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If this condition prolongs proven kamagra chewable 100 mg, the superficial tissues necroses purchase 100 mg kamagra chewable with amex, skin breaks down and formation of an ulcer takes place discount kamagra chewable 100mg with visa. The following condition causes prolonged pressure: 1) Leaving a patient in one position for a long time discount kamagra chewable 100mg online. These patients are unable to appreciate the weight of pressure and change their position 2) Paralysed patients (Paraplegic and quadriplegic patients). Diabetes Prevention of decubitus ulcers: A) Prevent Pressure: 1) Establish a turning schedule for bedridden patients; turn hourly. B ) Prevent Friction: 1) When changing position of your patient lift him and do not drag him on to bed. D ) Prevent Predisposing causes: 1) Improve patient’s health by means of good food, ventilation, sunlight and exercises. E ) Observe early signs and symptoms of decubitus ulcers: 1) Redness 2) Dark discoloration 3) Bruising 4) Tenderness of the area 5) Burning sensation 9 F ) Give good care to pressure points: Careful cleaning and massage should be carried out 3 or 4 times a day for all bed­ridden patients. Equipment 1) A bowl of warm water 2) Sponge cloth 3) Soap 4) Towel 5) Dusting powder 6) Spirit Procedure: 1) Explain procedure to patient­ Arrange articles at the bedside. Treatment of decubitus ulcer: 1) Clean ulcers with aseptic precautions­Use antiseptics such as eusole (or) hydrogen peroxide. Give long firm strokes from back of neck to the buttocks 14) Watch for any redness over the pressure areas. Type of Therapeutic Baths 1) Hot water tub bath: Immersion in hot water helps relieve muscle soreness and spasm. Problems may result from poor care of the feet and nails such as biting nails or trimming them improperly, exposure to chemicals and wearing poorly fitted shoes. Purposes of care of the nails 1) To keep nails harmless 2) To prevent accumulation of dirt under the nails and reduce occurrence of infection. Characteristics of a healthy nails:A normal healthy nail is transparent, smooth and convex with pink nail beds and translucent white tips. Common foot and nail problems 1) Callus: Is a thickened portion of epidermis caused by local friction or pressure. A person’s appearance and a feeling of well­being depend on the way the hair looks and feels hair growth, distribution and pattern can be indicators of general health status. Proper hair care: 1) Frequent brushing helps keep hair clean and distributes oil evenly along hair shafts. Hold it with your left hand tightly at the root of the hair to prevent pulling of hair and comb it from top to downwards. B) Pediculosis corporis or vestimenti (Body louse) –Refer Antiseptic Bath in procedure “Applying Hot Applications”. C) Pediculosis pubis (Crab louse) · A tray containing a) Protective sheet and towel b) Bowl of warm water c) Razor and blade d) Soap and brush e) Antiseptic lotion in a kidney tray and paper bag. Guidelines 1) Combing: Hair are combed and arranged in the style the patient prefers at least twice a day. B) Rash a) Neck and behind ears in head louse b) All over the body in body louse c) On and around the part affected in crab louse. C ) Sores a) Scalp in head louse b) Body in body louse c) On the part affected in crab louse The common parasiticides used are: a) Mediker. Wait for atleast 15 minutes § Before placing the thermometer in the mouth rinse the thermometer in cold water to remove all disinfectants § Do not use hot water for washing thermometer § Before placing thermometer in position wipe it from the bulb to stem to keep the bulb clean § After taking the thermometer wipe it from stem to bulb to avoid contaminating the fingers of the care giver with saliva and faeces. In auxiliary method leave the thermometer in position for 5 minutes 6) Count the pulse and respirations while the thermometer is still in place 7) Place the patients hand over his chest with the wrist extended and the palm downwards. Place the finger tips over the pulse point 8) Holding the watch in the left hand, start to count the pulse rate with zero then 1,2 etc. If the pulse is not regular, count the rate for one full minute 10) Continue palpation of the pulse to assess the rhythm, volume, tension and irregularity 11) With the right hand still on the pulse count respiration by watching the rise of the chest, with out the knowledge of the patient 12) If the respirations are normal count the number of respirations in the 30 seconds and multiply by 2. If the respirations are abnormal, count the rate for full one minute and note the pattern of breathing 13) Remove the thermometers after 2 minutes (after 5 minutes in case of auxillary method). Keep clients upper body and lower extremities covered with sheet or blanket 3) Apply disposable gloves 4) Hold end of glass thermometer with finger tips 5) Read mercury level while gently rotating thermometer at eye level.

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Clean-contaminated: Minor break in technique buy generic kamagra chewable 100 mg line, oropharynx entered trusted kamagra chewable 100 mg, gastrointestinal or respiratory tracts entered without significant spillage purchase kamagra chewable 100mg overnight delivery, genitourinary or biliary tracts entered in absence of infected urine or bile buy kamagra chewable 100 mg on-line. If other serious conditions exist, which endanger the patient’s life, the wound should be covered with sterile gauze and priorities attended to. However, the goal in all cases is to establish a good environment to assist wound healing and prevent infection. Proper wound care includes the following measures: • Adequate hemostasis locally to stop bleeding. However, general guidelines that can be followed are: • Clean wounds should be closed primarily • Clean-contaminated wounds can be primarily closed if they can be converted, into clean wounds • Untidy, contaminated wounds which cannot be converted to tidy wounds should not be closed primarily • All missile wounds, animal and human bites should never be primarily closed unless strongly indicated Primary closure Primary closure is effective in wounds presenting within 6-8 hours and can accurately be debrided. It provides a reliable drainage and opportunity for repeated inspection and debridement as necessary. There is no specific management needed except local compress and analgesics if pain is severe. Management: - It usually gets absorbed spontaneously and should be left - Local compress to alleviate pain - Aseptic evacuation or aspiration only if very large (expanding) or over a cosmetic area or leading to compression of vital structures. Management: - Cleanse using scrubbing brushes - Use antiseptic or lean tap water and soap - Analgesic Punctures These may be compound wounds which involve deeper structures. Management: - Careful inspection - Adequate cleansing - Closure, if feasible, under appropriate anesthesia - Proper wound debridement if needed - Appropriate antibiotic prophylaxis - Tetanus Prophylaxis - Analgesics as needed Crush and avulsion wounds These are compound complicated wounds. They are usually associated with systemic involvement and have more extensive damage than may appear. Management: - Correct associated life threatening conditions - Proper wound debridement - Early skin cover if possible or late graft, wound left open if contaminated - Appropriate antibiotics - Tetanus Prophylaxis - Analgesics as needed Missile injuries These are type of wounds which are compound and complicated. They usually present with severe life threatening conditions and should be carefully managed. Human bites These are relatively rare but more heavily contaminated than those of most animalss due to polymicrobial nature including anaerobic organisms as a normal oral flora. To avoid this complication the animal must be kept for observation for at least 10 days. Management should include: First aid measures: - Local wound irrigation - Apply pressure bandage proximally to avoid or reduce venom spread with caution on the blood supply - Immobilize the limb to minimize venom absorption - Transport patient immediately to nearby hospital Hospital Measures: - Identify the species - Conduct necessary laboratory investigations like hemoglobin, renal function. Local: Local complications may manifest as one or more of the following conditions- - Hematoma - Seroma 55 - Infection - Dehiscence - Granuloma formation - Scar formation - Contracture leading to loss of joint function etc Systemic: - Death may occur if un controlled sepsis or hemorrhage - Systemic manifestations of hemorrhagic shock due to massive bleeding - Bacteremia and sepsis from a source of locally infected wound 56 Review Questions 1. A) Duration of injury B) The circumstance of wounding C) The mechanism of injury D) Local appearance of the wound E) All of the above 2. A) Bullet wound of one hour duration B) Human bite of 30 minutes duration C) Glass laceration of five hours duration D) Crush injury of the leg following car accident E) None of the above 3. A proper wound care includes all measures except A) Removing all devitalized tissue B) Removing foreign bodies impregnated to the wound C) Wound inspection following primary management D) Inadequate hemostasis of a bleeding artery E) Decision to close a wound primarily 4. A) Forearm laceration from a knife B) Dog bite to the calf of one hour duration C) Blast wound to the thigh of two hours duration D) Stick wound to the scalp of four hours E) B and C are correct 5. In a contaminated wound left open to heal without closure, healing is effected by A) First intention B) Second intention C) Third intention D) Purely by epithelialization E) All of the above 7. A) Presence of foreign body B) Systemic illness C) Sex of the patient D) Poor patient nutritional state E) Presence of infection 58 Key to the Review Questions 1. It can be defined broadly as an infection related to or complicating a surgical therapy and requiring surgical management. Many infections occupy a non-vascularized space of tissue, thus are likely to respond to non-surgical treatments. These types of infection therefore definitely require surgery as a primary or definitive therapeutic approach. Examples of such infections, which definitely need surgery, can be: - Gas gangrene - Abscess - Appendicitis. On the other hand, any infection that is related to surgical therapy but that may not definitely require surgery is also categorized as a surgical infection. Examples: - Urinary tract infections after catheterization for surgical purpose - Pulmonary complications following intubation for surgery - Tracheotomy site infection All wounds that follow operative procedure or incision are also grouped as surgical infections. According to temporal relation to surgery, surgical infections are grouped into three types.

It may also present with a classic pattern on the dorsal surface of the foot or as chronic dry generic 100 mg kamagra chewable with visa, scaly hyperkeratosis of the soles and heels kamagra chewable 100mg mastercard. Tinea versicolor (Pityriasis versicolor) Versicolor versicolor is a common buy kamagra chewable 100 mg visa, benign best 100 mg kamagra chewable, superficial cutaneous (stratum corneum) fungal infection at the level of stratum corneum characterized by hypo pigmented or hyperpigmented macules and patches with faint scale on the chest and the back. Etiology: Malassezia furfur (Pityrosporon ovale,) M furfur is a member of normal flora of the skin found in 18% of infants and 90-100% of adults. Predisposing factors include - genetic predisposition, warm, humid environments, excessive sweating, immunosuppression, malnutrition, and Cushing disease. Treatment Patients should be informed that it is caused by a normal flora of the skin hence it is not transmitted and any skin color alterations resolve within 1-2 months after treatment. Effective topical agents include: Sodium thiosulphate solution, selenium sulfide and azole, ciclopiroxolamine, and allylamine antifungals. Weekly applications of any of the topical agents for the following few months may help prevent recurrence. Ketoconazole 200-mg daily for 10-days and as a single-dose 400-mg treatment, have comparative results. Oral therapy does not prevent the high rate of recurrence, unless repeated on an intermittent basis throughout the year. Candidiasis Candida infections caused by yeast-like fungi Candida albicans commonly occur in moist, flexural sites. Under certain conditions, they can become so numerous that they cause infections, particularly in warm and moist areas. Pruritic rash that begins with vesiculopustules, which enlarge and rupture, causing maceration and fissuring. Paronychia and onychomycosis Frequently, paronychia and onychomycosis are associated with immersion of the hands in water. Patients present with a painful and erythematous area around and underneath the nail and nail bed, warm, glistening, tense, and tender. There is secondary nail thickening, ridging, discoloration, and occasional nail loss in chronic cases. Physical examination reveals a diffuse erythema and white patches that appear on the surfaces of the buccal mucosa, throat, tongue, and gums. The presence of retrosternal pain, epigastric pain, nausea, and vomiting may suggest esophageal candidiasis Vulvovaginal candidiasis: This is the second most common cause of vaginitis. A patch resembling thrush appears on the glans and may spread to the thighs, gluteal folds, buttocks, and scrotum. Treatment Candida intertrigo - Topical azoles and polyenes, including clotrimazole, miconazole, and nystatin, are effective. Paronychia - the most important intervention is drainage followed by oral antifungal therapy with either ketoconazole, fluconazole or itraconazole. Single daily dose of itraconazole taken for 3-6 months or a pulsed-dose regimen that requires a slightly higher dose daily for 7 days, followed by 3 weeks off therapy. Vulvovaginal candidiasis – Azole suppository or pessaries , in resistant case systemic therapy for 10 days. Warts Warts or verrucae are benign growths on the skin or mucous membranes that cause cosmetic problems as well as pain and discomfort. The incubation period of a wart is 2 to 9 months during which time an excessive proliferation of skin growth slowly develops. Common warts, especially in children, do not necessarily need to be treated, because they exhibit a high rate of spontaneous remission. Treatment ™ Salicylic acid 25% ointment twice daily followed by cutting or scraping ™ Preparation of salicylic acid 5-20% and lactic acid 5-20 in collodion are easier to use ™ Electrodessication and curettage ™ Freezing with liquid nitrogen if available. Protect the skin around the wart with Vaseline apply the podophyllin with a match stick carefully on the top of the war and wash after 6 hours. Molluscum contagiosum Molluscum contagiosum is a viral infection of the skin that causes discrete papules that may be mistaken for warts. The rash of molluscum contagiosum is characterized by discrete, 2 to 5 mm papules that are flesh- colored (skin color) and dome-shaped with a central umbilication (depressed centre). Cryosurgery - Using liquid nitrogen to freeze the lesion Salicylic Acid (Compound W) - A solution applied to the lesion with or without tape occlusion 3. Pathogenesis of herpes simplex virus 30 Primary infection Latency Transmission can occur in all stages; more at the primary Reactivation stage What causes latency?

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Your glucose records and your A1C test results will show when you have maintained a safe range for a period of time 100 mg kamagra chewable with amex. You may need to change your meal plan and your usual physical activity generic kamagra chewable 100mg without a prescription, and you may need to take more frequent insulin shots cheap 100mg kamagra chewable visa. This condition order kamagra chewable 100mg, which is called gestational diabetes, can be controlled just like other kinds of diabetes. Check again for diabetes at least 6 weeks after your baby is born and at regular times for the rest of your life. If you learn you have diabetes when you’re pregnant, work closely with your health care team to stay healthy. If you notice vaginal itching, tell your health care provider, who can tell you about medicines you can buy at the drugstore and about how to prevent yeast infections. All women—whether or not they have diabetes—need to Getting Pap smears and have these tests mammograms is important regularly. If you feel sleepy or can’t think clearly, have someone call your health care provider or take you to an emergency room. If you feel sleepy or can’t think clearly, have someone call your health care provider or take you to an emergency room. If you feel sleepy or can’t think clearly, have someone call your health care provider or take you to an emergency room. If you feel sleepy or can’t think clearly, have someone call your health care provider or take you to an emergency room. If you feel sleepy or can’t think clearly, have someone call your health care provider or take you to an emergency room. Studies indicate that it may also help prevent or slow the progression of kidney disease in people with diabetes. However, too much cholesterol can make fats stick to the walls of the arteries and cause a disease that decreases or stops circulation. Diabetes results when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin. In this disease, the vessels swell and leak liquid into the retina, blurring the vision and sometimes leading to blindness. High blood pressure tires the heart, harms the arteries, and increases the risk of heart attack, stroke, and kidney problems. Symptoms include feeling anxious or confused, feeling numb in the arms and hands, and shaking or feeling dizzy. A drop of blood from the fngertip is placed on a special coated strip of paper that “reads” (often through an electronic meter) the amount of glucose in the blood. Women who have this infection may feel itching, burning when urinating, and pain, and some women have a vaginal discharge. American Association of Diabetes Educators 100 West Monroe, Suite 400 Chicago, Illinois 60603-1901 800-832-6874 800-338-3633 (for names of diabetes educators) http://www. Comments and suggestions regarding this draft document should be submitted within 90 days of publication of the Federal Register notice announcing the availability of the draft guidance. All comments should be identified with the docket number listed in the notice of availability that publishes in the Federal Register. You can use an alternative approach if the approach 11 satisfies the requirements of the applicable statutes and regulations. The information presented will help applicants plan clinical studies, design clinical 24 protocols, implement and appropriately monitor the conduct of clinical trials, collect 25 relevant data for analysis, and perform appropriate types of analyses of study data. Development 29 programs for these treatments should be discussed with the review division before 30 initiation. Applicants are encouraged 34 to discuss development plans with the review division before embarking on studies to 35 ensure that the clinical trial design and analysis plan meet defined objectives. Instead, guidances describe the Agency’s current thinking on a topic and 41 should be viewed only as recommendations, unless specific regulatory or statutory 42 requirements are cited. The use of the word should in Agency guidances means that 43 something is suggested or recommended, but not required. Closed comedones may be more difficult to detect visually and may require 65 stretching of the skin to aid in visualization.

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