By M. Arokkh. Biola University. 2018.

External Automated Defibrillators In the event that the electrical activity of the heart is severely disrupted 2.5 mg altace sale, cessation of electrical activity or fibrillation may occur discount 2.5 mg altace overnight delivery. In fibrillation, the heart beats in a wild, uncontrolled manner, which prevents it from being able to pump effectively. The most common treatment is defibrillation, which uses special paddles to apply a charge to the heart from an external electrical source in an attempt to establish a normal sinus rhythm (Figure 19. These devices contain simple and direct verbal instructions that can be followed by nonmedical personnel in an attempt to save a life. In order to speed up the heart rate and restore full sinus rhythm, a cardiologist can implant an artificial pacemaker, which delivers electrical impulses to the heart muscle to ensure that the heart continues to contract and pump blood effectively. These artificial pacemakers are programmable by the cardiologists and can either provide stimulation temporarily upon demand or on a continuous basis. Oxygen from the lungs is brought to the heart, and every other organ, attached to the hemoglobin molecules within the erythrocytes. Normally, these two mechanisms, circulating oxygen and oxygen attached to myoglobin, can supply sufficient oxygen to the heart, even during peak performance. Both fatty acid droplets and glycogen are stored within the sarcoplasm and provide additional nutrient supply. The period of contraction that the heart undergoes while it pumps blood into circulation is called systole. Both the atria and ventricles undergo systole and diastole, and it is essential that these components be carefully regulated and coordinated to ensure blood is pumped efficiently to the body. Pressures and Flow Fluids, whether gases or liquids, are materials that flow according to pressure gradients—that is, they move from regions that are higher in pressure to regions that are lower in pressure. Accordingly, when the heart chambers are relaxed (diastole), blood will flow into the atria from the veins, which are higher in pressure. As blood flows into the atria, the pressure will rise, so the blood will initially move passively from the atria into the ventricles. When the action potential triggers the muscles in the atria to contract (atrial systole), the pressure within the atria rises further, pumping blood into the ventricles. During ventricular systole, pressure rises in the ventricles, pumping blood into the pulmonary trunk from the right ventricle and into the aorta from the left ventricle. Again, as you consider this flow and relate it to the conduction pathway, the elegance of the system should become apparent. Phases of the Cardiac Cycle At the beginning of the cardiac cycle, both the atria and ventricles are relaxed (diastole). Blood is flowing into the right atrium from the superior and inferior venae cavae and the coronary sinus. The two atrioventricular valves, the tricuspid and mitral valves, are both open, so blood flows unimpeded from the atria and into the ventricles. The two semilunar valves, the pulmonary and aortic valves, are closed, preventing backflow of blood into the right and left ventricles from the pulmonary trunk on the right and the aorta on the left. As the atrial muscles contract from the superior portion of the atria toward the atrioventricular septum, pressure rises within the atria and blood is pumped into the ventricles through the open atrioventricular (tricuspid, and mitral or bicuspid) valves. At the start of atrial systole, 862 Chapter 19 | The Cardiovascular System: The Heart the ventricles are normally filled with approximately 70–80 percent of their capacity due to inflow during diastole. Atrial contraction, also referred to as the “atrial kick,” contributes the remaining 20–30 percent of filling (see Figure 19. Atrial systole lasts approximately 100 ms and ends prior to ventricular systole, as the atrial muscle returns to diastole. At the end of atrial systole and just prior to atrial contraction, the ventricles contain approximately 130 mL blood in a resting adult in a standing position. Initially, as the muscles in the ventricle contract, the pressure of the blood within the chamber rises, but it is not yet high enough to open the semilunar (pulmonary and aortic) valves and be ejected from the heart. This increase in pressure causes blood to flow back toward the atria, closing the tricuspid and mitral valves. Since blood is not being ejected from the ventricles at this early stage, the volume of blood within the chamber remains constant. Consequently, this initial phase of ventricular systole is known as isovolumic contraction, also called isovolumetric contraction (see Figure 19. In the second phase of ventricular systole, the ventricular ejection phase, the contraction of the ventricular muscle has raised the pressure within the ventricle to the point that it is greater than the pressures in the pulmonary trunk and the aorta. Pressure generated by the left ventricle will be appreciably greater than the pressure generated by the right ventricle, since the existing pressure in the aorta will be so much higher. During the early phase of ventricular diastole, as the ventricular muscle relaxes, pressure on the remaining blood within the ventricle begins to fall. When pressure within the ventricles drops below pressure in both the pulmonary trunk and aorta, blood flows back toward the heart, producing the dicrotic notch (small dip) seen in blood pressure tracings. Since the atrioventricular valves remain closed at this point, there is no change in the volume of blood in the ventricle, so the early phase of ventricular diastole is called the isovolumic ventricular relaxation phase, also called isovolumetric ventricular relaxation phase (see Figure 19.

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Duties include opening sterile packs best 10mg altace, delivering supplies and instruments to the sterile team proven 2.5mg altace, delivering medications to sterile nurse, labeling specimens, and keeping records during the surgical procedure. This person acts as a client advocate by monitoring the situation and maintaining safety in the operating room. Post- operative Care Purpose • To prevent any complication from anesthesia • To detect any sign of post- operative complications 333 • To rehabilitate the patient. Equipment • Anesthetic bed • Oxygen • Sphygmomanometer • Stetoscope • Suction machine (as needed) • Extra rubber sheet (as needed) • I. V stand • Emergency drugs (to be ready in wards) • Bed blocks (as needed) for shock Procedure • Prepare anesthetic bed (see section on bed making) • Assist operating room nurse in placing patient in bed. Charting • Time of return • General condition and appearance ⇐ State of consciousness ⇐ Color of skin ⇐ Temperature of skin to touch ⇐ Skin- moist or dry ⇐ Blood pressure, plus and respiration ⇐ Any unusual condition such as bleeding drainage, Vomiting etc. Generals Instructions • If patient shows any signs of shock immediate action should be taken and then be reported to the doctor. The head of the bed should be lowered (If no gatches on bed, bed blocks may be used) • Do not leave unconscious patient alone. Breast Surgery • Encourage deep breathing often, because of danger of pneumonia • Special arm exercises should be given Abdominal Surgery • Encourage deep breathing • Turn from side to side often st • Sit patient on edge of bed 1 day postoperatively and • Start walking second day post operatively (unless contra- indicated) • Intake and output should be recorded 336 • If gastric suction is present make sure it is working properly • Frequent mouth care for patients who are not allowed to drink. Eye Surgery • Must lie very still because the incision and sutures can be damaged by pulling on the eye muscles. This will make it easier to breathe since the pressure of dressing and swelling may give choking feeling. Key terminology Autopsy Cheyne-Stkes respiration postmortum examination Brain death Kussmal’s breathing A. Spirituality and Death Death often forces people to consider profaned questions: the meaning of life, the existence of the soul, and the possibility of an after life. Individuals faced with death, their close friends, and family often relies on a spiritual foundation to help them meet these challenging concepts. For those whose spirituality does not include beliefs rooted in organized religion, support may take the form of compassionate care and the acceptance of personal beliefs. Meeting basic human needs is an expression of caring that dying individuals will appreciate even if they can no longer communicate with you verbally. As a person learns of his or her own impending death, he or she experiences grief in relation to his or her own loss. The denial may be partial or complete and may occur not only during the first stages of illness or confrontation but later on from time to time. This initial denial is usually a temporary defense and is used as a buffer until such time as the person is able to collect him or herself, mobilize his or her defenses, and face the inevitability of death. This emotion may be directed toward persons in the environment or even projected into the environment at random. Ross discusses this reaction and the difficulty in handling it for those close to the person by explaining that we should put ourselves in the client’s position and consider how we might feel intense anger at having our life interrupted abruptly. The person attempts to strike a bargain for more time to live or more time to be without pain in return for doing something for God. Usually, when people have completed the processes of denial, anger, and bargaining, they 341 move into depression. In this form of depression, the person is reacting against the impending loss of life and grieves for him or herself. This occurs when the person has worked through the previous stages and accepts his or her own inevitable death. With full acceptance of impending death comes the preparation for it; however, even with acceptance, hope is still present and needs to be supported realistically. Personal values and beliefs about life; views of personal successes, both financial and emotional; the way they look physically when experiencing the dying process; their family and friends and their families’ attitudes and reactions; their past experiences in coping with difficult or traumatic situations; and, finally, the health care staff who are caring for them during this process – all affect an individual’s attitude toward dying. Notify the charge nurse if there is an impending crisis and perform emergency actions until help arrives. Encourage dying clients to do as much as they can for themselves so that they do not just give up-a state that only reinforces low self-esteem. Recognize that your physical presence is comforting by staying physically close to the client if he or she is frightened. Respect the client’s need for privacy and with draw if the client has a need to be alone or to disengage from personal relationships. Be tuned into client’s cues that he or she wants to talk and express feelings, cry, or even intellectually discuss the dying process. Understand that different family members react differently to the impending death and support the different reactions. Be aware that demonstrating your concern and caring assists the family to cope with the grief process. Explore your own feelings about death and dying with the understanding that until you have faced the subject of death you will be inadequate to support the client or the family as they experience the dying process. Share your feelings about dying with the staff and others; actively work through them so that negativity does not get transferred to the client.

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Microscopically there is necrotizing cerebritis purchase altace 2.5mg otc, diffusely scattered foci of coagulative necrosis followed by calcification altace 2.5 mg discount, meningeal inflammatory exudate. Hydrocephaly may occur as a result of periaqueductal inflammation, repair and aqueductal stenosis. Frequently both parenchyma and meninges are affected, and the condition is often referred to as meningoencephalitis. The ultimate diagnosis, however, depends on the isolation of the virus and/or correlation with positive serological tests. Infiltration by Inflammatory Cells: This is usually the most conspicuous histologic abnormality. Hyperplasia and Proliferation of Microglia: Seen throughout the brain and particularly in the cortex and basal ganglia. The microglia hypertrophy to form "rod cells" and these subsequently acquire long and slightly convoluted nuclei. They are most active in and around destroyed tissue where many become converted to lipid phagocytes (foam cells). Neuronophagia: This refers to phagocytosis of an injured neuron by a dense mass of hypertrophied microglia often obscuring the dead cell. However, in acute infections such as in polio, polymorphonuclear leukocytes are the cells involved in neuronophagia. Microglial Nodules and Gliomesenchymal nodules: Are often used synonymously to describe clusters of hypertrophied microglia admixed with other mononuclear cells not specifically related to nerve cells and occurring mainly in the white matter. It should be remembered that both neuronophagia and the microglial nodules, although frequently observed in viral encephalitidies, are by no means specific since both phenomena can occur in hypoxic brain damage. Astrocytic Proliferation: In acute encephalitis, enlarged astrocytes with plump cytoplasm are usually restricted to regions of tissue destruction. Intracellular inclusion bodies: These are important and may be diagnostic of a specific viral infection. The Cowdry type A inclusion is an eosinophilic oval or spherical mass with a clear halo surrounding it. Intracytoplasmic inclusions are characteristically seen in rabies, especially in Purkinje cells and pyramidal cells of the hippocampus. Neuronal Changes: Acute degeneration of neurons such as chromatolysis, eosinophilia of cytoplasm, and pyknosis of nuclei can occur but are by no means characteristic unless there is actual necrosis of the nerve cells associated with neuronophagia. With the polio vaccination programs, acute polio has been practically eradicated in the Western Hemisphere. The polio virus selectively destroys the motor neurons of the spinal cord and brain stem to cause flaccid, asymmetric weakness of the muscles innervated by the affected motor units. The major reservoir host, however, is not the dog but the skunk in the Midwest and the fox in the Eastern Seaboard. Increasing numbers of raccoons and skunks have become infected in the New York metropolitan area over the last few years. Bats seem to be important in maintaining the circulation of virus in some regions. In both dog and man, Negri bodies are most numerous in the pyramidal layer of hippocampus and Purkinje cells. Negri bodies are well-defined, rounded, acidophilic, intracytoplasmic inclusions about 5-10 nm. Rabies virus antigen has been identified in them by the immunoperoxidase technique. After an incubation period in the arthropod vector, the virus reaches the salivary glands, and is inoculated into a new host where it proliferates. A period of viremia follows during which period a further arthropod may become infected. Man is not a natural host of any of the arboviruses but becomes infected accidentally during periods of epizootic spread among the natural hosts. The important thing to remember about arbovirus infections is that they occur as seasonal epidemics since climate exerts a strong influence in maintaining the vector-host cycle. In this country, mosquitoes are the principal vectors of arboencephalitides while in the Far East and Central and Eastern Europe, tickborne encephalitides are far more common. Eastern equine encephalitis has a high mortality rate that can attain 75% while the Western the rate is about 10%. California encephalitis: Almost entirely affects children who usually have a history of recreational exposure in the woods prior to the onset of the disease. Woodland mosquitoes are probably the vectors and small animals and birds do not appear to be involved. Although the disease may be quite severe, death is rare, and sequelae occur in only 15% of the children. Type 1 is usually associated with primary oropharyngeal lesions and causes acute encephalitis in adults. Type 2 is associated with genital lesions and causes disseminated infection in neonates and an aseptic meningitis in adults. Clinical symptoms and signs: Starts with fever and headaches Seizures are common Nuchal rigidity may be present Progressive mental deficits, confusion and personality changes Pathological findings: Intense meningitis Necrotic, inflammatory, or hemorrhagic lesions Predilection for frontal and temporal lobes.

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The glucose in the circulating blood and tissue fuids is drawn upon by all the cells of the body and used for the production of energy generic altace 5 mg free shipping. In fact the brain largely depends upon carbohydrate metabolism as a source of energy and quickly ceases to function properly when the blood glucose level falls much below normal purchase altace 2.5mg visa. Glucose is degraded in the cell by way of a series of phosphorylated intermediates mainly via two metabolic pathways. This pathway is unique in the sense that it can proceed in both aerobic (presence of O ) and anaerobic (absence of O ) conditions. Conversion of glucose 6-phosphate to fructose 6-phosphate Glucose 6-phosphate is converted to fructose 6-phosphate by the enzyme phosphogluco isomerase. Conversion of fructose 6-phosphate to fructose 1,6 diphosphate Fructose 6-phosphate is phosphorylated irreversibly at 1 position catalyzed by the enzyme phosphofructokinase to produce fructose 1,6-diphosphate. Actual splitting of fructose 1,6 diphosphate Fructose 1,6 diphosphate is split by the enzyme aldolase into two molecules of triose phosphates, an aldotriose-glyceraldehyde 3-phosphate and one ketotriose - dihydroxy acetone phosphate. Reactions of this type in which an aldehyde group is oxidised to an acid are accompanied by liberation of large amounts of potentially useful energy. Oxidation of glyceraldehyde 3-phosphate to 1,3-bisphosphoglycerate Glycolysis proceeds by the oxidation of glyceraldehyde 3-phosphate to form 1,3-bisphosphoglycerate. Conversion of 1,3-bisphosphoglycerate to 3-phosphoglycerate The reaction is catalyzed by the enzyme phosphoglycerate kinase. Conversion of 2-phosphoglycerate to phosphoenol pyruvate The reaction is catalyzed by the enzyme enolase, the enzyme requires the presence of either Mg2+ or Mn2+ ions for activity. Conversion of phosphoenol pyruvate to pyruvate Phosphoenol pyruvate is converted to pyruvate, the reaction is catalysed by the enzyme pyruvate kinase. Under aerobic conditions, pyruvate is oxidatively decarboxylated to acetyl coenzyme A (active acetate) before entering the citric acid cycle. Formation of citrate The frst reaction of the cycle is the condensation of acetyl CoA with oxaloacetate to form citrate, catalyzed by citrate synthase. Formation of isocitrate via cis aconitate The enzyme aconitase catalyzes the reversible transformation of citrate to isocitrate, through the intermediary formation of cis aconitate. Conversion of succinyl CoA to succinate The product of the preceding step, succinyl CoA is converted to succinate to continue the cycle. Hydration of fumarate to malate The reversible hydration of fumarate to malate is catalyzed by fumarase. As one molecule of glucose gives rise to two molecules of pyruvate by glycolysis, intermediates of citric acid cycle also result as two molecules. The frst reaction of the pentose phosphate pathway is the dehydrogenation of glucose 6-phosphate by glucose 6-phosphate dehydrogenase to form 6-phosphoglucono d-lactone. Glycogenesis is a very essential process since the excess of glucose is converted and stored up as glycogen which could be utilised at the time of requirement. In the absence of this process the tissues are exposed to excess of glucose immediately after a meal and they are starved of it at other times. Step 1 The frst step in the breakdown of glycogen is catalyzed by two enzymes which act independently. The frst enzyme, namely glycogen phosphorylase with inorganic phosphate catalyses the cleavage of a terminal a 1-4 bond of glycogen to produce glycogen with one molecule less and a molecule of glucose 1-phosphate. This is carried out by another enzyme called the debranching enzyme (a 1-6 glucosidase) which hydrolyses these bonds and thus make more a 1-4 linkage accessible to the action of glycogen phosphorylase. The combined action of glycogen phosphorylase and the debranching enzyme converts glycogen to glucose 1-phosphate. Glucose 6-phosphatase removes phosphate group from glucose 6-phosphate enabling the free glucose to diffuse from the cell into the extra cellular spaces including blood. It usually occurs when the carbohydrate in the diet is insuffcient to meet the demand in the body, with the intake of protein rich diet and at the time of starvation, when tissue proteins are broken down to amino acids. In glycolysis, glucose is converted to pyruvate and in gluconeogenesis pyruvate is converted to glucose. Fructose 6-phosphate is formed from fructose 1,6-diphosphate by hydrolysis and the enzyme fructose 1,6-diphosphatase catalyses this reaction. Most of the glucogenic amino acids are converted to the intermediates of citric acid cycle either by transamination or deamination. Further metabolism of glycerol does not take place in the adipose tissue because of the lack of glycerol kinase necessary to phosphorylate it. Instead, glycerol passes to the liver where it is phosphorylated to glycerol 3-phosphate by the enzyme glycerol kinase. Hence, glycogen stored up in the muscle is converted into lactic acid by glycogenolysis followed by anaerobic glycolysis and thus lactate gets accumulated in the muscle. Muscle tissue lacks the enzyme glucose 6-phosphatase hence it is incapable of synthesizing glucose from lactic acid and the conversion take place only in the liver. In the liver lactate is oxidised to pyruvate which undergoes the process of gluconeogenesis resulting in the resynthesis of glucose.

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Principal features of training that optimize the fidelity of the programs There are very few studies that analyze the actual impact that training has on the performance of teachers and/or the results of students order altace 10 mg otc. The few studies that have assessed teacher training have focused primarily on analyzing whether some training strategies or components are more efficacious than others cheap altace 10 mg mastercard. In these studies, when strategies have produced positive effects, these have occurred mainly in the degree of knowledge acquired by teachers and, to a lesser extent, in the attitudes held towards preventive approaches (Dusenbury, et al. With regard to the features of the teacher training, studies indicate that it should include direct training on the application of sessions, employing videos and role-playing and be followed up with booster sessions. Furthermore, training is best appreciated when it is done by the program designers, offered to motivated teachers and lays out concrete and detailed instructions. Nevertheless, it has been found that after live training, in comparison with video training, there is a greater likelihood of applying role-playing programs and techniques (Basen-Enquist et al. However, it is argued that more extensive training is associated with greater fidelity (Fors and Doster, 1985; Smylie, 1988; Perry et al. The first programs developed to prevent drug use were based on: a) the transmission of information and the use of fear. Resistance skills-based programs focus on countering the influence on adolescents by: a) the leisure and entertainment industry. Personal skills improvement programs emphasize components such as: a) resistance skills training against the offer of drugs. Based on their implementation methodology, school-based programs can be classified into: a) interactive and non-interactive programs. In reference to the activities, strategies or components that that constitute the efficacious elements of a school-based program, research highlights that: a) their preventive potential depends on the methodology with which they are applied. However, when transmitting information, it should be borne in mind that the information: a) be subjective and moralistic. Among the elements that efficacious school-based programs include, specialized literature highlights: a) informative talks given by former drug users. The implementation of a program in the school setting is enhanced by: a) the inclusion of visits to nightlife venues. The assessment phase that consists of both describing the problem and identifying strategies to address it is called: a) process assessment. Evaluating the extent to which a school-based program has been implemented with fidelity to the planned design is known as an assessment of: a) the efficiency of the program. The field journals filled in by teachers are an example of an indicator that we can employ in the evaluation of: a) results. The evaluation of outcomes may include judgments about: a) the efficacy, efficiency and effectiveness of the program. Impact assessment differs from the assessment of results: a) in assessing the percentage of the target population that receives the program. As regards the features most emphasized by the review studies on school- based prevention, the specialized literature indicates that: 34 Mónica Gázquez Pertusa, José Antonio García del Castillo, Diana Serban and Diana Bolanu a) the optimal number of sessions is 15. In reference to the prior training of the teaching staff responsible for implementing the programs: a) it should include the application of the sessions, use of videos and role playing, and be followed up with booster sessions. The Moderator-Mediator Variable Distinction in Social Psychological Research: Conceptual, Strategic and Statistical Considerations. Adolescent tobacco, alcohol and drug abuse: prevention strategies, empirical findings and assessment issues. Prevention in the Classroom: Drug Education and Gambling Workshops for Educators Influences on Substance Use: Risk and Protective Factors. Listado de indicadores elaborados para el Curso: Calidad en Prevención: Avances Teóricos e Instrumentos Prácticos (Unpublished document). Scotland: University of Strathclyde, Scottish Executive Effective Interventions Unit, Scottish Executive Drug Misuse Research Programme. Testing the generalizability of intervening mechanism theories: understanding the effects of adolescent drug use prevention interventions. The long-term prevention of tobacco use among junior high school students: classroom and telephone intervention. Social and personal factors in marijuana use and intentions to use drugs among inner city minority youth. Deterring the onset of smoking in children: Knowledge of immediate psychological effects and coping with peer pressure, media pressure, and parent modeling. The Seattle Social Development Project: Effects of the first four years on protective factors and problem behaviors. Changing teaching practices in mainstream classrooms to reduce discipline problems among low achievers. La prevención del consumo de drogas y la conducta antisocial en la escuela: análisis y evaluación de un programa. The effectiveness of supportive refutational defences in immunizing and restoring beliefs against persuasion. Mediating mechanisms in a school-based drug prevention program: first year effects of the Midwestern Prevention Project. Preventing Drug Abuse Among Children and Adolescents: A Research-Based Guide for Parents, Educators, and Community Leaders, Second Edition.

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