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The patient and family are taught to perform postural drainage and to avoid exposure to others with upper respiratory and other infections skin care nz purchase decadron online now. If the patient experiences fatigue and dyspnea b5 generic decadron 1mg on-line, strategies to conserve energy while maintaining as active a lifestyle as possible are discussed acne shoes purchase decadron 0.5 mg online. The patient needs to become knowledgeable about early signs of respiratory infection and the progression of the disorder so that appropriate treatment can be implemented promptly skin care qvc quality decadron 0.5mg. Assessment and Diagnostic Findings Bronchiectasis is not readily diagnosed because the symptoms can be mistaken for those of simple chronic bronchitis. A definite sign is offered by the prolonged history of productive cough, with sputum consistently negative for tubercle bacilli. Medical Management Treatment objectives are to promote bronchial drainage to clear excessive secretions from the affected portion of the lungs and to prevent or control infection. Postural drainage is part of all treatment plans because draining the bronchiectatic areas by gravity reduces the amount of secretions and the degree of infection. Chest physiotherapy, including percussion and postural drainage, is important in secretion management. Smoking cessation is important because smoking impairs bronchial drainage by paralyzing ciliary action, increasing bronchial secretions, and causing inflammation of the mucous membranes, resulting in hyperplasia of the mucous glands. Infection is controlled with antimicrobial therapy based on the results of sensitivity studies on organisms cultured from sputum. A year-round regimen of antibiotic agents may be prescribed, with different types of antibiotics at intervals. Some clinicians prescribe antibiotic agents throughout the winter or when acute upper respiratory tract infections occur. Bronchodilators, which may be prescribed for patients who also have reactive airway disease, may also assist with secretion management. Surgical intervention, although used infrequently, may be indicated for the patient who continues to expectorate large amounts of sputum and has repeated bouts of pneumonia and hemoptysis despite adhering to the treatment regimen. However, the disease must involve only one or two areas of the lung that can be removed without producing respiratory insufficiency. The goals of surgical treatment are to conserve normal pulmonary tissue and to avoid infectious complications. Diseased tissue is removed, provided that the postoperative lung function will be adequate. It may be necessary to remove a segment of a lobe (segmental resection), a lobe (lobectomy), or rarely an entire lung (pneumonectomy). The chief advantage is that only diseased tissue is removed and healthy lung tissue is conserved. The objective is to obtain a dry (free of infection) tracheobronchial tree to prevent complications (atelectasis, pneumonia, Asthma Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Asthma differs from the other obstructive lung diseases in that it is largely reversible, either spontaneously or with treatment. Patients with asthma may experience symptom-free periods alternating with acute exacerbations, which last from minutes to hours or days. Despite increased knowledge regarding the pathology of asthma and the development of better medications and management plans, the death rate from asthma continues to increase. For most patients it is a disruptive disease, affecting school and work attendance, occupational choices, physical activity, and general quality of life. Chronic exposure to airway irritants or allergens also increases the risk for developing asthma. Common allergens can be seasonal (eg, grass, tree, and weed pollens) or perennial (eg, mold, dust, roaches, or animal dander). Common triggers for asthma symptoms and exacerbations in patients with asthma include airway irritants (eg, air pollutants, cold, heat, weather changes, strong odors or perfumes, smoke), exercise, stress or emotional upsets, sinusitis with postnasal drip, medications, viral respiratory tract infections, and gastroesophageal reflux. Pathophysiology the underlying pathology in asthma is reversible and diffuse airway inflammation. The inflammation leads to obstruction from the following: swelling of the membranes that line the airways (mucosal edema), reducing the airway diameter; contraction of the bronchial smooth muscle that encircles the airways (bronchospasm), causing further narrowing; and increased mucus production, which diminishes airway size and may entirely plug the bronchi. The bronchial muscles and mucus glands enlarge; thick, tenacious sputum is produced; and the alveoli hyperinflate. This is called airway "remodeling" and occurs in response to chronic inflammation.

Hypovolemic shock is characterized by a fall in venous pressure acne 6 weeks postpartum decadron 1 mg otc, a rise in peripheral resistance acne 101 cheap decadron online amex, and tachycardia acne rash cheap decadron 1mg fast delivery. Neurogenic shock acne 7061 decadron 0.5mg without prescription, a less common cause of shock in the surgical patient, occurs as a result of decreased arterial resistance caused by spinal anesthesia. It is characterized by a fall in blood Maintaining a Patent Airway the primary objective in the immediate postoperative period is to maintain pulmonary ventilation and thus prevent hypoxemia (reduced oxygen in the blood) and hypercapnia (excess carbon dioxide in the blood). Both can occur if the airway is obstructed and ventilation is reduced (hypoventilation). Patients who have experienced prolonged anesthesia usually are unconscious, with all muscles relaxed. When the patient lies on his or her back, the lower jaw and the tongue fall backward and the air passages become obstructed. Signs of occlusion include choking, noisy and irregular respirations, decreased oxygen saturation scores, and within minutes a blue, dusky color (cyanosis) of the skin. To regain backward tilt of the neck, lift with both hands at the ascending rami of the mandible. Airway Tongue Epiglottis Trachea Esophagus pressure due to pooling of blood in dilated capacitance vessels (those with the ability to change volume capacity). Cardiogenic shock is unlikely in the surgical patient except if the patient has severe preexisting cardiac disease or experienced a myocardial infarction during surgery. The airway passes over the base of the tongue and permits air to pass into the pharynx in the region of the epiglottis. The airway should remain in place until the patient recovers sufficiently to breathe normally. As the patient regains consciousness, the airway usually causes irritation and should be removed. Cardiotonic, vasodilator, and corticosteroid medications may be prescribed to improve cardiac function and reduce peripheral vascular resistance. The patient is kept warm while avoiding overheating to prevent cutaneous vessels from dilating and depriving vital organs of blood. It can present insidiously or emergently at any time in the immediate postoperative period or up to several days after surgery (Table 20-1). When blood loss is extreme, the patient is apprehensive, restless, and thirsty; the skin is cold, moist, and pale. The pulse rate increases, the temperature falls, and respirations are rapid and deep, often of the gasping type spoken of as "air hunger. Transfusing blood or blood products and determining the cause of hemorrhage are the initial therapeutic measures. If bleeding is evident, a sterile gauze pad and a pressure dressing are applied, and the site of the bleeding is elevated to heart level if possible. The patient is placed in the shock position (flat on back; legs elevated at a 20-degree angle; knees kept straight). If the source of bleeding is concealed, the patient may be taken back to the operating room for emergency exploration of the surgical site. Dysrhythmias are associated with electrolyte imbalance, altered respiratory function, pain, hypothermia, stress, and anesthetic medications. The nurse checks the medical record for special needs and concerns of the patient. Intravenous or intramuscular administration of droperidol (Inapsine) is common, especially in the ambulatory setting. Other medications such as metoclopramide (Reglan), prochlorperazine (Compazine), and promethazine (Phenergan) are commonly prescribed (Karch, 2002; Meeker & Rothrock, 1999). Although it is costly, ondansetron (Zofran) is a frequently used, effective antiemetic with few side effects. Time Frame Primary Intermediary Secondary Hemorrhage occurs at the time of surgery. Hemorrhage occurs during the first few hours after surgery when the rise of blood pressure to its normal level dislodges insecure clots from untied vessels.

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These locations do not correspond to the anatomic locations of the valves within the chest; rather acne images discount decadron 1 mg overnight delivery, they reflect the patterns by which heart sounds radiate toward the chest wall skin care hospitals in hyderabad cheap decadron 1 mg visa. For example skin care 60 purchase decadron without prescription, the actions of the mitral valve are usually heard best in the fifth intercostal space at the midclavicular line skin care collagen generic decadron 0.5 mg otc. Ventricular disease, however, can give rise to transient sounds in systole and diastole that are called gallops, snaps, or clicks. Significant narrowing of the valve orifices at times when they should be open, or residual gapping of valves at times when they should be closed, gives rise to prolonged sounds called murmurs. Closure of the mitral and tricuspid valves creates the first heart sound (S1), although vibration of the myocardial wall also may contribute to this sound. Although S1 is heard over the entire precordium, it is heard best at the apex of the heart (apical area). Its intensity increases when the valve leaflets are made rigid by calcium in rheumatic heart disease and in any circumstance in which ventricular contraction occurs at a time when the valve is caught wide open. The latter circumstance occurs, for example, when a premature ventricular contraction interrupts the normal cardiac cycle. S1 varies in intensity from beat to beat when atrial contraction is not synchronous with ventricular contraction. This is because the valve may be fully or partially closed on one beat and open on the subsequent one as a function of irregular atrial activity. S1 is easily identifiable and serves as the point of reference for the remainder of the cardiac cycle. The apical impulse normally is located at the fifth intercostal space to the left of the sternum at the midclavicular line. The nurse locates the impulse with the palm of the hand and palpates with the fingerpads. It is so named because it appears to lift the hand from the chest wall during palpation. An apical impulse below the fifth intercostal space or lateral to the midclavicular line usually denotes left ventricular enlargement from left ventricular failure. Normally, the apical impulse is palpable in only one intercostal space; palpability in two or more adjacent intercostal spaces indicates left ventricular enlargement. If the apical impulse can be palpated in two distinctly separate areas and the pulsation movements are paradoxical (not simultaneous), a ventricular aneurysm should be suspected. Abnormal, turbulent blood flow within the heart may be palpated with the palm of the hand as a purring sensation. Thrills also may be palpated over vessels when blood flow is significantly and substantially obstructed and over the carotid arteries if aortic stenosis is present or if the aortic valve is narrowed. It extends from the sternum to the midclavicular line in the third to fifth intercostal spaces. The first heart sound (S1) is produced by the closing of the mitral and tricuspid valves and is best heard at the apex of the heart (left ventricular or apical area). The second heart sound (S2) is produced by the closing of the aortic and pulmonic valves and is loudest at the base of the heart. Although these two valves close almost simultaneously, the pulmonic valve usually lags slightly behind. Therefore, under certain circumstances, the two components of the second sound may be heard separately (split S2). The splitting is more likely to be accentuated on inspiration and to disappear on exhalation. The aortic component of S2 is heard clearly in both the aortic and pulmonic areas, and less clearly at the apex. The pulmonic component of S2, if present, may be heard only over the pulmonic area. Therefore, one may hear a "single" S2 in the aortic area and a split S2 in the pulmonic area. If the blood filling the ventricle is impeded during diastole, as occurs in certain disease states, then a temporary vibration may occur in diastole that is similar to , although usually softer than, S1 and S2. The heart sounds then come in triplets and have the acoustic effect of a galloping horse; they are called gallops. This may occur early in diastole, during the rapid-filling phase of the cardiac cycle, or later at the time of atrial contraction. A gallop sound occurring during rapid ventricular filling is called a third heart sound (S3); it represents a normal finding in children and young adults.

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Diuresis acne under beard decadron 0.5 mg with mastercard, venodilating agents (eg skin care reddit order 1 mg decadron amex, nitrates) acne genetics buy genuine decadron line, and loss of blood or body fluids from excessive diaphoresis acne breakout decadron 1mg visa, vomiting, or diarrhea reduce preload. Preload is increased by increasing the return of circulating blood volume to the ventricles. Controlling the loss of blood or body fluids and replacing fluids (ie, blood transfusions and intravenous fluid administration) are examples of ways to increase preload. The second determinant of stroke volume is afterload, the amount of resistance to ejection of blood from the ventricle. For example, afterload is increased by arterial vasoconstriction, which leads to decreased stroke volume. The opposite is true with arterial vasodilation: afterload is reduced because there is less resistance to ejection, and stroke volume increases. Contractility is a term used to denote the force generated by the contracting myocardium under any given condition. Contractility is enhanced by circulating catecholamines, sympathetic neuronal activity, and certain medications (eg, digoxin, intravenous dopamine or dobutamine). Contractility is depressed by hypoxemia, acidosis, and certain medications (eg, beta-adrenergic blocking agents such as atenolol [Tenormin]). The heart can achieve a greatly increased stroke volume (eg, during exercise) by increasing preload (through increased venous return), increasing contractility (through sympathetic nervous system discharge), and decreasing afterload (through peripheral vasodilation with decreased aortic pressure). The percentage of the end-diastolic volume that is ejected with each stroke is called the ejection fraction. With each stroke, about 42% (right ventricle) to 50% (left ventricle) or more of the end-diastolic volume is ejected by the normal heart. The ejection fraction can be used as an index of myocardial contractility: the ejection fraction decreases if contractility is depressed. Gerontologic Considerations Changes in cardiac structure and function are clearly observable in the older heart. Studies show that the normal aging heart can produce adequate cardiac output under ordinary circumstances but may have a limited ability to respond to situations that cause physical or emotional stress. In an elderly person who is less active, the left ventricle may become smaller (atrophy) as a consequence of physical deconditioning. These changes lead to decreased myocardial contractility, increased left ventricular ejection time (prolonged systole), and delayed conduction. Therefore, stressful physical and emotional conditions, especially those that occur suddenly, may have adverse effects on the aged person. The heart cannot respond to such conditions with an adequate rate increase and needs more time to return to a normal resting rate after even a minimal increase in heart rate. Because the coronary arteries of a woman are smaller, they occlude from atherosclerosis more easily, making procedures such as cardiac catheterization and angioplasty technically more difficult, with a higher incidence of postprocedure complications. Another significant difference between the genders is the physiologic effects of estrogen on the cardiovascular system. Two important effects of estrogen, regulation of vasomotor tone and of response to vascular injury, may be the mechanisms that protect women against the development of atherosclerosis. An additional, potentially beneficial effect of estrogen is its action on the liver, which results in improved lipid profiles. On the other hand, less favorable effects of estrogen include an increase in coagulation proteins and a decrease in fibrinolytic protein, which enhance the risk of thrombus formation. The assessment of the acutely ill cardiac patient will be different from that of a patient with stable or chronic cardiac conditions. For this patient, the health history, physical assessment, and important nursing interventions (eg, cardiac monitoring, administration of intravenous medications) are performed simultaneously. Once the condition of the patient stabilizes, a more extensive history can be obtained. With stable patients, a complete health history is obtained during the initial contact. Initially, demographic information regarding age, gender, and ethnic origin is obtained. The family history, as well as the physical examination, should include assessment for genetic abnormalities associated with cardiovascular disorders (see Genetics in Nursing Practice box). Height, current weight, and usual weight (if there has been a recent weight loss or gain) are established. During the interview, the nurse conveys sensitivity to the cultural background and religious practices of the patient.