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Symptomatic: Numbness and tingling discount 50mg fluconazole with amex, hyperactive tendon reflexes buy fluconazole 150mg line, muscle and abdominal cramp discount fluconazole 150 mg otc, tetany with carpopedal spasm and convulsions. Symptoms can include fatigue, lassitude, weakness of varying degree, anorexia, nausea and vomiting. Other symptoms include severe headaches, pain in the back and extremities, thirst, polydypsia and polyuria. Alkalosis (accumulation of Base or loss of acid) Metabolic Alkalosis Causes • Loss of acid from the stomach by repeated vomiting or aspiration • Excessive ingestion of absorbable alkali • Hypokalemic alkalosis in patients with pyloric stenosis: potassium loss due to repeated vomiting. Clinical Features • Cheyne-stokes respiration with periods of apnea • Tetany sometime occurs. It can also be caused by hyperventilation due to severe pain, hyper pyrexia and high altitude. Treatment Can be corrected by breathing into a plastic bag, or insufflation of carbon dioxide. Acidosis (accumulation of acid or loss of base) Metabolic Acidosis Causes Increase in fixed acids due to: • Anaerobic tissue metabolism (shock, infection, tissue injury) • Retention of metabolites in renal insufficiency • Formation of ketone bodies in diabetes or starvation Loss of bases in: ƒ Chronic diarrhea, gastro colic or high intestinal fistula, excess intestinal aspiration Clinical Features Besides signs and symptoms of the primary etiology like shock and infection, rapid, deep, noisy breathing is found. Treatment ƒ Tissue hypoxia should be treated by reperfusion ƒ Sodium bicarbonate can be given where bases have been lost or where the degree of acidosis is so severe that myocardial function is compromised. Respiratory Acidosis Causes Impaired alveolar ventilation due to: - Airway obstruction - Thoracic and upper abdominal incisions, abdominal distention in ileus - Pulmonary diseases (pneumonia, atelectasis especially post operative - Inadequate ventilation of the anesthetized patient Clinical Features Restlessness, hypertension and tachycardia may indicate inadequate ventilation with hypercapnia. Renal (slow) Diarrhea, As in respiratory acidosis Small-bowel fistula Metabolic Loss of fixed Vomiting Pulmonary (rapid) alkalosis acids Gastric suction Decrease rate and depth of Gain of base (pyloric obstruction) breathing bicarbonate Excessive bicarbonate Renal (slow) Potassium intake As in respiratory alkalosis depletion Diuretics 14 Review Questions 1. Know blood transfusion reactions and their preventions Definition Blood transfusion is the procedure of introducing the blood of a donor, or pre-donated blood by a recipient into the recipient’s bloodstream. Indications for blood transfusion The need for blood transfusion in patients with acute hemorrhage is based on • The volume lost • The rate of bleeding • The hemodynamic status of the patient; hematocrit may be normal if determined. It must be remembered that crystalloid infusions should be provided while the blood compound is obtained. Symptomatic patients exhibiting air hunger, dizziness, significant tachycardia or cardiac failure should, of course, be transfused. Component therapy is indicated when specific factor deficiencies are demonstrated. Compatibility tests If administrated blood is incompatible with the patients own blood, life threatening reactions may result. Group-A contains anti-B antibodies, Group-B contains anti-A antibodies, Group-O contains anti-A and anti B antibodies. In some instances when fully cross- matched compatible blood is depleted or unavailable; type specific or O negative blood should be given. Irregular recipient antibodies cannot be detected and extra vascular hemolysis can also occur. Overall, O negative blood, if randomly transfused, has a serologic safety of about 99. Component therapy Treatment of specific hematologic abnormality often requires only a single component of whole blood. Blood banks reduce the whole blood received from donors to a variety of components. The available products include whole blood, red blood cells, white blood cells, platelet concentrates and plasma in several forms. When it is used within 24 hours it is considered fresh, whole blood and after this time it is referred to as stored. In acute massive hemorrhage transfusion with one unit of whole blood raises the recipient’s hematocrite by 3%. Platelet concentrate Platelets are separated from one unit of blood and suspended in a small volume of the original plasma. Cryoprecipitate 0 This is a protein fraction removed from a unit of fresh frozen plasma that is thawed at 4 c. Plasma protein fraction Similar to albumin but contains additional protein molecules. Complications and risks of blood transfusion Hemolytic transfusion reactions Intravascular hemolytic transfusion reactions; are potentially life threatening reactions that can occur by blood transfusion. Pathophysiology During hemolytic transfusion reaction all donor cells hemolyze, leading to hemoglobinemia, hemoglobinuria and renal failure. These reactions also activate the complement system with subsequent release of vasoacative amines causing hypotension. Treatment ƒ Stop transfusion immediately ƒ Administration of fluids and diuresis with mannitol or frusemide ƒ Transfused blood with patients blood sample should be sent for analysis ƒ Sodium bicarbonate may prevent precipitation of hemoglobin in the renal tubules ƒ Steroids may ameliorate the immunologic consequences. Transfusion reactions from mismatches involving the Rh system or minor antibodies usually induce extravascular hemolysis, since these reactions occur slowly, serious complications do not often develop. Non-hemolytic transfusion reaction Non-hemolytic reaction may occur after transfusions. Allergic reaction: occurs in 2-3% of all transfusion and manifests by urticaria and rashes. Other complications: Complications that can occur with massive transfusion include • Citrate toxicity • Acidosis • Hyperkalemia N. B:- As blood transfusion is accompanied by various complications mentioned above, the decision to transfuse should only be made when it is believed to be life saving. What factors determine the need for blood transfusion in patients with chronic blood loss or chronic anemia? But in addition to this, the patient’s pre-operative situation should be well evaluated so as to make the patient able to withstand the stress of surgery. Factors which make the patient high risk for surgery should be controlled as much as possible. Also, the patients’ postoperative course highly depends on the postoperative care given, and anticipation with early diagnosis and management of postoperative complications. General consideration Preoperative evaluation should include a general medical and surgical history, a complete physical examination and laboratory tests. The most important laboratory tests are: • Complete blood count • Blood typing and Rh-factor determination • Urinalysis • Chest x-ray Further laboratory tests should be performed only when indicated by the patients’ medical condition or by the type of surgery to be performed. Patients with heart disease should be considered high-risk surgical candidates and must be fully evaluated. The perioperative monitoring, induction, and maintenance techniques of anesthesia, and post – operative care can be tailored to the specific cardiovascular diseases. Pulmonary system The following respiratory tract problems make patients high risk for surgery; • Upper airway infections • Pulmonary infections • Chronic obstructive pulmonary diseases: chronic bronchitis, emphysema, asthma Elective surgery should be postponed if acute upper or lower respiratory tract infection is present. If emergency surgery is necessary in the presence of respiratory tract infection, regional anesthesia should be used if possible and aggressive measures should be taken to avoid postoperative atelectasis or pneumonia. Renal system Renal function should be appraised • If there is a history of kidney disease, diabetes mellitus and hypertension • If the patient is over 60 years of age • If the routine urinalysis reveals proteinuria, casts or red cells It may be necessary to further evaluate renal function by measuring creatinine clearance, blood urea nitrogen and plasma electrolyte determination.

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In the cortex examine the germinal centers and the dark surrounding zone within the lymphatic nodules 200mg fluconazole. The dark zone surrounding the germinal center is composed of densely packed small and medium-sized lymphocytes purchase fluconazole 150mg, separated from each other by layers of flattened pale- staining reticular cells generic 200mg fluconazole fast delivery. Under high magnification the germinal center of the Germinal center follicle may be observed to contain abundant lymphocytes. Note the activated B cells, which have a large centrally located nucleus and prominent nucleolus surrounded by a relatively narrow rim of strongly basophilic cytoplasm. Within the paracortex, identify the postcapillary venules lined by unusual cuboidal endothelial cells. The postcapillary venules are the site of entrance of B and T lymphocytes into the parenchyma of the lymph node. The T cells remain in the thymic dependent cortical zone and the B cells migrate to the nodular regions. The medullary cords are more cellular and consist of reticular cells, lymphocytes, macrophages, and plasma cells. Plasma cells have abundant, very basophilic cytoplasm, a prominent Golgi zone, and an eccentric nucleus whose chromatin has a "cartwheel" appearance. The functional blood-thymus barrier consists of epithelial reticular cells, their basal laminae, and endothelial cells joined by tight junctions. This barrier keeps antigens in blood vessels from entering the thymus, preventing reaction with developing T-cells. Thinner connective tissue partitions extend from the capsule and divide the thymic parenchyma incompletely into many angular thymic lobules, most of which are characterized by a peripheral dark cortex and a central paler medulla. At higher magnification, the cortex may be seen as a dense layer of closely packed cells, mainly thymocytes. The fairly sharp demarcation of heavily stained small thymocytes in cortex is more obvious than in the medulla. It is the round nuclei of these small thymocytes with very condensed chromatin that impart to the cortex a deeply stained appearance in this H&E preparation. Careful examination of the parenchyma reveals larger, paler cells whose nuclei have a loose chromatin network and one or more prominent nucleoli, the epithelial-reticular cells. Fewer of these epithelial cells are noticeable in the cortex because they are obscured by the numerous thymocytes. Epithelial reticular cells The medulla contains the same types of cells as the cortex but in different proportions. In the medulla, the thymocytes are reduced in number and the epithelial-reticular cells are much more prominent. Most of them have a deeply eosinophilic hyaline central mass surrounded by Hassall’s corpuscle large concentrically arranged, epithelial-reticular cells. Unlike lymph nodes, the thymus is not interposed in the lymph circulation and has no afferent lymphatic vessels. As seen on the preceding slide, in childhood (from birth to 10 years of age) the thymus consists of closely crowded lobules of thymic tissue with thin connective tissue capsule and septa. At puberty (from about 11 to 15 years), the thymic parenchyma remains prominent but the interlobular septa become broader. Then the thymus begins to decrease in size, fat begins to appear, and changes known as "age involution" occur. From about 21 to 45 years, the adipose tissue becomes increasingly prominent and occupies a larger area than the parenchyma of the thymus. The red pulp is the site of blood filtration and the white pulp is lymphoid tissue that responds to blood-borne antigens. There is a dense connective tissue capsule that sends conspicuous trabeculae to partially subdivide the organ. Lymphoid nodules with or without germinal centers and with prominent eccentric central arterioles (called “central arteries”) may be observed randomly distributed throughout the splenic pulp. Look for the penicilli (short, straight arterioles that branch from the central artery and enter the red pulp). These penicilli branch into capillaries surrounded by accumulations of reticular cells and macrophages and known as "ellipsoids" (or "sheathed capillaries”). Germinal center with central artery Between the white pulp and the red pulp is the near the 6 o’clock position marginal zone, a vascular region that is devoid of sinuses. The region is the site of immunological activities due to the presence of numerous blood antigens 45 The remainder of the spleen consists of red pulp and is composed of sinusoids (modified blood vessels) and splenic cords (of Billroth). The latter are cellular regions organized as plates of loose lymphatic tissue separating the sinusoids. It is not always possible to distinguish Billroth cords from the sinusoids, as is evident in this preparation where the sinusoids are partially collapsed. The lining cells of these sinusoids are elongated endothelial cells with tapered ends that lie parallel to the long axis of the vessel. In cross sections of sinusoids, therefore, the lining reticular cells are cut transversely and appear as cuboidal blocks arranged loosely in a circle, with intervening gaps. In section, the membrane may be seen as a succession of black points or short lines of silver-impregnated substance. The cardiovascular system is composed of the heart and a continuous system of blood vessels including arteries, arterioles, capillaries, venules, and veins. The innermost layer is the tunica intima, which includes a single layer of cells lining the lumen called the endothelium. There are important histological differences in the composition of these layers within each component of this system, which will be explored later in this lab. Valve Ventricle Atrium #17 Heart, Monkey, Sagittal Section (Mallory-Azan) The epicardium includes a layer of simple squamous epithelium called the mesothelium and underlying supportive connective tissue. The epicardium is the outermost layer surrounding the heart, and is comparable to the tunica adventitia of vessels. In the region of the atrium the epicardium contains fatty connective tissue and vessels of the coronary circulation. The distribution of blue-staining collagen fibers reveals the fascicle organization of the myocardium, which is comparable to the tunica media. In areas where muscle 47 fascicles are longitudinally sectioned, note the intercalated discs which appear as red-staining step-like lines perpendicular to the long axis of the fiber. The endocardium contains an endothelium on the free surface and underlying supportive connective tissue. Conduction continues through the atrioventricular bundle of His and into Purkinje fibers of the ventricles. Purkinje fibers are hypertrophied cardiac muscle fibers that are specialized for conducting an impulse rather than for contraction. They contain one or two nuclei, centrally situated in a pale staining mass of sarcoplasm that is rich in mitochondria and glycogen. Major branches of the bundle of His lie outside the myocardium in the subendocardium, as seen on the right side of this slide. Purkinje fibers traverse the myocardium where the terminal From left to right: muscle fiber, connective tissue, branches merge into muscle fascicles.

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The neonatal death reflects not only the quality of care available to women during pregnancy and childbirth but also the quality of care available 7 Pediatric Nursing and child health care to the newborn during the first months of life order 200 mg fluconazole amex. Approximately 80 % of infants who die within 48 hours of birth weigh less than 2500 g buy discount fluconazole 150mg on-line. Post-natal mortality rate: - The number of deaths over 28 days but under one year of age per 1000 live births cheap 150 mg fluconazole otc. Infant mortality rate: - The number of infant under one year of age dies per 1000 live births. The primary cause is immaturity and the second leading cause is gastroenteritis, which can be prevented by putting the newborn immediately with the mother and advocating breast-feeding. Child mortality rate: - The number of deaths between 1 and 4 years in a year per 1000 children. This rate reflects the main environmental factors affecting the child health, such as nutrition, sanitation, communicable diseases and accidents around the home. It is a sensitive indicator of socioeconomic development in a community and may be 25 times higher in developing countries compared to developed countries. The reasons why they need special health care are: • Large numbers: constitute 15 – 20% of population in developing countries. The major causes of death in this group are due to malnutrition and infection, both preventable. C) Antenatal and deliver care: Every child begins as a fetus, and the months before delivery are some of the most important in his life. Pregnant mothers should be checked regularly and advised on their nutrition and any other difficulties they have. Finally, skilled help during labor and delivery will provide the final step for a good start in life. These methods of primary prevention are available and effective and should be given to every child. Some of these traditional practices are good for health, such as breast feeding or the acceptance of modern medicine, should be supported. Those traditional practices and beliefs, which are bad (cutting of uvula, female genital mutilation etc ) need to be gradually changed. This is another important area in which health workers can have a strong influence in improving health. Discuss the components of safe motherhood that can contribute to the reduction of neonatal morbidity and mortality. B) History of the present illness: this is a chronologic description and duration of the chief complaint. We try to answer the following questions; 13 Pediatric Nursing and child health care • Duration of disease onset • Severity • Aggravating and alleviating factors • Associated symptoms • Any treatment and response to treatment • History of contact with similar illness • Relevant pediatric history (like history of immunizations) related to chief complaints or history present illness C) Past medical history: this is made up of the illness the patient has had in the past. Past medical history section of pediatrics contains (Past illness, child hood illness, Prenatal history, birth history). Find out if your patient has been hospitalized previously and for what conditions. Do the symptoms he/she has now resemble the one he had in connection with these past conditions, if so then they might be due to the same illness. If a child has a rash now which resembles measles you do not have to worry about this condition if he has already had measles or if he has been immunized against measles. D) Social and family history: The social history should include the parents’ occupation as 14 Pediatric Nursing and child health care well as the current living condition. You may have to educate a poor mother with malnourished baby that the best treatment for her baby is to be breast-fed exclusively till the age of one or more. If a mother feeds the baby food containing unbilled water the baby may get diarrhea. E) Immunization status: Immunization is a way of protecting children against the major diseases of childhood, which harm, cripple or kill thousands of children. Ask the mother about immunization status and if he/she is not properly immunized, take the opportunity of a minor illness to prevent major diseases by advice and vaccination. No proper history can be obtained without observation of the child and the mother. Some rules in history taking: Be an intelligent observer (while you are waiting for the undressing of the child or while you are taking with the mother) Situation your action in history taking The very sick child try to find out quickly what is causes 15 Pediatric Nursing and child health care The Symptoms of disease (e. See how the proposed illness affects the general wellbeing or growth of the child. Listen to the mother’s description of the complaints carefully and get the main symptoms. This is best done by looking at the weight chart which the mother preferably should have and bring to outpatients’ department at every visit. In the child, however, there should be increased emphasis on the symptoms related to the respiratory, gastrointestinal, and genitourinary systems. The high incidence of symptoms and diseases related to these symptoms obligate the interviewer to focus in this area. To get the important points: The patient usually comes with his mother and the task is to pick out from all the different information the mother is giving what is important. To examine the whole body we start with the head and end at feet in older children and adults. In order not to frighten small children it is best to examine things that are uncomfortable or frightening to them last so as not to loose their cooperation. This means the last thing to do in a child is auscultation of the heart, inspection of the ears with an auriscope and inspection of the throat with a throat stick. We use our eyes, ears and hands in addition to a few special items of equipment to perform the physical examination. General appearance: This is what you observe while examing your patient The mental state of the patient • is he acting normally? The general physical state of the patient • general state of health • weight and body build • colors • respiration • signs of dehydration • edema b. Vital signs:- These are: • Temperature • Pulse rate • Respiratory rate • Blood Pressure 19 Pediatric Nursing and child health care The temperature: All sick children should have their temperature measured (rectally, orally, and axially) The normal temperature is about • • 37 C. A temperature below 36 C is abnormally low and may be a sign of infection in a small baby. When there is a fever it usually means an infection is present and you must try to locate the site of the infection and decide whether it needs treatment and with what. The pulse:- The pulse can be felt and count in children radically for fifteen seconds multiply by four. In the infant it is sometimes easiest to count the heart rate with the stethoscope apically. Normal pulse rate: • babies 100-140 beats per minute • children 80-100 beats per minute In fever the pulse rate generally rises.

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