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By: I. Ketil, M.A.S., M.D.

Vice Chair, Morehouse School of Medicine

For example medications prescribed for ptsd buy arava visa, the use of a reading support system called Kurzwiel treatment zoster ophthalmicus buy arava us, reads any digital text to symptoms liver disease discount arava online master card the student and offers audio and visual reinforcement of assignments. Eyes require a large amount of energy and reducing that energy drain and conserving energy through the use of a computer programs and technology can be very helpful. Dragon Naturally Speaking is another software package that is especially useful, allowing a user to type by simply speaking to a computer or other device. The Neuro Psych evaluation includes a discussion of if and/or where changes might be expected over time. Often times, students themselves can tell when there is a change in their status or abilities, but the neurological evaluation provides the map and baseline. The role of a neurological psychologist on the team is to be aware of all these cognitive and behavioral issues, recommending needed accommodations in the academic setting. Education plans for those with Mito can have both a medical component and a neuro psych component. Because fatigue is a huge part of Mito and affects cognition, the neuro psych evaluation is essential. Neuro psych testing is respected by schools, helping establish the need for both accommodations and support. Fatigue is a huge part of the disease but can vary in intensity from one day to the next. General executive functioning which consistently affects memory, problem solving, and goal orientation. Symptoms then are dependent on both the individual person and the variability of the disease. With Mito, no luxury of a single cause exists, so the treatment, and even tracking of the disease, is much more complex. Parents and students were asked to complete two forms: (1) Behavior Rating of Individual Executive Function and (2) Behavioral assessment evaluating anxiety, depression, self esteem and social skills to assess how parents and students viewed themselves, similarly or dissimilarly. Schreibers study found that students did indeed view themselves differently than their parents. The students, however, felt that how they felt about school at a particular time, positive or negative, determined how things were going. If things at school were not going well, for example, then they felt anxious or depressed. The social environment, especially of college, is very different from high school. For example, if a student will be living in the dorms, a single room may be needed to ensure that there is enough good sleep time. Finding a balance in new setting is mainly a trial and error procedure, but students need to be able to pace themselves. Parents often struggle with these issues because it can be difficult to figure out what is just "normal" fatigue and what is due to the Mito. Dysautonomia and fluctuations in energy are hard to stay on top of and are very unpredictable. Parents can stress that their child needs to be an individual and do what they are able to do, not necessarily what his/her peers are doing. Visit various schools to determine which one is the best fit and visit the Office for Disabilities. Try to determine what a typical day would be like and anticipate what life would be like at this school. Sometimes students need to start slowly by living at home first and only taking a few courses, building up to a more regular schedule and student life. Some students like to start full force then pull back when it proves to be too much, but this method may not be best since it may denote failure. Students should try to find someone in their field of study and shadow that person for a day, providing the student with Mito a realistic view of what it is like to take a particular course or major, and also allowing time to reconsider a course of study or choice of major. Anyone with a long term struggle or a chronic disease, looking to what might or might not be in their future, will have depression secondary to these life events. Mental health issues, however, can also be neurobiological due to decreased energy and directly related to the Mito diagnosis.

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Expected Outcome: Patient will participate in physical activity as Administer supplemental oxygen as needed symptoms west nile virus generic 20 mg arava with amex. Elevate the head of the pressure medicine 4839 generic arava 10mg fast delivery, diaphoresis 7 medications that cause incontinence purchase generic arava canada, pallor, complaints of chest pain, excessive bed to reduce the work of breathing. Provide a bedside commode, fatigue, or palpitations indicate activity intolerance. The failing heart is unable to increase car these measures reduce cardiac workload. Assessing response to activities helps evaluate cardiac func Excess Fluid Volume tion. Decreasing activity tolerance may signal deterioration of cardiac function, not overexertion. As cardiac output falls, compensatory mechanisms cause salt and wa ter retention, increasing blood volume. This increased fluid volume places additional stress on the already failing ventricles, making them Organize nursing care to allow rest periods. Encourage independence within pre denced by weight loss and decreases in edema, jugular venous disten scribed limits. Consult with physical therapist on Declining respiratory status indicates worsening left heart failure. Acute pulmonary edema, a medical emergency, can develop rapidly, necessitating immediate intervention to preserve life. Chapter 31 Nursing Care of Patients with Cardiac Disorders 935 Deficient Knowledge: Low Sodium Diet Desired and adverse effects of prescribed drugs; monitoring for Diet is an important part of long term management of heart failure to effects; importance of compliance with drug regimen to prevent manage fluid retention. Understanding fos Exercise recommendations to strengthen the heart muscle and ters compliance with the prescribed diet. Dietary planning and Provide referrals for home healthcare and household assistance teaching increase the patients sense of control and participation in (shopping, transportation, personal needs, and housekeeping) as disease management. Referrals to community agencies, such as local cardiac Teach how to read food labels for nutritional information. Pulmonary edema is an abnormal accumulation of fluid in the Encourage small, frequent meals rather than three heavy meals interstitial tissue and alveoli of the lung. Small, frequent meals provide continuing energy resources diac disorders can cause pulmonary edema. Cardiogenic pulmonary edema, the focus of this section, is a sign of se Delegating Nursing Care Activities vere cardiac decompensation. Risk factors are those associated with heart failure, and treatment Heart failure is a chronic condition requiring active participation focuses on maintaining oxygenation and improving cardiac function. In teaching for Noncardiogenic pulmonary edema is a primary or secondary lung home care, include the following topics: disorder. Treatment focuses on maintaining the disease process and its effects on the patients life oxygenation and the primary, underlying disorder. If you get tired during any activity, stop what you are doing Week 1 200400 ft Twice a day, slow and rest for 15 minutes. Eat a high fiber diet Weeks 34 1 mile 30 min, minimum and drink plenty of water to prevent constipation. Use laxatives of 3 times per week or stool softeners, as approved by your physician, to avoid con Weeks 45 1 1/2 miles 30 min, minimum stipation and straining during bowel movements. Walking is good exercise that Weeks 56 2 miles 40 min, minimum does not require any special equipment (except a good pair of of 3 times per week walking shoes). On discharge, he was started on a regimen of enalapril (Vasotec), Administer oxygen per nasal cannula at 2 L/min. Monitor digoxin, furosemide (Lasix), warfarin (Coumadin), and a potassium oxygen saturation continuously. Jackson states that he has not been able to ferred activities and scheduled rest periods. Jackson met with the dietitian, who helped them de cardiac impulse is left of the midclavicular line. He has crackles and velop a realistic eating plan to limit sodium, sugar, and fats. Jackson jugular venous distention, 3+ pitting edema of feet and ankles, and is relieved to know that he can still enjoy Chinese food prepared abdominal distention are noted. Chest x ray shows cardio and the physical therapist designed a progressive activity plan with megaly and pulmonary infiltrates.

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Place a three way stop cock in line so that due to medicine buddha mantra discount arava 20 mg visa hypovolaemia 7r medications buy arava 10 mg lowest price, myocardial depression medicine you cant take with grapefruit order arava mastercard, or associated blood or normal saline can be pushed with a 20 60ml syringe. Blood should be given based upon blood loss, with the goal of At the end of surgery, consider the options for extubation improving oxygen delivery dictated by cardiac output, oxygen carefully. Studies have shown that in decompress the bowel and the abdominal compartment may stable sepsis in the paediatric population that a haemoglobin not be too tight. In severe this fgure may need to be higher due to the weak medical cases of obstruction and sepsis, primary anastomosis would infrastructure and support systems. In either case, the child needs to be fully awake, breathing well Inotropes will need to be started if blood pressure remains low and adequately reversed, indicated clinically by fexion of the despite fuid administration. In addition, movement of The two most important factors for safe postoperative care are bacteria from the obstructed, and possibly necrotic intestines the location in the hospital and the nurse: patient ratio. The to the blood stream may release mediators and hydrogen ideal location should have oxygen, suction, good lighting, be ions (producing acidosis), resulting in more cardiovascular close to the nursing station; the room should be warm, the instability during surgical manipulation and repair of the head of the bed elevated, and there should be, one paediatric damaged intestines. In many hospitals the nurse: may be useful whilst an infusion of adrenaline is prepared patient ratio is 1:15, with very ill children, and this will not (dilute 1 mg adrenaline in 1000ml saline to give a solution of be safe for this child for the 72 hour period when the risk 1mcg. Many of these patients will have an oxygen requirement reFerenceS for a few days while the sepsis and any pneumonia resolves. Profle of pediatric The respiratory status, respiratory rate, should be monitored abdominal surgical emergencies in a developing carefully, particularly if opioids are given to a child receiving countries. A fall in saturation is a late fnding and narcotics should only be used in the setting of a 1:2 nurse:patient ratio. Mayo Clin Proc 2003; 29: 605 606, Emergency surgery for bowel obstruction in children presents vii. Children have a great reserve and ability to heal but may also hide the seriousness of their illness, 5. Red blood cell transfusion thresholds in and have the potential for sudden decompensation. PediatrCrit Care Med 2011; outcomes rely on meticulous perioperative planning, proper 12, No. The open fontanelles varies with age and children with serious head and sutures also predispose infants to a higher trauma often have multiple injuries. The presentation of head injury from road trafc collisions and sports related causes of death and disability varies with the severity of the insult ranging from injuries. Children with serious head trauma often an altered level of consciousness to deep coma. Early Early identifcation and proper management identifcation and proper cerebral blood fow of these patients greatly afects the outcome. Children have a disproportionately larger brain injury; in this situation, cerebral blood and heavier head and relatively weak neck fow follows cerebral perfusion pressure passively. Sudden acute changes in intracranial pressure Cerebral perfusion pressure less than 50mmHg has been are not well tolerated at any age. If compensatory mechanisms demonstrated to be a predictor of poor outcome in severe are overwhelmed, intracranial pressure will increase rapidly traumatic brain injury in children and adults. Extreme and the brain will herniate through the structures within the hypertension should also be avoided, as it will result in skull or the foramen magnum (coning) to cause coma and increased cerebral blood fow and cerebral oedema. Treatment is usually surgical drainage to detect associate injuries (consider non accidental injury). Establish a patent airway with jaw thrust, making sure to It can be self limiting but if large can raise the intracranial keep the cervical spine immobilised. Foreign objects in the mouth and pharynx the blood vessels within the brain tissue. The fgure below should be scooped out with a fnger and secretions gently shows the three types of intracranial haemorrhage as would suctioned. Listen for presence/absence classically associated with spontaneous rupture of cerebral of breath sounds. Pathologies to look out for include frequently communicates with intraventricular blood. Unreactive pupils can be caused by an on the afected side expanding mass compressing the third cranial nerve.

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Non union: If a fracture fails to symptoms 6 days after embryo transfer buy 20 mg arava otc heal medicine nausea purchase arava discount, this is known as non union and the brous joint formed between the broken ends of the bones is known as a pseudarthrosis treatment of hyperkalemia purchase generic arava from india. This seems to occur often with forearm fractures, presumably because it was difcult to immobilise the arm, or because individuals with fractures started to use the arm before healing was complete. Failure of immobilisation is by far the most common cause of non union, but it may also occur is some soft tissue muscle or fat, for example intrudes between the broken ends of the bones; fractures through pathological bone almost never heal. Shortening and deformity:3 If a broken limb is not properly reduced, it will heal with shortening or angulation (Figure 8. When assessing fractures in the skeleton it is always useful to determine the degree of shortening by reference to the normal contralateral bone, and to assess the degree of angulation. Infection: All fractures are susceptible to infection but open fractures much more so than closed ones. As we have seen earlier, a wide variety of organisms may 3 this is sometimes also referred to as mal union. Theobliquefractureline(arrowed)isclearly visible and has entered the ankle joint; there is also a good deal of heterotopic ossication aroundthefracture. Thefracturewasnotreducedandthereisconsiderableangulationwhich would have caused some difculty with walking during life. The remodelled proximal end of the distal bular fragment (arrow head) would easily have been felt through the skin. It is remarkable how few fractures seen in a skeletal assemblage show signs of infection, another testimony to the care with which they were treated, or to the robust natural immunity enjoyed by our ancestors in the days before we were overcome by pathological cleanliness. Avascular necrosis: If damaged bone is cut off from its blood supply, it will die over a period of several months and the necrotic bone is eventually resorbed. This is particularly likely to happen with fractures of the femoral neck, the scaphoid, the lunate and the talus. Femoral head: Most of the femoral head is supplied by the lateral epiphyseal artery, which is a branch of the medial circumex artery. The lower part of the femoral head is supplied in addition by the inferior epiphyseal artery, a branch of the lateral circumex. There is also a supply from the artery that runs in trauma 145 the ligamentum teres but this is extremely variable in extent. The blood vessels supplying the head of the femur run in the joint capsule and a fracture of the femoral neck is likely to disrupt them, especially if the femoral head is displaced. If the blood supply from the ligamentum teres is inadequate, as it is likely to be most of the time, then the head will become necrotic. Necrosis may also be caused by what is known as the tamponade effect, that is, by raised pressure within the joint capsule which is sufcient to disrupt the blood supply to the head of the femur. Femoral neck fractures may be seen in skeletal assemblages with the loss of the head. The stump of the femoral neck may remain in articulation with the acetabulum or make a pseudarthrosis with the ilium. There is little prospect of union having taken place in the past but where the head remains, this must indicate that there was a plentiful blood supply from the ligamentum teres. Scaphoid: the blood supply to the scaphoid comes predominantly from the radial artery. The proximal three quarters of the bone is supplied by dorsal vessels and the distal quarter by palmar branches. The proximal pole of the scaphoid has only a limited blood supply, and large areas of it are reliant on a single vessel which may be damaged by a fracture. Lunate: the lunate receives its blood supply from the dorsal radiocarpal arch and the palmar intercarpal arch; the proximal pole is relatively less well supplied than the remainder of the bone. Fractures of the lunate are not common but may compromise the blood supply with subsequent necrosis. Firstly, if the fracture heals in poor alignment so that the normal mechanics of the joint above or below the fracture are altered; and secondly, if the fracture line extends into a joint; in the latter case, osteoarthritis is almost inevitable. Since osteoarthritis will take many years to develop, its presence in the skeleton will indicate that the individual survived for some considerable time after the injury that caused the fracture. Ankylosis: A fracture that extends into a joint, or a fracture dislocation of a joint will almost certainly result in blood entering the joint, which greatly increases theriskthatthejointwillbecomeankylosed.

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