By L. Aschnu. California State University, Fullerton. 2018.

    Achieves metabolic balance a generic 20mg levitra soft mastercard, Avoid extremes of glucose level( Hpo/hyperglycemia b cheap levitra soft 20mg without a prescription, Demonstrate rapid resolution of hypoglycemia episode c, Avoid further weight loss 3. Identifies factors that cause the blood glucose level - to fall (insulin, exercise) - to rise ( food, illness and infection ) d- describes the major treatment modalities - diet - Exercise - Monitoring - Medication - Education Treatment Modalities (insulin, diet, monitoring, Education) a, Demonstration proper technique for drawing up and injecting insulin b, Verbalize insulin injection rotation plan c, Verbalize understanding of classification of food group d, Verbalize appropriate schedule for eating snacks and meals e. Verbalizes symptoms of hypoglycemia (shakiness, sweating headache, hunger, Numbness or tingling of lips or finger, weakness, fatigue, difficult concentration, Change of mood and dangers of untreated hypoglycemia (seizure and coma) b. Identify appropriate circumstance for calling the physician eg- when ill, when glucose level repeatedly increasing 4. States measures to prevent occurrence of complications Keys for the pretest and post test questions for Nurses 1. A- site of injection -Preparations of medication -Rotations -About syringe and needle -Some problems with insulin injections B)-Too much insulin -Too little food or -Excessive physical exercise -Delay of meal or omitting of snacks C) Sweating -Tremor -Tachypnea -Confusion -Seizure -Loss of consciousness 68 D) Having snack, not delaying the meal, right dose of medications, having Candies at hand F)-assess foot daily for sensation, redness and broken skins -Wash dry feet daily - If skin is dry apply a thin coat of lubricating oil -Tie shoes loosely but firmly -If your feet perspire, change shoe and stocking during the day -Wear shoe and stocking that gives room for the movement of the toe Part-ii True or false A. Purpose of the module Diabetes mellitus is a diverse group of hyper glycemic disorders with different etiologies and clinical pictures; there fore timely diagnosis and management based on true laboratory results are crucial. This Satellite Module on Diabetes Mellitus is intended to resolve the critical shortage of clinical chemistry reference materials both for students and for other professionals of the same field working in different health institutions 1. Pre- test questions Instructions: choose the appropriate answer from the alternatives given for each question and write the answers on a separate sheet of paper. Why is there a discrepancy between the whole blood glucose concentration and the plasma glucose concentration? Which one of the following organs uses glucose from digested carbohydrates and stored it as glycogen for later use as a source of immediate energy by the muscles? Learning objectives After studying this satellite module the student will be able to:- Æ Collect, preserve or prepare the correct specimens for diagnosis of diabetes mellitus Æ Perform different clinical chemistry tests in management of diabetes mellitus Æ Practice different quality control procedures in laboratory diagnosis of diabetes mellitus 4. The blood specimen can be collected both from vein or capillary, it depends on the type of sample the test procedure needs, and if serum or plasma is needed Venus blood should be collected with clean, dry, capped test tube, and with or with out anticoagulant. Urine samples are also possible to collect using, a clean, dry, free of any disinfectant, large and wide mouth container so as to do both qualitative and quantitative determination of glucose and others 4. To more completely detect diabetes mellitus, stressing the system with a defined glucose load tests carbohydrate metabolic capacity. To do this, a high- carbohydrate drink or meal is given to the patient, blood is collected 2 hours after ingestion, and the glucose concentration is determined. In the fasting state the arterial (capillary) blood glucose concentration is 5 mg/dl higher than the venous concentration. Preparation and preservation Samples for glucose determination The following factors which affects the stability of glucose in body fluid must be take in to account, such as: • Those glycolytic enzymes found particularly in the red cells, which under goes glycolysis at an average rate of approximately 10 mg/dl/hr in whole blood or 5 mg/dl/hr in sufficiently centrifuged plasma which still contain leukocytes Keeping these considerations in mind, there are several ways to prevent or retard glycolysis in specimen to be analyzed. For example: • Sample for glucose analysis should be delivered to the laboratory as soon as possible after being drowned from the patient. Note When certain enzymatic glucose methods are used, fluoride anticoagulated blood should not be used, as the fluoride might inhibit the enzyme. Use of serum separator gel tubes, processed as quickly as possible with in thirty minutes if possible- is preformed for these methods. For non pregnant adults, the fasting serum or plasma glucose concentration should normally be less than 110 mg/dl and the serum or plasma glucose taken 2 hours 140 mg/dl. Including in the new criteria from the expert committee on the diagnosis and classification of Diabetes Mellitus. A random blood glucose (blood drawn with out considering time since the last meal) equal to or greater than 200 mg/dl, along with symptoms of diabetes (polyuria, polydipsia, and un explained weight loss), 3. A 2- hour post load glucose level equal to or greater than 200 mg/dl during an oral glucose tolerance test. The various methods for the quantitative determination of glucose can be divided in to three general categories. Of these, enzymatic methods using hexokinase or glucose oxidase methodology are most commonly used 76 7. The use of enzymes is a means of achieving absolute specificity in the determination of glucose concentration. The two most widely used automated enzyme glucose methods are based on the enzymes hexokinase and glucose oxidase. In the presence of peroxidase enzyme the released H2O2 reacts with oxygen acceptors like aminophenazene and phenol forming a rose colored quinone rose derivative.

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    Cornea - Is the main refractive media of the eye (75 % of refractory function of the eye) discount 20mg levitra soft. Iris - has central hole (pupil) through which light reaches the retina - consists of a vascular stroma covered by mesothelium anteriorly and by two pigmented layers of epithelium posteriorly levitra soft 20mg visa. Its size is subject to various factors like aging, illumination, sleep, change of gaze, emotional status. Ciliary body - Triangular structure that is situated between the iris anteriorly and choroids posteriorly. Circulation of aqueous fluid Aqueous fluid is produced by ciliary process of ciliary body. It flows from the posterior Chamber along the pupillary opening to the anterior chamber. Finally it will be drained through the Canal of schlemn in the Trabecular meshwork to episcleral veins Stroma Endothelium Epithelium Trabecular meshwork Canal of Schlemn Iris Anterior Lens Chamber angle Posterior chamber Ciliary Processes Ciliary body Fig. The Choroids - It is network of blood vessels - The arteries and veins are located externally while capillaries are found internally. Have two layers I- Outer layer - Next to choroid, single layer of fragment epithelial cell. The electrical impulses produced by each rod or cone passes across synapses to the bipolar cell. Then the impulses are modified in various ways as they pass through the bipolar and ganglion cells. The nerve fibers from the ganglion cells travel in the nerve fibers layer on the surface of the retina to the optic disc and form the optic nerve. This is used to protect the macular cones from the dazzle of incident light, which occurs even with maximal pupillary constriction. Anterior chamber - Delineated anteriorly by the posterior corneal surface and posteriorly by iris. Posterior chamber - Limited anteriorly and laterally by the posterior iris surface and ciliary body and posterior by lens & vitreous body C. Vitreous space - Filled with vitreous humor - Transparent, roughly spherical and gelatinous structure occupying posterior 4/5 of the globe with volume of 4 ml. The lymphatic drainage of the medial eye lid is to sub mandibular lymph node and that of lateral one is to the superficial preauricular lymph nodes and then to deeper cervical lymph nodes. Ahmed 4 - Albert and Jakoboiec Principle and practice of ophthalmology 5 - Up to date - (C) 2001 - www. To give a clear idea about the approach to ophthalmic patients and specific examination techniques. At the end of the course the students are expected to know how to examine ophthalmic patients and use of certain ophthalmic instruments 2. Family history The main purpose of the history is to find out what exactly the patient is complaining. However it is always helpful to find out some background information about the patient e. Such information will indicate what vision the patient needs for work and for personal satisfaction. Major symptom of eye disease given • Disturbances of vision • Discomfort or pain in the eye • Eye discharge A. Disturbances of vision • The most common visual symptom • Can be sudden or gradual ¾ Blurring or reduction of vision ¾ Dazzling/glare/ – difficulty of seeing in bright light, may be caused by opacities in the cornea or lens ¾ Diplopia/ double vision/ ¾ Decreased peripheral vision – may be caused by various disorders in the retina, optic nerve or visual pathway pathology up to the visual cortex. Visual field Visual field is that portion of one’s surroundings that is visible at one time during central vision Not a routine test in all patients ¾ Important to do in any patients with suspected glaucoma, diseases of the optic nerves in visual pathways, and certain retinal diseases Confrontation test - Simple and no need of special equipment - Will detect serious visual field defects. To examine the front of the eye, this requires both a good light illumination with bright light, torch and magnifying lens(loupe). Normal eye • Eye lids should open and close properly • Eye lashes should grow forward and out ward • white part of the eye should be white • Cornea should be clear and transparent • Pupil is black and reactive to light During Examination of the Eye One Has to Comment the Following Things 1. Examination of the front aspect of the eye Eye lids – ™ In growing eye lash, misdirected ™ Everted eyelid examinations; follicles, papillary reaction, foreign body, concretions ™ Any mass, ulcer, discharge • Characterize it ™ Opening and closing pattern and defect of eye lid • Lagophthamos – eye lid that can’t close • Ptosis – eye lid drooping Nasolacrimal apparatus ™ Punctum ™ Mass, Ulcer or discharge over the Nasolacrimal apparatus Conjunctiva ƒ Color ƒ Growth 22 ƒ Bleeding ƒ Foreign body ƒ Spot - white foamy ƒ Follicles, papillae, scarring Characterize each findings Limbus ƒ Herbert’s pit ƒ Ciliary /circumcorneal/ injection ƒ Arcus Cornea Color and transparency Size Ulcer, scar, infiltrates Foreign body Laceration, perforation Blood vessels growth Sensation to touch Iris /pupil • Color ƒ Defect ƒ Reaction to light ƒ Relation with adjacent parts ƒ Pupillary margin: shape, adhesion between lens , iris and cornea Lens ƒ Transparency ƒ Position, sublaxated or dislocated 23 Anterior chamber • look for clarity • Depth 2. Ophthalmoscope is a form of illumination, which allows the examiner to look down the same axis as the rays of light entering the patient’s eye. To see the fundus • Ocular media must be healthy and transparent • Dilate the pupil with mydriatic drops • With the ophthalmoscope it appears 15 times larger than its actual size • In myopic patient the magnification is greater, but in hypermetropic patient it is less.

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    Dantrolene prophy- surgical procedure should be terminated as quickly as laxis can be given preoperatively to high risk patients generic 20 mg levitra soft otc. Triggers are avoided by using a Patients should be monitored for recrudescence of the “trigger-free” anesthetic machine which is free of va- reaction as well as for complications such as myoglobin- pourizers generic levitra soft 20 mg online, and has been flushed clear of residual vola- uria, renal failure and disseminated intravascular co- tile gases. The patient 82 can be discharged home if instructions regarding worri- some symptoms have been given and understood, and if the patient has reasonable access to the hospital from home, should problems arise. The best Physiologic Changes of Pregnancy means of avoiding this outcome is to avoid gen- Physiologic and anatomic changes develop across 1. Physiologic Changes of eral anesthesia (by using a regional technique) Pregnancy many organ systems during pregnancy and the and thus maintain intact laryngeal reflexes. Pretreatment of all par- changes are those that affect the respiratory and turients with a non-particulate antacid (30 cc so- circulatory systems. Finally, There is an increased risk of difficult or failed intu- a rapid sequence induction with cricoid pressure bation in the parturient. Laryngoscopy can be further With the apnea that occurs at induction of anesthe- impeded by the presence of large breasts. Gastric motility is decreased and “oxygen reserve” during apnea, has decreased by gastric secretions increase. This, combined with a 20% due to upward displacement of the dia- decrease in the integrity of the gastroesophageal phragm. In fact, airway complications (dif- Adequate ventilation must be maintained during ficult intubation, aspiration) are the most common anesthesia. The concomitant rightward shift in Labour Analgesia the oxyhemoglobin dissociation curve allows increased fetal trans- There are many methods of relieving the pain and stress of labour. This is significant for two rea- oxide), intravenous (opioids) or regional (epidural) are associated sons. Firstly, the normal signs of hypovolemia may not be seen un- with side effects and risks to both fetus and mother. This extends to include sacral segments (S2-4) during Due to the increasing uterine size, aortocaval compression (obstruc- the second stage. Thus, the principle of epidural analgesia is to ad- tion of the inferior vena cava and aorta) becomes relevant in the minister local anesthetics (with or without opioids) into the third trimester. When the pregnant patient is in the supine posi- epidural space to block the aforementioned spinal segments. The patient remains alert and coopera- lateral tilt, usually achieved with a pillow under the woman’s right tive. In the absence of complications, there are no ill effects on the hip, is an important positioning maneuver. Epidural analgesia can be therapeutic for patients with pre- eclampsia or cardiac disease where a high catecholamine state is detrimental. Finally, the level and intensity of an epidural block can be extended to provide anesthesia for operative delivery (Cae- sarian section). As well as blocking sensory fibres, local anesthetics in the epidural space interrupt transmission along sympathetic and motor neu- rons. The hypotension associated with sympathetic blockade can be minimized by a one litre bolus of crystalloid prior to institution of the block, slow titration of the local anesthetic, the use of lower concentrations of local anesthetic and vigilant guarding against aor- tocaval compression. Whether it also leads to an increased incidence of op- nant patient are those related to the respiratory system. The degree of motor block the risks of aspiration and failed intubation, and the depressant ef- can be minimized by using lower concentrations of local anesthet- fects of anesthetic agents on the fetus, general anesthesia is ics along with opioid adjunct. The use of a local anesthetic infusion avoided (where possible) in the parturient undergoing Caesarian (as opposed to boluses or “top-ups”) may give a more consistent section. Regional anesthesia is the preferred technique and can be level of block, lower total dose of local anesthetic, less motor block provided by administering spinal anesthesia or by extending the and less risk of drug toxicity. These include coagulopathy, hypovolemia, infection, certain cardio- vascular conditions and patient refusal. The second situation where a regional technique may not be appro- priate is in the setting of severe fetal distress.

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    At the axon terminal generic levitra soft 20 mg overnight delivery, the electrical signal prompts the release of a chemical signal called a neurotransmitter that carries the message across the synaptic cleft to elicit a response in the neighboring cell levitra soft 20mg. Neurotransmitters can be classified as paracrines because, upon their release from a neuron’s axon terminals, they travel across a microscopically small cleft to exert their effect on a nearby neuron or muscle cell. A hydrophobic hormone diffuses through the cell membrane and binds to the intracellular hormone receptor, which may be in the cytosol or in the cell nucleus. This initiates the transcription of a target gene, the end 1380 Answer Key result of which is protein assembly and the hormonal response. This can raise blood calcium levels so excessively that calcium deposits begin to accumulate throughout the body, including in the kidney tubules, where they are referred to as kidney stones. Estrogens play an important role in the development of the female reproductive tract and secondary sex characteristics. All insulin-dependent cells of the body require insulin in order to take up glucose from the bloodstream. Destruction of the beta cells would result in an inability to produce and secrete insulin, leading to abnormally high blood glucose levels and the disease called type 1 diabetes mellitus. For example, gastrin is secreted in response to stomach distention and causes the release of hydrochloric acid in the stomach. Secretin is secreted when acidic chyme enters the small intestine, and stimulates the release of pancreatic bicarbonate. In contrast, andropause is a much more gradual and subtle decline in testosterone levels and functioning. A man typically maintains fertility until very old age, although the quantity, quality, and motility of the sperm he produces may be reduced. Chapter 18 1 There are values given for percent saturation, tension, and blood gas, and there are listings for different types of hemoglobin. Acute myelogenous leukemia impairs the production of erythrocytes and other mature formed elements of the myeloid stem cell lineage. A burn is especially likely to increase the proliferation of leukocytes in order to ward off infection, a significant risk when the barrier function of the skin is destroyed. Chapter 19 1 The pressure gradient between the atria and the ventricles is much greater than that between the ventricles and the pulmonary trunk and aorta. Without the presence of the chordae tendineae and papillary muscles, the valves would be blown back (prolapsed) into the atria and blood would regurgitate. However, the papillary muscles also contract, placing tension on the chordae tendineae and holding the atrioventricular valves (tricuspid and mitral) in place to prevent the valves from prolapsing and being forced back into the atria. The semilunar valves (pulmonary and aortic) lack chordae tendineae and papillary muscles, but do not face the same pressure gradients as do the atrioventricular valves. As the ventricles relax and pressure drops within the ventricles, there is a tendency for the blood to flow backward. However, the valves, consisting of reinforced endothelium and connective tissue, fill with blood and seal off the opening preventing the return of blood. Beginning with all chambers in diastole, blood flows passively from the veins into the atria and past the atrioventricular valves into the ventricles. When ventricular pressure rises above the pressure in the two major arteries, blood pushes open the two semilunar valves and moves into the pulmonary trunk and aorta in the ventricular ejection phase. When the pressure falls below that of the atria, blood moves from the atria into the ventricles, opening the atrioventricular valves and marking one complete heart cycle. In order for the heart to maintain adequate flow to overcome increasing afterload, it must pump more forcefully. From the head, these are the truncus arteriosus, bulbus cordis, primitive ventricle, primitive atrium, and sinus venosus. The bulbus cordis develops into the right ventricle, whereas the primitive ventricle becomes the left ventricle. As their own lumen averages just 30 micrometers or less, arterioles are critical in slowing down—or resisting—blood flow.

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