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Historically generic malegra dxt plus 160 mg with mastercard, antireflux surgery was recommended only for patients with refractory or complicated gastroesophageal reflux buy generic malegra dxt plus on-line. The rapid postoperative recovery seen with laparoscopic surg- ery is now feasible following antireflux procedures malegra dxt plus 160 mg fast delivery. Rather than focus- ing therapy only on controlling symptoms purchase malegra dxt plus online, modern treatment aims to eliminate symptoms, improve a patient’s quality of life, and institute a lifelong plan for management. Surgical treatment was significantly more effective in improving symp- toms and endoscopic signs of esophagitis for as long as 2 years. Other longitudinal studies report good to excellent long-term results in 80% to 93% of surgically treated patients (Table 12. Barrett’s oesophagus: effect of antireflux surgery on symptom control and development of complications. Conservative treatment versus antireflux surgery in Barrett’s oesoph- agus: long-term results of a prospective study. Long-term results of classic antireflux surgery in 152 patients with Barrett’s esophagus: clinical, radiologic endoscopic, manometric, and acid reflux test analysis before and late after operation. Swallowing Difficulty and Pain 221 Indications: Antireflux surgery should be considered in patients in whom intensive medical therapy has failed. Antireflux surgery also should be offered to patients whose symptoms recur immedi- ately after stopping medications and who require long-term daily medication. Many patients want to avoid the cost, inconvenience, and side effects of long-term medication and want to preserve their quality of life. However, patients with these complications usually have more severe disease, require more intensive medical therapy, and are referred for surgical evaluation. Ambulatory pH monitoring has been thought to provide the most objective way to select these patients for surgery, but an abnormal pH study does not correlate well with symptom relief following antireflux surgery. Preoperative Evaluation: The preoperative evaluation should both justify the need for surgery and direct the operative technique to opti- mize outcome. Equally important is its use in assessing esophageal body pressures and identifying individuals with impaired esophageal clearance who may not do as well with a 360-degree fundoplication. Advances in laparoscopic technology and technique allow the repro- duction of “open” procedures while eliminating the morbidity of an upper midline incision. Open antireflux operations remain indicated when the laparoscopic technique is not available or is contraindicated. Only a very experienced laparoscopic surgeon should attempt the minimally invasive approach in the presence of previous upper abdominal operation or prior antireflux surgery. In patients with normal esophageal body peristalsis, laparoscopic Nissen fundoplication (Fig. Thousands of laparoscopic Nissen fundoplication patients have been reported in the world litera- 222 J. The Toupet fundoplication may be best used in patients with impaired esophageal body peristalsis. Hiatal Hernias: Sliding and Paraesophageal Hernias Overview The majority of patients with hiatal hernia are asymptomatic, and the diagnosis often is made incidentally during investigation of other gas- trointestinal problems. It consists of a simple herniation of the gastroesophageal junction into the chest. This is the most common hiatal hernia and is frequently diagnosed in women and in the fifth and sixth decades of life. Swallowing Difficulty and Pain 223 hiatus while the gastric fundus herniates alongside the esophagus, through the hiatus, and into the chest. As in Case 3, paraesophageal hernias are found predomi- nantly in older individuals. Diagnosis When symptoms are present, sliding hernias have a different pre- sentation from paraesophageal hernias. Paraesophageal hernias tend to produce more dysphagia, chest pain, bloating, and respiratory prob- lems than do sliding hernias. Sutyak Treatment Because a hiatal hernia is a purely mechanical abnormality, nonop- erative treatment does not exist. In contrast, a significant number of patients with type I hiatal hernias are asymptomatic and remain so throughout the remainder of their life. Therefore, the presence of a sliding (type I) hiatal hernia alone does not mandate intervention. However, patients with a type I hernia and gastroesophageal reflux, chest pain, dysphagia, regurgitation, or other symptoms referable to their hernias should undergo symptom-specific workup and may be best treated with an operative repair. Occult gastrointestinal bleeding is a complication of hiatal hernia thought to result from the mechanical trauma of the stomach moving into and out of the chest, causing subtle erosions in the stomach that slowly bleed and lead to anemia. The operation can be performed through the chest or abdomen and via “open” or minimally invasive techniques. Routine addition of a fun- doplication to the repair of the other three types of hiatal hernia is con- troversial. Barrett’s Esophagus Overview Barrett’s esophagus is a condition in which the normal squamous epithelium of the esophagus is partially replaced by metaplastic columnar epithelium, placing patients at risk for developing adeno- carcinoma. Intestinal metaplasia (not gastric-type columnar changes) constitutes true Barrett’s esophagus, with a risk of progression to dys- plasia and adenocarcinoma. The estimated incidence of adenocarcinoma in patients with Barrett’s esophagus is 0. Only patients with specialized columnar epithelium are at an increased risk of developing Barrett’s adenocarcinoma. The presence of epithelial dysplasia, partic- ularly high-grade dysplasia, is a risk factor for adenocarcinoma, and the progression of specialized columnar epithelium to dysplasia and invasive carcinoma is well documented. Swallowing Difficulty and Pain 225 Diagnosis Heartburn, regurgitation, and—with stricture formation—dysphagia are the most common symptoms. Heartburn is milder than in the absence of Barrett’s changes, presumably because the metaplastic epithelium is less sensitive than squamous epithelium. The diagnosis often is suggested by the esophagoscopic finding of a pink epithelium in the lower esophagus instead of the shiny gray-pink squamous mucosa, but every case should be verified by biopsy. Radiographic findings consist of hiatal hernia, stricture, ulcer, or a reticular pattern to the mucosa—changes of low sensitivity and specificity. Treatment Treatment goals for patients with Barrett’s esophagus are relief of symptoms and arrest of ongoing reflux-mediated epithelial damage. Patients with Barrett’s have more severe esophagitis and frequently require more intensive therapy for control of reflux. Regardless of medical versus surgical treatment, patients with Barrett’s esophagus require long-term endoscopic surveillance with biopsy of columnar segments for progressive metaplastic changes or progression to dys- plasia. Esophagectomy, if performed with a low operative mortality, is indicated in patients with a diagnosis of high-grade dysplasia. Several studies have compared medical and surgical therapy in patients with Barrett’s esophagus. Current evidence suggests that neither medical nor surgical therapy result in regression of Barrett’s epithelium. There is evidence suggest- ing that antireflux surgery may prevent progression of Barrett’s changes and protect against dysplasia and malignancy. These are very strong data in support of the favorable impact of operative therapy on the natural history of Barrett’s esophagus. Squamous cell carcinoma is esti- mated to develop in approximately 5% of patients at an average of 20 years after initial diagnosis. Conservative treatment versus antireflux surgery in Barrett’s oesophagus: long-term results of a prospective study. Long-term results of Nissen fundoplication in reflux esophagitis without strictures. A comparison of three tech- niques of esophagectomy for carcinoma of the esophagus from one institution with a res- idency training program. Sutyak years earlier than in the general population and is associated with a worse prognosis, possibly due to delayed diagnosis. Diagnosis Patients typically describe dysphagia for solids and, to varying degrees, for liquids. Exacerbation of dysphagia may occur with inges- tion of cold liquids or during emotional stress. Recurrent respiratory infections, aspiration pneu- monia, and lung abscess also may be initial presentations.

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Both counseling and psy- tured and focus on interpersonal-relationship chotherapy can be short term and solution building purchase generic malegra dxt plus from india, self-insight order malegra dxt plus cheap, reflection purchase generic malegra dxt plus on line, and discussion directed buy 160mg malegra dxt plus, but psychotherapy more often is used (Vannicelli 1992). This might involve their acquiring job skills, developing hobbies, or rebuilding relationships. Group treatment can treatment of sexual abuse for patients during provide a sense that individuals are not alone substance abuse treatment. A helpful, straightforward handbook for seling, it should develop referral relationships patients is About Methadone (Lindesmith for outside diagnosis and treatment. Strategies to engage these patients in treatment ï Effects and side effects of addiction treatment are described in chapter 6. Both cravings types of education may involve presenting infor- ï Developing nonñdrug-related leisure activities mation about substance abuse and addiction to patients alone, in groups, or with their families. Question assumptions about alcohol and drug use, and clarify that such use undermines recovery. Involvem ent Holding sessions for several families can be cost The consensus panel believes that family effective, supportive, and mutually beneficial. The concept of ìfamilyî tion and allow participants to express their feel- should be expanded to include members of the ings and concerns. These continuing forums help secure family support for patient treatment and identify acute family problems needing focused therapy. Nunes and colleagues (1998b) staff and reserved for families with serious recommended that treatment providers ask problems with behaviors or attitudes that about the mental health and adjustment of contribute to patientsí addictions, which, if patientsí children and consider routine psychi- unchecked, might affect recovery. Dawe and referrals to community-based services often are colleagues (2000) reported improved needed, and the consensus panel urges that parentñchild relations and positive outcomes such connections be established. Family therapy for children with conduct problems after may be more effective for some patients than behavioral training that provided their parents individual counseling, group therapy, or family with improved parenting techniques. Child assessment stable, treatment focus on concerns about cus- requires trained personnel and may be unreal- tody, children, and parenting. A counselor who determines that Psychodynamic parenting groups take a more a patient is neglecting or abusing young children intensive approach, exploring topics such as is required to report the neglect or abuse. Counselors should incorporate appropriate assessment procedures, referrals, or treatment responses for violence. They might have to help Peer Support, or M utual-Help, patients remove themselves from dangerous situ- Program s ations. Counselors should have a broad view of domestic violence that includes female (to male) The most popular, widely used mutual-help aggression, same-sex physical and emotional models are 12-Step recovery programs, such abuse, and issues related to elder abuse. They are sources for social provide general didactic groups or seminars and support, peer identification, relapse preven- other resources addressing domestic violence. Members of sup- port groups gain strength and security from others who understand and share their con- Integrative cerns and who offer practical strategies for surviving ìone day at a time. Some patients, unable to handle rejection, have chosen not to return, others have chosen prematurely to taper from maintenance medication, and some have used this diffi- culty as justification to self-medicate. For information, contact the National Alliance of Methadone Advocates (212-595-6262 or www. Other Approaches Decreases in substance abuse among group participants have been associated with attend- In acupuncture, thin needles are inserted ing meetings frequently, obtaining a sponsor, subcutaneously at points on the body for thera- ìworkingî the 12 Steps, and leading meetings peutic purposes. Some believe that acupunc- (American Psychiatric Association 1995, 1996; ture can relieve pain, anxiety, and withdrawal Landry 1997). However, 12-Step groups are symptoms related to substance abuse, although not for everyone. Its use to treat opioid with- Patients should not be pressured to attend sup- drawal was first reported in 1973. Resistance to attendance should However, a National Institutes of Health be discussed and respected. Every effort consensus statement lists addiction as one con- should be made to help a patient find an dition for which acupuncture treatment might appropriate peer support program. Although the mechanism of acupunc- ative strategies have evolved to promote ture is not understood, some researchers have mutual-help programs, such as simulated meet- focused on the analgesic effects of opioid pep- ings to introduce patients to the language, cus- tides released during the procedure (National toms, and rules of groups. A useful manual is Relapse strategy to ensure that a severe relapse is Prevention W orkbook (Daley 2002). Relapse Prevention Strategies for M ultiple Substance Use Education about relapse is a key part of treat- Patients who abuse multiple substances may ment. Educational approaches should teach require modified relapse prevention strategies. Separate interventions drug cravings and slips to prevent full-blown may be necessary for each substance because relapses. Relapse prevention strategies often the associated risks of relapse are different for distinguish between slips and relapses, with each. For course, no level of opioid use should be con- example, a patient may associate heroin use doned, but when a relatively mild and isolated with socializing and cocaine use with alleviating episode occurs, the consensus panel recom- depression. Providing Com prehensive Care and M axim izing Patient Retention 137 Some researchers have noted that an absti- treatment for relapse prevention concluded nence violation effect may occur when a patient that these treatments, although studied for abstains from a substance but then relapses years, were ineffective (Conklin and Tiffany and possibly overuses it. W hen a slip or lapse occurs, the patientís self- Patient Follow up Strategies esteem can be lowered, which he or she may Patient followup and continuing care have been attempt to repair by continuing or increasing found to be critical to preventing relapse and substance use. The consensus panel by repeated exposures to an experience that believes that these discharges are, in many previously triggered drug use (Childress et al. Zanis and W oody many substance abuse (1998) found substantial increases in death treatment programs, fairly and rates among those involuntarily discharged for lends itself to such continued drug use. W hen discharge is unavoidable, it should complete abstinence be handled fairly and humanely, following pro- was not achieved (e. Treatment for other substance use and addiction should be offered to patients coping Reasons for Adm inistrative with dual addictions (see chapter 11). If all lence should be taken seriously, and interven- of these avenues are exhausted and a patient tions should be rapid. Staff should document must be discharged for inability to pay fees, problem behavior. To ensure that patients are and consistently enforce guidelines for patient not cut off abruptly from medication, some behavior. However, this may pre- tant factors in preventing administrative sent serious obstacles for many patients, espe- discharge. Training in interpersonal techniques 2003, the American Association for the to handle aggressive or upset patients in non- Treatment of Opioid Dependence released new provocative ways should be part of training for guidelines for addressing involuntary with- all staff. These problem should be to identify it, review the guidelines can be found at www. Preventing and Finding Dosing should not be a behavioral tooló patients should not be disciplined by having Alternatives to Adm inistrative their medication dosage decreased or withheld, Discharge nor should they be rewarded for good conduct by having their dosage increased. Programs Com m unicating program are encouraged to develop nonpunitive ways to rules clearly set limits and contain disruptive behavior. However, in some cases, involuntary discharge Including program rules in patient orientation becomes necessary. Involuntary dis- should include escalating warnings and specified charge should be done with the understanding consequences including referral. Some States have devel- schedules require medical determination (see oped regulations to guide this process. Staff members not directly involved with a dis- ciplinary action should conduct a review of Members of the consensus panel agree that that action. Participation the National Alliance of Methadone Advocates in these organizations helps empower patients (www. Advancement of Addiction Treatment Other benefits include practice in group inter- (www. Because patients should be educated about their treat- accreditation agencies are concerned with input ment and encouraged to participate in it. In from patients, such involvement by patients general, these advocacy groups are made up usually is viewed favorably by these agencies. Administrators use drug test results in response to quality assurance Development of requirements.

After the capsules are removed safe malegra dxt plus 160 mg, patients are promptly returned to normal fertility order malegra dxt plus with american express. The implant is surgically placed in the vitreous cavity of the eye and delivers therapeutic levels of ganciclovir for up to 32 weeks buy generic malegra dxt plus 160 mg online. Matrix-type implants are fabricated by physically mixing the drug with a polymer powder and shaping the mixture into various geometries (e order discount malegra dxt plus online. The total payload of a drug determines the drug’s physical state in a polymer: • Dissolved: the drug is soluble in the polymer matrix. A dissolved matrix device (also known as a monolithic solution) appears at a low payload. When the drug content occupies more than 30% volume of the polymer matrix, the leaching of drug particles results in the formation of pores or microchannels that are interconnected. Regardless of a drug’s physical state in the polymeric matrix, the release rate of the drug decreases over time. As release continues, molecules must travel a greater distance to reach the exterior of the implant and thus increase the time required for release (Figure 4. This increased diffusion time results in a decrease in the release rate from the device with time (Figure 4. Numerous equations have been developed to describe drug release kinetics obtainable with dissolved, dispersed, and porous-type matrix implants, in different shapes, including spheres, slabs and cylinders. Suffice to say here that in all cases, the release rate initially decreases proportionally to the square root of time: (Equation 4. Thus a reservoir system can provide constant release with time (zero-order release kinetics) whereas a matrix system provides decreasing release with time (square root of time-release kinetics). A summary of the drug release properties of reservoir and matrix nondegradable devices in given in Table 4. The decreasing drug release rate with time of a matrix system can be partially offset either by: • designing a special geometry that provides increasing surface over time (this strategy is used in the Compudose implant, described in Section 4. The initial diffusion of drug molecules leaves a drug- depleted polymeric zone with a length h, which increases with time. This event leads to an increase in diffusional distance over time System Release Mechanism Release Properties Release Kinetics Matrix Diffusion through a polymeric Drug release decreases with time Square root of time release “M t1/ matrix 2” 4. This particular design, consisting of a thin layer of the drug-containing matrix and a relatively thick drug-free inert core, minimizes tailing in the drug release profile. When this implant is placed under the skin of an animal, estradiol is released and enters into systemic circulation. This stimulates the animal’s pituitary gland to produce more growth hormone and causes the animal to gain weight at a greater rate. At the end of the growing period, the implant can be easily removed to allow a withdrawal period before slaughter. The Compudose implant is available with a thick silicone rubber coating (Compudose-400) and releases estradiol over 400 days, whereas one with a thinner coating (Compudose-200) releases the drug for up to 200 days. Once implanted in the animal’s ear, the implant delivers estradiol valerate at the rate of 504 µg cm−2 day−1/2 over a period of 16 days. Such systems are designed in an attempt to improve the “M t1/2” release kinetics of a matrix system, so that release approximates the zero-order release rate of a reservoir device. The mixture is blended with a cross-linking agent, which results in the formation of millions of individually sealed microreservoirs. The mixture is then placed in a silicone polymer tube for in situ polymerization and molding. Drug molecules initially diffuse through the microreservoir membrane and then through the silicone polymer coating membrane. This implant provides zero-order release kinetics, rather than square root of time-release kinetics. The two open ends of the implant do not affect the observed zero-order release pattern because their surface area is insignificant compared to the implant’s total surface area. The drug permeation through the polymer membrane occurs at a rate that is 20 times slower than that through the polymer matrix, thus diffusion through the membrane is rate-limiting, which again improves the matrix-type square root of time-release kinetics, so that the release is like the zero-order release rate of a reservoir device. Following implantation in the upper arm, a single rod of Implanon releases 3-ketodesogestrel at the rate of > 30 µg/day for up to 3 years. However, some fundamental limitations of such implants include: • The implants must be surgically removed after they are depleted of drug. Degradation can take place via: • bioerosion—the gradual dissolution of a polymer matrix; • biodegradation—degradation of the polymer structure caused by chemical or enzymatic processes. For example, natural polymers such as albumin may be used; such proteins are not only water-soluble, but are readily degraded by specific enzymes. The terms degradation, dissolution and erosion are used interchangeably in this chapter, and the general process is referred to as polymer degradation. Thus polymers used in biodegradable implants must be water-soluble and/or degradable in water. In bulk erosion, the entire area of polymer matrix is subject to chemical or enzymatic reactions, thus erosion occurs homogeneously throughout the entire matrix Accordingly, the degradation pattern is sometimes termed homogeneous erosion. In surface erosion, polymer degradation is limited to the surface of an implant exposed to a reaction medium. Erosion therefore starts at the exposed surface and works downwards, layer by layer. If water is readily able to penetrate the polymer, the entire domain of polymer matrix is easily hydrated and the polymer undergoes bulk erosion. On the contrary, if water penetration into its center is limited, the erosion front is restricted to the surface of the polymer matrix and the implant undergoes surface erosion. In practice, the polymer degradation occurs through a combination of the two processes. As for non-degradable polymeric implants, biodegradable polymeric implants are divided into two main types: • reservoir devices in which the drug is surrounded by a rate-controlling polymer membrane (such devices are particularly used for oral-controlled release—see Section 6. The drug release for biodegradable polymeric implants is governed not by diffusion through a membrane, but by degradation of the polymer membrane or matrix. If the rate of polymer degradation is slow compared to the rate of drug diffusion, drug release mechanisms and kinetics obtained with a biodegradable implant are analogous to those provided by a nonbiodegradable implant (therefore a reservoir system gives a zero-order release profile and a matrix system gives a square root of time release profile). After drug depletion, the implant subsequently degrades at the site of implantation and eventually disappears. However, in many cases, drug release takes place in parallel with polymer degradation. In such cases the mechanism of drug release is complicated as drug release occurs by drug diffusion, polymer degradation and/or polymer dissolution. The permeability of the drug through the polymer increases with time as the polymer matrix is gradually opened up by enzymatic/chemical cleavage. The references cited at the end of this chapter deal with the relevant mathematical treatments of this topic. The polymers are prepared from lactide and glycolide, which are cyclic esters of lactic and glycolic acids. Low molecular weight polymers (< 20,000 g/mol) are directly synthesized from lactic and glycolic acid via polycondensation. High molecular polymers (> 20,000 g/mol) are prepared via ring-opening polymerization (Figure 4. Variations in lactic acid:gycolic acid ratios, as well as molecular weights, affect the degree of crystallinity, hydrophobicity/hydrophilicity, and water uptake. Lactic acid-rich copolymers are more stable against hydrolysis than glycolic acid-rich copolymers. Polymer degradation generally takes place in four major stages: • Polymer hydration causes disruption of primary and secondary structures. Zoladex implants are indicated for use in the palliative treatment of advanced breast cancer in pre- and peri- menopausal women, in the palliative treatment of advanced carcinoma of the prostate and in the management of endometriosis, including pain relief and the reduction of endometriotic lesions. The release profile of goserelin from the implants has been well characterized during product development. The initial release was then followed by a lag period up to 4 days, in which there was a rapid decline in the plasma concentration of the drug. As water penetrates the polymer matrix and hydrolyzes the ester linkages, the essentially hydrophobic polymer becomes more hydrophilic. Extensive polymer degradation is followed by the development of pores or microchannels in the polymer matrix, which are visible by scanning electron microscopy (Figure 4. After the initial induction period required to initiate polymer degradation, drug release is accelerated thereafter by polymer degradation. In the above study this maintained the mean goserelin concentrations in the range of about 0.

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The skin over the pressure points is assessed for redness or breaks; the perineum is checked for soilage malegra dxt plus 160 mg amex, and the catheter is observed for adequate drainage buy malegra dxt plus 160mg mastercard. Special attention should be given to pressure areas in contact with the transfer board buy cheap malegra dxt plus 160mg on line. Pressure-sensitive areas should be kept well lubricated and soft with hand cream or lotion purchase 160mg malegra dxt plus. To increase understanding of the reasons for preventive measures, the patient is educated about the danger of pressure ulcers and is encouraged to take control and make decisions about appropriate skin care (Kinder, 2005). Because the patient has no sensation of bladder distention, overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder function. At an early stage, family members are shown how to carry out intermittent catheterization and are encouraged to participate in this facet of care, because they will be involved in long- term follow-up and must be able to recognize complications so that treatment can be instituted. The patient is taught to record fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics of urine, and any unusual sensations that may occur. The management of a neurogenic bladder (bladder dysfunction that results from a disorder or dysfunction of the nervous system) is discussed in detail in Chapter 11. As soon as bowel sounds are heard on auscultation, the patient is given a high-calorie, high-protein, high-fiber diet, with the amount of food gradually increased. The nurse administers prescribed stool softeners to counteract the effects of immobility and analgesic agents. Providing Comfort Measures A patient who has had pins, tongs, or calipers placed for cervical stabilization may have a slight headache or discomfort for several days after the pins are inserted. Patients initially may be bothered by the rather startling appearance of these devices, but usually they readily adapt to it because the device provides comfort for the unstable neck. The patient may complain of being caged in and of noise created by any object coming in contact with the steel frame of a halo device, but he or she can be reassured that adaptation to such annoyances will occur. The Patient in Halo Traction The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. A torque screwdriver should be readily available in case the screws on the frame need tightening. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The liner of the vest should not become wet, because dampness causes skin excoriation. Powder is not used inside the vest, because it may contribute to the development of pressure ulcers. If the patient is to be discharged with the vest, detailed instructions must be given to the family, with time allowed for them to return demonstrate the necessary skills of halo vest care (Chart 63-9). The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies are performed if a significant increase is noted. Patients remain at high risk for thrombophlebitis for several months after the initial injury. Patients with paraplegia or tetraplegia are at increased risk for the rest of their lives. Anticoagulation is initiated once head injury and other systemic injuries have been ruled out. Low-dose fractionated or unfractionated heparin may be followed by long- term oral anticoagulation (ie, warfarin) or subcutaneous fractionated heparin injections. Additional measures such as range-of-motion exercises, thigh-high elastic compression stockings, and adequate hydration are important preventive measures. Pneumatic compression devices may also be used to reduce venous pooling and promote venous 421 return. It is also important to avoid exter-nal pressure on the lower extremities that may result from flexion of the knees while the patient is in bed. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Interruption in the reflex arcs that normally produce vasoconstriction in the upright position, coupled with vasodilation and pooling in abdominal and lower extremity vessels, can result in blood pressure readings of 40 mm Hg systolic and 0 mm Hg diastolic. Orthostatic hypotension is a particularly common problem for patients with lesions above T7. In some patients with tetraplegia, even slight elevations of the head can result in dramatic changes in blood pressure. A number of techniques can be used to reduce the frequency of hypotensive episodes. Thigh-high elastic compression stockings should be applied to improve venous return from the lower extremities. Abdominal binders may also be used to encourage venous return and provide diaphragmatic support when the patient is upright. Activity should be planned in advance, and adequate time should be allowed for a slow progression of position changes from recumbent to sitting and upright. Autonomic Dysreflexia Autonomic dysreflexia (autonomic hyperreflexia) is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). Because this is an emergency situation, the objectives are to remove the triggering stimulus and to avoid the possibly serious complications. The following measures are carried out: The patient is placed immediately in a sitting position to lower blood pressure. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. If one is present, a topical anesthetic is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. The process begins during hospitalization, as acute symptoms begin to subside or come under better control and the overall deficits and long-term effects of the injury become clear. Patient teaching may initially focus on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the injury and the resulting disability, the focus of teaching broadens to address issues necessary for carrying out the tasks of daily living and taking charge of their lives (Kinder, 2005). They will require dedicated nursing support to gradually assume full care of the patient. Although maintaining function and preventing complications will remain important, goals regarding self-care and preparation for discharge will assist in a smooth transition to rehabilitation and eventually to the community. The nurse becomes a support to both the patient and the family, assisting them to assume responsibility for increasing aspects of patient care and management. The nurse often serves as coordinator of the management team and as a liaison with rehabilitation centers and home care agencies. The patient and family often require assistance in dealing with the psychological impact of the injury and its consequences; referral to a psychiatric clinical nurse specialist or other mental health care professional often is helpful. Preconception assessment and counseling are strongly recommended to ensure that the woman is in optimal health and to increase the likelihood of an uneventful pregnancy and healthy outcomes. Therefore, teaching in the home and community focuses on health promotion and addresses the need to minimize risk factors (eg, smoking, alcohol and drug abuse, obesity) (Mastrogiovanni, Phillips & Fine, 2003). Assisting patients to identify accessible health care providers, clinical facilities, and imaging centers may increase the likelihood that they will participate in health screening. Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness. Management • Medical –Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder. No part of this book may be reproduced in any form, by photostat, microfilm, xerography or any other means, or incorporated into any information retrieval system, electronic or mechanical, without the written permission of Kaplan, Inc. Associate Professor Department of Biochemistry and Molecular Biology Kathlyn McGreevy Marshall University School of Medicine Huntington, wv Production Manager Michael Wolff Mary Ruebush, Ph. Cover Design Joanna Myllo Cover Art Christine Schaar Rich LaRocco • Contents Preface.