start Aspirin 300 mg and consider the following: Consider • treatment with statins alternative • blood pressure management diagnosis • lifestyle management. Surgical referral for Is surgical intracerebral referral for Yes haemorrhage • small deep haemorrhages decompressive • lobar haemorrhage without craniectomy Previously fit patient with: hydrocephalus or rapid neurological indicated? Refer within • haemorrhage with hydrocephalus or deterioration * • who is deteriorating neurologically. It is calculated based on: A – age (≥60 years, 1 point) B – blood pressure at presentation (≥140/90 mmHg, 1 point) C – clinical features (unilateral weakness, 2 points or speech disturbance without weakness, 1 point) D – duration of symptoms (≥60 minutes, 2 points or 10–59 minutes, 1 point). Anticoagulants A group of drugs used to reduce the risk of clots forming by thinning the blood. Antiphospholipid Sometimes called ‘sticky blood syndrome’ because the blood clots too syndrome quickly due to antibodies that form against the body’s phospholipids. Antiplatelets A group of drugs used to prevent the formation of clots by stopping platelets in the blood sticking together. Arterial dissection This is caused as a result of a small tear forming in the tunica intima lining of the arterial wall.

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Examples of such enzymes include alcohol dehydrogenase order cheap silagra on line erectile dysfunction drugs in ghana, peroxidase buy genuine silagra line erectile dysfunction shake recipe, catalase and xanthine oxidase etc. The toxicity of many compounds such as hydrogen cyanide and hydrogen sulphide results from their action as enzyme inhibitors. Three general types of reversible inhibition is observed: competitive, noncompetitive and un-competitive, depending on the following factors. Whether the inhibitor binds with the active site or site other than the active site (allosteric site). Whether the inhibitor binds with the free enzyme only or with the enzyme substrate complex only or with either of the two. The combination of a competitive inhibitor (I) with enzyme (E) can be written in the same manner as combination with substrate, although the inhibitor cannot be chemically transformed to products. Thus, by increasing the substrate concentration we can decrease the degree of inhibition keeping inhibitor concentration at constant level. The classic example is the inhibition of succinate dehydrogenase by malonate and other dicarboxylic acids. Succinate dehydrogenase is a member of the group of enzymes catalyzing the Krebs tricarboxylic acid cycle. Succinate dehydrogenase is inhibited by malonate, which resembles succinate in having two ionized carboxyl groups. So, sulfa drugs act as competitive inhibitor and occupy the active site of some bacterial enzyme catalyzing this reaction. When this reaction is affected, it blocks the folic acid biosynthesis which is essential for the growth of micro organisms, ultimately results in the death of the micro organisms. Thus, many sulfa drugs act as antibiotics + Enzyme Substrate Enzyme - substrate complex + Inhibitor Products Enzyme - inhibitor complex Fig. Non competitive inhibition in contrast to competitive inhibition cannot be overcome by increasing substrate concentration. For example various heavy metal ions such as Ag2+, Hg2+, Pb2+ inhibit the activity of a variety of enzymes. The irreversible inhibitor dissociates very slowly from its target enzyme because it becomes very tightly bound to its active site, thus inactivating the enzyme molecule. Alkylating agents such as iodoacetamide, irreversibly inhibit the catalytic activity of some enzymes by modifying cysteine and other side chains. Organo phosphorous compounds such as diisopropyl phosphofouridate are potential irreversible inhibitors of enzymes that have active seryl residues at their catalytic sites. According to Michaelis Menton theory a) only a single substrate is involved b) the concentration of substrate is much greater than that of enzyme c) an intermediate enzyme substrate complex is formed d) all the above 3. The reciprocal form of M-M equation was considered by a) Lineweaver - Burk b) Fischer c) Koshland d) Dixon 4. While deriving Michaelis Menton equation it should be considered that the concentration of _________ is much greater than that of the _________ in the system. The degree of competitive inhibition cannot be decreased by increasing the concentration of the substrate. Based on their relationship to their host, microorganisms classifed as saprophytes (free living microbes that subsist on dead or decaying organic matter, mostly found in soil). Parasites (establish themselves and multiply in hosts (it may be pathogens - disease producing) or commensals (without causing any damage to the host-normal fora). Secondary infection : When new parasite sets up an infection in a host whose resistance is lowered by a preexisting infectious disease. Cross infection : When a patient already suffering from a disease a new infection is set up from another host or another external source. Latent infection : Some parasites, following infection, may remain in the tissues in a latent or hidden form, multiply and producing clinical disease when the host resistance is lowered. It may also occur by i) Inhalation of pathogen (Infuenza) ii) Ingestion of food or drinks contaminated by pathogens iii) Inoculation directly into the tissues of the host (Tetanus spores). Infectious disease may be localized ( superfcial or deep-seated) or generalized (spreading through tissue spaces and circulation). However, it can be Endemic (when a small number of cases occur constantly among the population of a community eg: Typhoid), Epidemic (The disease fares up and large number of cases develop with in a community with in a short time. Based on the structure and shape three major group of bacteria namely, Bacillus (cylindrical forms), Coccus (spherical forms) and Spiral. Humans and animals have abundant normal fora (microbes) that usually do not produce disease under normal healthy condition. The pathogenesis of bacterial infection includes initiation of the infectious process and mechanisms that lead to the development of signs and symptoms of disease. The virion consists of nucleic acid surrounded by a protein coat called capsid which protects the nucleic acid from deleterious environment and to introduce viral genome into the host cells by adsorbing readily to the cell surface. They may be sporadic like Mumps, endemic like Infectious hepatitis, epidemic like Dengue fever or pandemic like Infuenza. Depending on the clinical outcome, Viral infections can be classifed as unapparent (sub clinical) or apparent (clinical or overt) infections. Depending on the cell morphology fungi can be divided into four classes - i) Yeasts : Unicellular fungi which occur as spherical and reproduce by simple budding ii) Yeast like fungi : Grow partly as yeast and partly as elongated cells resembling hyphae form a pseudo mycelium iii) Moulds : True mycelia and they are reproduced by the formation of different types of spores. Superfcial mycoses are of two types - surface infections (only on dead layers of skin) and cutaneous infections (cornifed layer). Infectious diseases are caused by foreign substances like fungi, bacteria, virus or parasite, when they enter in to the human body. Though the disease by such pathogen affects the body for a shorter duration, the person may survive after loosing functions of some of the organ (eg. The immune system provides such freedom enjoyed by an individual, in order to keep them free from diseases. Immune system keep memory about the pathogens and when the same pathogen reenters a better immune response is produced. Recognition and destruction of the mutant cells that can become cancerous and this is known as Immunosurveillance. Normally, Immune system does not produce antibodies against its own body tissues (self antigens), called as Immune tolerance or Self recognization. Depending on the nature of response towards the pathogen, Immune system is broadly classifed into Natural and Acquired immunity. They developed from the bone marrow stem cells and give rise to two families of white blood cells namely the Myeloid cells (named after bone marrow) and the Lymphoid cells, which take their name from the lymphatic system. The lymphoid cells include T and B lymphocytes which get their maturation in different lymphoid organs. B-cell maturation begins in the liver (fetal) and continues within the bone marrow as maturation progresses (adult) and T cells complete their maturation in the thymus. Mechanisms involved in Natural immunity Skin barrier The skin covers and protects the body as a barrier to prevent invading pathogens. Intact skin prevents the penetration of most pathogens, by secreting lactic acid and fatty acids which lower the skin pH. Mechanical barriers Mucous membranes form the external layer where body is not covered with skin and it plays an important role in the prevention of pathogen entrance by traping them. Movement of the mucociliary process in the upper respiratory tract, the cilia in the eyelids act as escalators to remove the pathogens.

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Linen for one client is never (even momentarily) placed on another client’s bed 5 purchase genuine silagra erectile dysfunction video. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered for disposal 6 purchase silagra 100 mg with visa erectile dysfunction and diabetes treatment. Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain Basic Nursing Art 23 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on the other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the clients feet. Vertical - make a fold in the sheet 5-10 cm 1 to the foot Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot 10. While tucking bedding under the mattress the palm of the hand should face down to protect your nails. Bed spread Note • Pillow should not be used for babies • The mattress should be turned as often as necessary to prevent sagging, which will cause discomfort to the patient. Closed Bed • It is a smooth, comfortable, and clean bed that is prepared for a new patient Basic Nursing Art 24 Essential Equipment: • Two large sheets • Rubber draw sheet • Draw sheet • Blankets • Pillow cases • Bed spread Procedure: • Wash hands and collect necessary materials • Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed • Tuck sheet under mattress at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck sheet on the sides and foot of bed, mitering the corners • Tuck sheets smoothly under the mattress, there should be no wrinkles • Place rubber draw at the center of the bed and tuck smoothly and tightly • Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely • Place top sheet with wrong side up, center fold of sheet on center of bed and wide hem at head of bed • Tuck sheet of foot of bed, mitering the corner • Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the corner • Fold top sheet over blanket Basic Nursing Art 25 • Place bed spread with right side up and tuck it • Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothening out all wrinkles, put pillow case on pillow and place on bed • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands B. Occupied Bed Purpose: to provide comfort, cleanliness and facilitate position of the patients Essential equipment: • Two large sheets • Draw sheet • Pillow case • Pajamas or gown, if necessary Procedure: • If a full bath is not given at this time, the patient’s back should be washed and cared for • Wash hands and collect equipment • Explain procedure to the patient • Carry all equipment to the bed and arrange in the order it is to be used • Make sure the windows and doors are closed • Make the bed flat, if possible • Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow cases on the chair for receiving dirty linen Basic Nursing Art 26 • Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder and the shoulder hand over the patient’s knees, turn the patient towards you • Never turn a helpless patient away from you, as this may cause him/her to fall out bed • When you have made the patient comfortable and secure as near to the edge of the bed as possible, to go the other side carrying your equipment with you • Loosen the bedding on that side • Fold, the bed spread half way down from the head • Fold the bedding neatly up over patient • Roll dirty bottom sheet close to patient • Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half close to the patient, tucking top and bottom ends tightly and mitering the corner • Put on rubber sheet and draw sheet if needed • Turn patient towards you on to the clean sheets and make comfortable on the edge of bed • Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back care • Remove dirty sheet gently and place in dirty pillow case, but not on the floor • Remove dirty bottom sheet and unroll clean linen • Tuck in tightly at ends and miter corners • Turn patient and make position comfortable • Back rub should be given before the patient is turned on his /her back • Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious Basic Nursing Art 27 • Go to foot of bed and pull the dirty top sheet out • Replace the blanket and bed spread • Miter the corners • Tuck in along sides for low beds • Leave sides hanging on high beds • Turn the top of the bed spread under the blanket • Turn top sheet back over the blanket and bed spread • Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s toes and chest • Be sure the patient is comfortable • Clean bedside table • Remove dirty linen, leaving room in order • Wash hands Study Questions 1. Bath (Bathing and Skin Care) It is a bath given to a patient in the bed who is unable to care for himself/herself. Cleansing bath: Is given chiefly for cleansing or hygiene purposes and includes: • Complete bed bath: the nurse washes the entire body of a dependent patient in bed • Self-help bed bath: clients confined to bed are able to bath themselves with help from the nurse for washing the back and perhaps the face • Partial bath (abbreviated bath): only the parts of the client’s body that might cause discomfort or odor, if neglected are washed the face, hands, axilla, perineum and back (the Basic Nursing Art 29 nurse can assist by washing the back) omitted are the arms, chest, abdomen. Also used for therapeutic baths • Shower: many ambulatory clients are able to use shower • The water should feel comfortably warm for the client • People vary in their sensitivity to heat generally it should be o o 43-46 c (110-115 f) • The water for a bed bath should be changed at least once Before bathing a patient, determine a. The bed linen required Note: when bathing a client with infection, the caregiver should wear gloves in the presence of body fluids or open lesion. Principles • Close doors and windows: air current increases loss of heat from the body by convection • Provide privacy – hygiene is a personal matter & the patient will be more comfortable • The client will be more comfortable after voiding and voiding before cleansing the perineum is advisable • Place the bed in the high position: avoids undue strain on the nurses back Basic Nursing Art 30 • Assist the client to move near you – facilitates access which avoids undue reaching and straining • Make a bath mitt with the washcloth. It retains water and heat better than a cloth loosely held • Clean the eye from the inner canthus to the outer using separate corners of the wash cloth – prevents transmitting micro organisms, prevents secretions from entering the nasolacrmal duct • Firm strokes from distal to proximal parts of the extremities increases venous blood return Purpose: o To remove transient moist, body secretions and excretions, and dead skin cell o To stimulate circulation o To produce a sense of well being o To promote relaxation, comfort and cleanliness o To prevent or eliminate unpleasant body odors o To give an opportunity for the nurse to assess ill clients o To prevent pressure sores Two categories of baths given to clients o Cleansing o Therapeutic A. Bed Bath Equipment • Trolley • Bed protecting materials such as rubber sheet and towels • Bath blanket (or use top linen) • Two bath towels • Clean pajamas or gown • Additional bed linens Basic Nursing Art 31 • Hamper for soiled cloths 0 0 • Basin with warm water (43-46 c for adult and 38-40 c for children) • Soap on a soap dish • Hygienic supplies, such as, lotion, powder or deodorants (if required) • Screen • Disposable gloves Procedures 1. Prepare the patient unit • Close windows and doors, use screen to provide privacy. Make a bath mitt with the washcloth, so it retains water and heat than a cloth loosely held 4. Assist the patient with grooming • Apply powder lotion or deodorants (of pt uses) • Help patient to care for hair, mouth and nails. Recomfort the patient • Change linen if soiled • Arrange the bed • Put pt in comfortable position • Remove the screen 6. Give proper care of materials used for bathing • Document and report pertinent data • Observation of the skin condition • General appearance or reaction of the pt • Type of bath give Report any abnormal findings to the nurse in charge B. Therapeutic Baths • Are usually ordered by a physician • Are given for physical effects, such as sooth irritated skin or to treat an area (perineum) • Medications may be placed in the water • Is generally taken in a tub 1/3 or ½ full, about 114 liters (930’gal) • The client remains in the bath for a desired time, often 20-30 min • If the clients back, chest and arms are to be treated, immerse in the solution o • The bath temperature is generally included in the order, 37. Saline: 4 ml (1Tsp) NaCl to 500 ml (1 pt) water • Has a cooling effect • Cleans • Decrease skin irritation 2. Potassium permanganate (Kmno4): available in tablets, which are crushed, dissolved in a little water, and added to the bath • Cleans and disinfects • Treats infected skin areas Oatmeal (Aveeino) and cornstarch can also be used Back Care (massage): includes the area from the back and shoulder to the lower buttocks Purpose • To relieve muscle tension • To promote physical and mental relaxation • To improve muscle and skin functioning • To relieve insomnia • To relax patient • To provide a relieve from pain • To prevent pressure sores (decubitus) Procedure 1. Massaging the back • Pour small amount of lotion (oil) on your palm and rub your palms together to warm the lotion (oil) before massaging. Basic Nursing Art 35 • Complete the back rub using long, firm strokes up and sown the back. Petrissape: kneading and making large quick pinches of the skin, tissue, and muscle • Clean the back first • Warm the massage lotion or oil before use by pouring over your hands: cold lotion may startle the client and increase discomfort 1. Effleurage the entire back: has a relaxing sedative effect if slow movement and light pressure are used 2. Petrissape first up the vertebral column and them over the entire back: is stimulating if done quickly with firm p Basic Nursing Art 36 • Assess: signs of relaxation and /or decreased pain (relaxed breathing, decreased muscles tension, drowsiness, and peaceful affect) ⇒ Verbalizations of freedom from pain and tension ⇒ Areas or redness, broken skin, bruises, or other sings of skin breakdown Note • The duration of a massage ranges from 5-20 minutes • Remember the location of bony prominence to avoid direct pressure over this areas • Frequent positioning is preferable to back massage as massaging the back could possibly lead to subcutaneous tissue degeneration. Mouth Care Purpose • To remove food particles from around and between the teeth • To remove dental plaque to prevent dental caries • To increase appetite • To enhance the client’s feelings of well-being • To prevent sores and infections of the oral tissue • To prevent bad odor or halitosis • Should be done in the morning, at night and after each meal • Wait at least for 10 minutes after patient has eaten Equipments • Toothbrush (use the person’s private item. If patient has none use of cotton tipped applicator and plain water) • Tooth paste (use the person’s private item. If patient has none of use cotton tipped applicator and plain water) • Cup of water Basic Nursing Art 37 • Emesis basin • Towel • Denture bowel (if required) Procedure 1. Prepare the pt: • Explain the procedure • Assist the patient to a sitting position in bed (if the health condition permits). Brush the teeth • Moisten the tooth with water and spread small amount of tooth paste on it • Brush the teeth following the appropriate technique. Brushing technique • Hold the brush against the teeth with the bristles at up degree angle. Give pt water to rinse the mouth and let him/her to spit the water into the basin. Recomfort the pt Basic Nursing Art 38 • Remove the basin • Remove the towel • Assist the patient in wiping the mouth • Reposition the patient and adjust the bed to leave patient comfortably 5. Normal solution: a solution of common salt with water in proportion of 4 gm/500 cc of water 2. Move the floss up and down between the teeth from the tops of the crowns to the gum 3. A fracture, the slipper or low back pan Advantage ⇒ Has a thinner rim than as standard bed pan ⇒ Is designed to be easily placed under a person’s buttocks Disadvantage ⇒ Easier to spill the contents of the fracture pan Basic Nursing Art 40 ⇒ Are useful for people who are a. The pediatric bedpan • Are small sized • Usually made of a plastic Offering and Removing Bed Pan • If the individual is weak or helpless, two peoples are needed to place and remove bed pans • If a person needs the bed pan for a longer time periodically remove and replace the pan to ease pressure and prevent tissue damage • Metal bed pans should be warmed before use by: o Running warm water inside the rim of the pan or over the pan o Covering with cloth • Semi-Fowler’s position relieves strain on the client’s back and permits a more normal position for elimination Improper placement of the bedpan can cause skin abrasion to the sacral area and spillage o Place a regular bed pan under the buttocks with the narrow end towards the foot of the bed and the buttocks resting on the smooth, rounded rim o Place a slipper (fracture) pan with the flat, low end under the client’s buttocks o Covering the bed pan after use reduces offensive odors and the clients embarrassment Basic Nursing Art 41 If the client is unable to achieve regular defecation help by attending to: 1. Timing – do not ignore the urge to defecate • A patient should be encouraged to defecate when the urge to defecate is recognized • The patient and the nurse can discuss when mass peristalsis normally occurs and provide time for defecation (the same time each day) 3. Nutrition and fluids For a constipated client: increase daily fluid intake, drink hot liquids and fruit juices etc For the client with diarrhea – encourage oral intake of foods and fluids For the client who has flatulence: limit carbonated beverages; avoid gas- forming foods 4.

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These are surface markings where muscles silagra 100 mg free shipping erectile dysfunction operations, tendons and ligaments attached order discount silagra online erectile dysfunction 18, blood & lymph vessels and nerves pass. Example: External auditory meatus Groves and sulcus: are deep furrow on the surface of a bone or other structure. Example Medial condyle of femur Head, expanded, rounded surface at proximal end of a bone often joined to shaft by a narrowed neck. The upper part of the lower extremity, between the pelvis and knee, is the thigh; the leg is between the knees an ankle. Made up of horizontal, cribriform plate, median perpendicular plate, paired lateral masses; contains ethmoidal sinuses, crista galli, superior and middle conchae. Forms roof of nasal cavity and septum, part of cranium floor; site of attachment for membranes covering brain. Shaped like large scoop; frontal squama forms forehead; orbital plate forms roof of orbit; supraorbital ridge forms brow ridge; contains frontal sinuses, supraorbital foramen. Slightly curved plate, With turned- up edges; made up of squamous, base, and two lateral parts; contains foramen magnum, occipital condyles, hypo-glossal canals, atlanto-occipital joint, external occipital crest and protuberance. Protects posterior part of brain; forms foramina for spinal cord and nerves; site of attachment for muscles, ligaments. Wedge-shaped; made up of body, greater and lesser lateral wings, pterygoid processes; contains sphenoidal sinuses, sella turcica, optic foramen, superior orbital fissure, foramen 71 Human Anatomy and Physiology ovale, foramen rotundum, foramen spinosum Forms anterior part of base of cranium; houses pituitary gland; contains foramina for cranial nerves, meningeal artery to brain. Made up of squamous, petrous, tympanic, mastoid areas; contain zygomatic process, mandibular fossa, ear Ossicles, mastoid sinuses. Form temples, part of cheekbones; articulate with lower jaw; protect ear ossicles; site of attachments for neck muscles. Fontanels The skeleton of a newly formed embryo consist cartilage or fibrous membrane structures, which gradually replaced by bone the process is called ossification. Function • They enable skull of the fetus to compress as it pass through the birth canal • Permit rapid growth of brain during infancy • Serves as a landmark (anterior fontanel) for withdrawal of blood from the superior sagital sinus • Aid in determination of fetal position prior to birth. In the skull of the fetus there are 6 prominent fontanels: a) The Anterior (frontal) fontanel, between angle of two parietal bones & segment of the frontal bone. They are irregular in shape and begin to close at 1 or 2 months after birth and completed by 12 months. Largest, strongest facial bone; horseshoe-shaped horizontal bony with two perpendicular rami; contains tooth sockets, coronoid, condylar, alveolar processes, mental foramina. Made up of zygomatic, frontal, palatine, alveolar processes; contain infraorbital foramina, maxillary sinuses, tooth sockets. Horizontal plate forms posterior part of hard palate; vertical plate forms part of wall of nasal cavity, floor of orbit. Curved lateral part of (molar) cheekbones; made up of temporal process, zygomatic arch; contain zygomatico-facial and zygomatico-temporal foramina. U-shaped, suspended from styloid process of temporal bone; site of attachment for some muscles used in speaking, swallowing. Orbit has four walls and apex: 78 Human Anatomy and Physiology • The roof of the orbit consists of parts of the frontal & sphenoid bone. Some of the principal openings and And the structures passing through are: Optic foramen (canal) passes optic nerve Superior orbital fissure passes supra orbit nerve and artery. Inferior orbital fissure passes maxillary branch of trigeminal and zygomatic nerve and infra orbital vessel. Supra orbital foramen (notch) passes occulomotor, trochlear, ophthalmic branch of trigeminal and abducent nerves. Encloses & protect spinal cord, supports the head and serves as a point of attachment for the ribs & muscles of the back. Each disc is composed of the outer fibrous ring consisting fibro-cartilage called annulus fibrosis and the inner soft, pulpy highly elastic structure called the nucleus pulpous. The presences of the curve have several functions; these are absorption of shock, maintenance of balance, protection of 81 Human Anatomy and Physiology column from fracture and increasing the strength of the column. In the age of the fetus there is only a single anterior concave curve, but approximately the third post natal month, when the child begin to hold head erect, the cervical curve develops. The cervical & lumbar curves are an anteriorly convex and because they are modification of the fetal position they are called secondary curves. The thoracic and sacral curves are anteriorly concave, since they retain the anterior concavity of the fetal curve they are referred primary curves. The space that lies between the vertebral arch and body contains the spinal cord called vertebral foramina. The pedicles are notched superiorly & inferiorly to form an opening between vertebrae on each side of the column called Intervertibral foramen. Intervertibral foramen is an opening between the vertebras that serves as passage of nerves that come out of spinal cord to supply the various body parts. There are seven processes that arise from the vertebral arch at the point where the lamina and pedicle joins. Atlas supports head, permits "yes" motion of head at joint between skull and atlas; axis Permits "no" motion at joint between axis and atlas. Thoracic vertebrae (12) Bodies and transverse processes have facets that articulate T1-T12 with ribs; laminae are short, thick, and broad. Sacrum Wedge-shaped, made up of five fused bodies united by four (5 fused bones) intervertebral disks. Thorax is a bony cage formed by sternum (breast bone), costal cartilage, ribs and bodies of the thoracic vertebra. It consists 3 basic portions: the manubrium (superior portion), the body (middle & largest portion) and the xiphoid process (inferior & smallest portion). The xiphoid process consists hyaline cartilage during infancy and child hood and do not ossify completely up to the age of 40. The 8 – 10 ribs, which are groups of the false ribs are called vertebro chondrial ribs because their cartilage attach th one another and then attaches to the cartilage of the 7 rib. One or two knob like structures on the posterior end where the neck joins the body is the tubercles, which articulate with the 88 Human Anatomy and Physiology transverse process of the vertebra and to attach with muscles of the trunk. Connected and supported by the axial skeleton with only shoulder joint and many muscle from a complex of suspension bands from the vertebral column, ribs and sternum to the shoulder girdle. Arm Humerus (2) Longest, largest bone of upper limb; forms ball of ball- and socket joint with glenoid fossa of scapula. Forearm Radius (2) Larger of two bones in forearm; large proximal end consists of olecranon process (prominence of elbow). Hands and Fingers Metacarpals (10) Five miniature long bones in each hand in fanlike arrangement; articulate with fingers at metacarpo- phalangeal joint (the Knuckle). Thigh Femur (2) Thighbone; typical long bone; longest, strongest, heaviest bone; forms ball of ball-and-socket joint with pelvic bones; provides articular surface for knee. Leg Fibula (2) Smaller long bone of lower leg; articulates proximally with tibia and distally with talus. Ankle Tarsals (14) Ankle, heel bones; short bones; 7 in each ankle including talus, calcaneus, cuboid, navicular, 3 cuneiforms; with metatarsals, form arches of foot. Foot and Toes Metatarsals (10) Miniature long bones; 5 in each foot; form sole; with tarsal, form arches of feet.