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If it is not focused clearly buy relafen 500 mg fast delivery, rotate lenses into the aperture with your index finger until the optic disc is clearly visible as possible buy 500 mg relafen free shipping. The hyperopic purchase 500mg relafen free shipping, or far- sighted, eye requires more‘’ plus’’(black numbers)sphere for clear focus; the myopic, or near-sighted, eye requires ‘’ minus’’(red numbers) sphere for clear focus. Now examine the disc for clarity of outline, color, elevating and condition of the vessels. To locate the macula, focus on the disc, then move the light approximately 2 disc diameters temporally. You may also have the patient look at the light of the ophthalmoscope, which will automatically place the macula in full view. The red-free filter facilitates viewing of the center of the macula, or the fovea. To examine the left eye, repeat the procedure outlined above except that you hold the ophthalmoscope in the left hand, stand at the patient’s left side and use your left eye. If the patient has a refractive error, try dialing up plus or minus lenses in the ophthalmoscope to bring the fundus into focus. It is difficult to see the fundus clearly so use a strong minus lens in the ophthalmoscope. Seat the baby on his mother’s lap, so that her hands restrain his arms and steady his head 2. Wrap the baby in a sheet or blanket, with his head on the examiners lap, and continue what you are going to do 3. In very difficult cases, it may be necessary to apply a drop of local anesthetic, and use a speculum to hold open the eyelids. Intra ocular pressure ƒ Should be measured in any patient with suspected glaucoma. Ahmed 5- Albert and Jakoboiec Principle and practice of ophthalmology 6- Up to date - (C) 2001 - www. At the end of the course the students are expected to have adequate knowledge about eyelid and lacrimal apparatus disease; the diagnosis and management of such diseases. Internal Hordeolum • a small abscess collection in the Meibomian glands • Caused by staphylococcus Symptoms pain, redness, swelling within eye lid Signs tender, inflamed mass within the eye lid. Treatment _ Hot compress _ Topical antibiotics _ If the above treatment fails, referral for. External Hordeolum /stye/ ¾ An acute staphylococcal infection of a lash follicle and its associated gland of zeis or moll. Chalazion - A chronic lipogranulomatous inflammatory lesion caused by blockage of meibomian gland orifices and stagnation of sebaceous secretion - Patient with acne roscea or seborrheic dermatitis are at increased risk of Chalazion formation which may be multiple or recurrent. Symptom ¾ Painless nodule within the eye lid Sign ƒ Non tender, firm, roundish mass within the eye lid. Molluscum contagiosum - Uncommon skin infection caused by a poxvirus - It is common in children and immunocompromized patient. Sign ¾ Single or multiple ¾ Pale, waxy ¾ Umblicated nodules ¾ If the nodule is located on the lid margin it may give rise to ipsilateral chronic follicular conjunctivitis and occasionally a superficial keratitis Treatment ¾ Expression ¾ Shaving and excision ¾ Destruction of the lesion by cauterization, cryotherapy E. Blepharitis ¾ a general term for inflammation of the eyelid ¾ Can be associated with conjunctivitis There are two main types of blepharitis 1. Entropion - Means the eyelids turn in wards then the eyelashes rub and damage the globe Treatment - Referral for surgical correction C. It can cause ambylopia if it is unilateral Treatment - Referral for surgical correction 31 3. Treatment - Hot compression - Systemic antibiotic -Incision and abscess drainage may be required Complication - Preseptal cellulitis - Orbital cellulitis Chronic dacryocystitis Symptoms - Tearing - Swelling over the medial aspect of the eye - Mucoid or purulent discharge with pressure on the lacrimal sac area. Preseptal cellulitis Definition: it is infection of the tissues anterior to the orbital septum Symptom - No visual reduction - Mild periorbital pain - Localized eyelid redness and swelling Sign - V/A is normal - Tender and hot eyelid - Ocular motility is normal Treatment - Ciprofloxacillin 500mg po bid for seven days. Orbital cellulitis An infection of orbital tissue posterior to the orbital septum. Symptom -Pain -Proptosis -Fever - Limited ocular movement -Visual reduction 33 Sign - V/A is reduced -Tender eye - Reduced to absent ocular motility Treatment It is an ophthalmic emergency that needs admission; intravenous antibiotics and close follow up. Ahmed 4 - Albert and Jacoboiec Principle And Practice Of Ophthalmology 5 - Up to date - (C) 2001 - www. They will also be alert on the differential diagnoses ranging from self liming to sight threatening cause of red eye. They will be given a clear description on how to approach patients with red eye and what to do at their level. At the end of the course, students are expected to differentiate self limiting condition from sight threatening conditions; and to act early. If they are neglected and mismanaged they will complicate to the extent of sight threatening condition. Those patients who will not have improvement in less than 48 hrs need referral to a better center for better management. Epidemiology The prevalence of each is different in pediatric and adult population. The vast majority of pediatric cases are bacteria, while in adult’s bacterial and viral causes are equally common. Bacterial conjunctivitis • Commonly caused by staphylococcus aureus, streptococcus pneumonia, Hemophilic influenza, and moraxella catarrhalis • S. Symptoms:- • Patients typically complain of redness and discharge in one eye; although it can also be bilateral. Sign: - • On examination, patients will typically have purulent discharge at the lid margins and in the corners of the eye. More purulent discharge appears within minutes of wiping the lids • Red eye – due to dilatation of superficial blood vessels as apart of inflammation 36 • Edema of the conjunctiva (chemosis) and eyelids swelling • Cornea is mostly clear; but if it is involved, there will be different degree of corneal opacity it is common special in untreated and delayed patients (see color plate14) Diagnosis - Mostly clinical - Gram stains Course - It lasts for 1 - 2 weeks and then it usually resolves spontaneously. Symptoms _ Red eye _ Severe and persistent itching of both eyes _ Mucoid eye discharge _ No visual reduction Signs _V/A is normal _ papillary reaction to hypertrophy on tarsal conjunctiva Treatment _ Cold compress _Vasoconstrictor-antihistamine like cromolyn sodium _ Topical steroid -Terracortril eye suspension Neonatal Conjunctivitis (Ophthalmia Neonatorum) Defn: is conjunctivitis in a newborn (in the first 28 days of life) Etiology Gonococcus and Chlamydia are the commonest cause of which gonococcal is most serious Symptoms - profuse thin to thick purulent eye discharge Sign - purulent eye discharge, eye lids are swollen - If cornea is involved, ulcer, scarring, lately cornea will shrink. Treatment - It is sight threatening condition that needs systemic antibiotic and close follow up in better ophthalmic center - Start with tetracycline eye ointment 3-4 times a day - Urgent referral to ophthalmic center for further evaluation and management 38 Prevention - The eye lids should be cleaned with saline swabs as soon as the head was born and before the infant‘s eyes opened. The diagnosis of such diseases need experienced ophthalmic worker, appropriate instruments and especial diagnostic tests and procedures. Their visual out come highly depends on the time interval between onset of the disease and initiation of treatment and subsequent close follow up. Symptoms - Painful red eye - Sudden reduction of vision - Rapid progressive visual impairment. Symptoms - Painful disorder-typically a constant severe boring pain that worsens at night or in the early morning hours and radiates to the face and 42 periorbital region. To give a general over view on the burden of blindness on global and country levels 2. To give a clear idea on the disease that have been launched by vision 2020 to control disease 4. The hope is that by the year 2020 most of the avoidable blindness in the world should be eliminated, so that everyone in the world except those with untreatable and unavoidable disease should have a visual acuity of 20/20 by the year 2020. The three main components (priorities) of Vision 2020 are 1-human resources development 2- Infrastructure and appropriate technology 3- Disease control (cataract, trachoma, onchocercaisis, childhood blindness, refractive error glaucoma and low vision). The result of these two factors means that the population aged over 60 years will double during the next 20 yrs from approximately 400 million now, to around 800 million in 2020.

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Exclusion of this group would provide a partial (and probably biased) view of the overall occurrence of resistance order relafen 500 mg line. In some countries order relafen 500 mg mastercard, policy-makers are primarily interested in knowing the overall burden of resistance discount 500 mg relafen free shipping, regardless of treatment history. The following approaches were used to obtain combined estimates of drug resistance: • For settings reporting only combined cases, we took the data as reported by the national authorities. Final data from surveys in Colombia (1999) and Venezuela (1998–1999) are included, whereas only preliminary data on partial samples were included in the previous report. In previous reports, England and Wales, Northern Ireland, and Scotland submitted data separately. We have remained as consistent as possible with regard to area divisions in order to allow interpretation of trends, thus England, Wales and Ulster are combined for trend analysis, and Scotland remains separate. Additionally, the two data points for Argentina are not comparable because two different sampling schemes were applied. Final data from Ecuador and Honduras were not available at the time of analysis for this report, and results should be considered preliminary. The two can loosely be differentiated by the proportion and type of the population surveyed, the length of the intake period, and the frequency with which the process is repeated. Surveillance, in this report, refers to either continuous or sentinel surveillance. Surveys are periodic, and reflect the population of registered pulmonary smear- positive cases. Depending on the area surveyed, a cluster sampling technique may be adopted, or all diagnostic units included. While some countries, such as Botswana, repeat surveys every 3–5 years, for the purposes of this report they are considered as repeated surveys and not surveillance. In both survey and surveillance settings, the coverage area is usually the entire country, but in some cases subnational units are surveyed. Large countries, such as China, India, the Russian Federation and South Africa, tend to survey large administrative units (e. Some countries have opted to limit surveys or surveillance to metropolitan areas, as in the case of Democratic Republic of Congo, Serbia and Montenegro, and Spain. And some countries have restricted surveys to subnational areas because of the remoteness of certain provinces or to avoid conflict areas. This report includes survey data from 39 countries or geographical settings and surveillance data from 38 countries or geographical settings. Ideally, separate sample sizes should be calculated for new cases and previously treated cases. However, the number of sputum-positive previously treated cases reported per year is usually small and, the intake period needed to achieve a statistically adequate sample size would generally be too long. Therefore, most countries have obtained an estimate of the drug resistance level among previously treated cases by including all previously treated cases who present at centres during the intake period. While this may not provide a statistically adequate sample size, it can nevertheless give a reasonable estimate of drug resistance among previously treated cases. Sampling strategies for monitoring of drug resistance include: • countrywide, continuous surveillance of the population; • surveys with sampling of all diagnostic centres during a specified period; • surveys with randomly selected clusters of patients; • surveys with cluster sampling proportional to the number of cases notified by the diagnostic centre. In surveillance settings, a combination of smear and culture was used for initial diagnosis. The majority of laboratories used Löwenstein-Jensen (L-J) culture medium, and some used Ogawa medium. Drug resistance tests were performed using the simplified variant of the proportion method on L-J medium, the absolute concentration method, the resistance ratio method,60,61 or the radiometric Bactec 460 method. Resistance was expressed as the percentage of colonies that grew on critical concentrations of the drugs tested (i. The criterion used for drug resistance was growth of 1% or more of the bacterial population on media containing the critical concentration of each drug. Proficiency testing and quality control of survey results are two components of externala quality assurance. The percentage of isolates sent for checking is determined before the beginning of the survey. Additionally, there are now efforts to standardize the panels circulated to countries for easier interpretation of results between countries and over time. It was recommended that special groups likely to have higher levels of resistance, e. In almost all settings, with the exception of Australia, Kinshasa, Democratic Republic of Congo, and Scotland, data were divided by treatment status. In some European countries, “unknown” was a category of treatment status; though this category is not displayed individually the cases are captured in the combined column. In geographical areas where people may be reluctant to reveal treatment status, verification of treatment status plays a particularly important role. All data files and epidemiological profiles have been returned to countries for verification before publication. The Global Project requests that survey protocols include a description of methods used for the quality assurance of data collection, entry, and analysis. However, to date there has been no systematic procedure to ensure that the methods described are actually employed at the country level. The data checking was not restricted to the third report, but included also the first and second reports. Inconsistencies and errors have been corrected if the available evidence allowed it. Where the analysis of the trends showed irregularities, verification was requested from the reporting parties. Arithmetic means, medians and ranges were determined as summary statistics for new, previously treated, and combined cases, for individual drugs and pertinent combinations. For geographical settings reporting more than a single data point since the second report, only the latest data point was used for the estimation of point prevalence. Chi-squared and Fisher exact tests were used to test the null hypothesis of equality of prevalences. Ninety-five percent confidence intervals were calculated around the prevalences and the medians. Reported notifications were used for each country that conducted a representative nationwide survey. For surveys carried out on a subnational level (states, provinces, oblasts), information representing only the population surveyed is included where appropriate. In order to be comprehensive, all countries and settings with more than one data point were included in this exercise; thus some information from the second phase of the global project is repeated. In geographical settings where only two data points were available since the start of monitoring, the prevalences were compared through the prevalence ratio (the first data point being used as the base for comparison), and through error bar charts, representing the 95% confidence interval around the prevalence ratio. For settings that reported at least three data points, the trend was determined visually as ascending, descending, flat or “saw pattern”. Where the trend was linear, the slope was tested using a chi-squared test of trend. The variables included were selected in function of their presumed impact on resistance and their potential for retrieval.

Hypertonic glucose buy cheap relafen 500mg on line, along with crystalline 222 Basic Clinical Nursing Skills aminoacids purchase 500 mg relafen free shipping, fats buy relafen 500 mg with amex, electrolytes, vitamins and trace elements is given through central vein access. The technique requires especial handling and management of the client and the most expensive method of feeding. It should be used only if the intestines do not work adequately, if the client has an obstruction or has fistula, if the bowel rest is required. Implantable vascular access devices are placed under the skin in a subcutaneous pocket and a surgically tunneled silicone catheter is place in the cephalic or external jugular vein and threaded to the superior vana cava. Planning/Objective Setting - To provide a nitrogen source for clients unable to ingest protein normally. Teach Valsalva’s Maneuver for use during catheter insertion procedure if client does not have a cardiac disorder. Position client in head-down position with head turned to opposite direction of catheter insertion size. Cleanse insertion area with Betadine solution (if allergic to Betadine solution, use 70% isopropyl alcohol). But if unconscious, place in prone position with head over the edge of the bed or head lower than the body. Measure the tube from the tip of the nose up to the ear lobe and from the bridge of the nose to the end of the sternum. If required, and continue the process until the returned fluid becomes clear and the prescribed solution has been used. An electric suction machine The continues method is indicated when it is absolutely necessary and desirable to keep the stomach and duodenum empty and at rest. Draw plunger back to with draw the fluid collect specimen, If needed 236 Basic Clinical Nursing Skills 9. Enema Enema: is the introduction of fluid into rectum and sigmoid colon for cleansing, therapeutic or diagnostic purposes. Purpose: • For emptying – soap solution enema • For diagnostic purpose (Barium enema) • For introducing drug/substance (retention enema) Solution used: 1. Epsum salt 15 gm – 120 gm in 1,000 ml of H2O 237 Basic Clinical Nursing Skills Mechanisms of some solutions used in enema 1. Soap solution: increases peristalsis due to irritating effect of soap to the lumenal mucosa of the colon. Classified into: • Cleansing (evacuation) • Retention • Carminative • Return flow enema Cleansing enema Kinds: 1. High enema ƒ Is given to clean as much of the colon as possible ƒ The solution container should be 30-45 cm about the rectum 2. Low enema ƒ Is administered to clean the rectum and sigmoid colon only 238 Basic Clinical Nursing Skills Guidelines o Enema for adults are usually given at 40-43 c and for children at o 37. Colonoscopy ƒ To remove feces prior to a surgical procedure or a delivery ƒ For incontinent patients to keep the colon empty ƒ For diagnostic test E. Principles: ƒ Is given slowly by means of a rectal tube ƒ The amount of fluid is usually 150-200 cc ƒ Cleansing enema is given after the retention time is over ƒ Temperature of enema fluid is 37. Procedure Similar with the cleansing enema but the enema should be administered very slowly and always be preceded by passing a flatus tube 242 Basic Clinical Nursing Skills Note 1. Kinds of solution used to supply body with fluid are plain H2O, normal saline, glucose 5% sodabicarbonate 2-5% 6. Asafetida in 1:1000 to relieve distention Procedure • Insert the tube like the cleansing enema • The client lies on the bed with hips close to the side of the bed (client assumes a right side lying position for siphoning) • Open the clamp and allow to run about 1,000 cc of fluid in the bowel, then siphon back into the bucket • Carry on the procedure until the fluid return is clear Note: • The procedure should not take > 2 hrs • Should be finished 1 hr before exam or x-ray – to give time for the large intestine to absorb the rest of the fluid • Give cleansing enema ½ hr before the rectal wash out • Allow the fluid to pass slowly Amount of solution • 5-6 liters or until the wash out rectum fluid becomes clear Passing a Flatus Tube Purpose • To decrease flatulence (sever abdominal distention) • Before giving a retention enema 244 Basic Clinical Nursing Skills Procedure • Place the patient in left. Lateral position • Lubricate the tube about 15 cm • Separate the rectum and insert 12-15 cm in to the rectum and tape it • Connect the free end to extra tubing by the glass connector • The end of the tube should reach the (tape H2O) solution in the bowel • The amount of air passed can be seen bubbling through the solution (a funnel may be connected to free end of tube and placed in an antiseptic solution in bowel) • Teach client to avoid substances that cause flatulent • Leave the rectal tube in place for a period or no longer than 20 minute – can affect the ability to voluntarily control the sphincter if placement is prolonged • Reinsert the rectal tube every 2-3 hrs if the distention has been unrelieved or reaccumulates – allows gas to move in the direction of the rectum. Urinary Catheterization Definition of catheterization: Is the introduction of a tube (catheter) through the urethra into the urinary bladder • Is performed only when absolutely necessary for fear of infection and trauma 245 Basic Clinical Nursing Skills Note. Determine appropriate catheter size - are determined by diameter of lumen - graded on French scale or number. Determine appropriate catheter length by the clients gender • For adult male – 40 cm catheter • For adult females – 22 cm catheter 4. Select appropriate balloon size • 5 ml – for adults • 3 ml – for children Catheterization Using a straight catheter Purpose • To relieve discomfort due to bladder distention • To assess the residual urine • To obtain a urine specimen • To empty the bladder prior to surgery Equipment I. Clean • Waste receiver • Rubber sheet • Flash light • Measuring jug • Screen Procedure • Prepare the client and equipment for perennial wash • Position the patient – dorsal recumbent (pillows can be used to elevate the buttocks in females). Ask the client to take deep breaths - relaxes the external sphincter (slight resistance is normal) • Dorsal Recumbent Female - for a better view of the urinary meatus and reduce the risk of catheter contaminate. Male- allows greater relaxation of the abdominal and perennial muscles and permits easier insertion of the tube. Purpose • To manage incontinence • To provide for intermittent or continuous bladder drainage and irrigation • To prevent urine from contacting an incision after perineal surgery (prevent infection) • To measure urine out put needs to be monitored hourly Procedure • Explain the procedure to the patient • Prepare the equipment like: Retention catheter Syringe ⇐ Sterile water ⇐ Tape ⇐ Urine collection bag and tubing • After catheter insertion, the balloon is inflated to hold the catheter in place with in the bladder. Key Terminology ampule ohpthalimic parentral brand name pharmacokinectics trade name capsule pharmacology transdermal chemical name potentiating toxicity dosage prescription transfusion enteric coated synergistic vial generic name otic z-track infusion tablet 253 Basic Clinical Nursing Skills medication topical Pharmacology is the study of drugs. Therapeutic agents are drugs or medications that, when introduced in to living organism, modify the physiologic functions of that organism. Drug Metabolism Drug metabolism in the human body is accomplished in four basic stages: absorption, transportation, biotransformation, and excretion. For a drug to be completely metabolized, it must first be given in sufficient concentration to produce desired effect on body tissues. Route of Absorption Drugs are absorbed by the mucus membranes, the gastro intestinal tract, the respiratory tract, and the skin. The mucus membranes are one of the most rapid and effective routes of absorption because they are highly vascular. The rate of absorption depends on the pH of the stomach’s contents, the food contents in the stomach at the time of ingestion, and the presence of disease conditions. Most of the drug concentrate dissolves in the small intestine where the large 254 Basic Clinical Nursing Skills vascular surface and moderate pH level enhance the process of breaking down the drug. Transportation The second stage of metabolism refers to the way in which a drug is transported from the site of introduction to the site of action. When the body absorbs a drug, a portion of the drug binds to plasma protein and may compete with other drugs for this storage site. As the free drug moves from the circulatory system, it crosses cell membranes to reach its site of action. Lipid-soluble drugs are distributed to and stored in fat and then released slowly in to the bloodstream when drug administration is discontinued. The amount of the drug that is distributed to body tissues depends on the permeability of the membranes and blood supply to the absorption area. Biotransformation:- The third stage of metabolism takes place as the drug, which is a foreign substance in the body; is converted by 255 Basic Clinical Nursing Skills enzymes into a less active and harmless agent that can be easily excreted. Most of this conversion occurs in the liver, although some conversion does take place in the lungs, kidney plasma and intestinal mucosa Excretion:- The final stage in metabolism takes place when the drug is changed in to an inactive form or excreted from the body. The kidneys are the most important route of excretion because they eliminate both the pure drug and the metabolism of the parent drug.

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