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    But if unconscious discount 260 mg extra super avana visa, place in prone position with head over the edge of the bed or head lower than the body discount 260mg extra super avana free shipping. Measure the tube from the tip of the nose up to the ear lobe and from the bridge of the nose to the end of the sternum. Gently pass the tube over the tongue, slightly to one side of the midline towards the pharynx. Ask patient to swallow while inserting the tube and allow to breath in between swallowing. If air bubbles, cough and cyanosis are noticed the tube is with drawn and procedure commenced again. After inserting, place funnel end in a basin of water to check if the tube is in the air passage. Fill the small pint measure and power gently until the funnel is empty, then invert over the pail. If required, and continue the process until the returned fluid becomes clear and the prescribed solution has been used. Before solution stops running, turn up funnel and add another quantity of solution 7. In case of gastrointestinal obstruction, to remove the stomach or gastric contents Basic Nursing Art 93 3. To aspirate the stomach contents for diagnostic purposes There are two type of gastric Aspiration 1. Intermittent method: - In this case, Aspiration is done as condition requires and as ordered. Continues method: - Attached to a drainage bag There are 2 ways of supplying suction a. An electric suction machine The continues method is indicated when it is absolutely necessary and desirable to keep the stomach and duodenum empty and at rest. Explain procedure to patient, in order to gain her/his co-operation Basic Nursing Art 94 2. Insert the tube as directed in nasal feeding and ask the patient to swallow as the tube goes down. Instruct patient to open her or his mouth to make sure the tube is in the stomach 7. Always measure the amount withdrawn accurately noting color, contents and small 3. Enema Enema: is the introduction of fluid into rectum and sigmoid colon for cleansing, therapeutic or diagnostic purposes. Purpose: • For emptying – soap solution enema the cloth • For diagnostic purpose Barium enema Basic Nursing Art 95 • For introducing drug/substance (retention enema) Mechanisms of some solutions used in enema 1. Soap solution: increases peristalsis due to irritating effect of soap to the lumenal mucosa of the colon. Classified into: ƒ Cleansing (evacuation) ƒ Retention ƒ Carminative ƒ Return flow enema Cleansing enema is of two kinds: 1. High enema ƒ Is given to clean as much of the colon as possible ƒ The solution container should be 30-45 cm about the rectum 2. Low enema ƒ Is administered to clean the rectum and sigmoid colon only Guidelines o o Enema for adults are usually given at 40-43 c and for children at 37. Colonoscopy ƒ To remove feces prior to a surgical procedure or a delivery ƒ For incontinent patients to keep the colon empty ƒ For diagnostic test E. Epsum salt 15 gm – 120 gm in 1,000 ml of H2O Cleansing Enema Procedure ƒ Inform the patient about the procedure ƒ Put bed side screen for privacy ƒ Attach rubber tube with enema can with nozzle and stop cock or clamp ƒ Place the patient in the lateral position with the Rt. Procedure Similar with the cleansing enema but the enema should be administered very slowly and always be preceded by passing a flatus tube Note 1. Kinds of solution used to supply body with fluid are plain H2O, normal saline, glucose 5% sodabicarbonate 2-5% 6.

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    And quite different are the consequences: an influenza pandemic may be a thousand times more deadly than even the deadliest tsunami discount extra super avana 260 mg without prescription. The next pandemic may be relatively benign order extra super avana 260 mg otc, as it was in 1968 and 1957, or truly malignant, as was the 1918 episode. We don’t know if the next pandemic will be caused by the current bête noire, H5N1, or by another influenza strain. We ignore how the next pandemic will evolve over time, how rapidly it will spread around the world, and in how many waves. The ongoing outbreak of H5N1 influenza among birds with occa- sional transmission to human beings is of major concern because of intriguing par- allels between the H5N1 virus and the 1918 influenza strain. As the threat is global, strategies must be global – a tricky task when our planet is divided into more than two hundred nations. In the following paragraphs, we shall take a look at the various facets of the war on influenza: the global and individual impact of the disease, the virus itself, and the individual and global management of what may one day turn out to be one of the most challenging healthcare crises in medical history. The most important thing to remember when talking about pandemic influenza is that its severe form has little in common with seasonal influenza. Global Impact Epidemics and Pandemics Influenza is a serious respiratory illness which can be debilitating and cause com- plications that lead to hospitalisation and death, especially in the elderly. Every 18 Influenza 2006 year, the global burden of influenza epidemics is believed to be 3–5 million cases of severe illness and 300,000–500,000 deaths. The new variants are able to elude human host defences and there is therefore no lasting immunity against the virus, neither after natural infection nor after vaccination, as is the case with smallpox, yellow fever, polio, and measles. These permanent and usually small changes in the antigenicity of in- fluenza A viruses are termed “antigenic drift” and are the basis for the regular oc- currence of influenza epidemics (Figure 1). In addition, there is now evidence that multiple lineages of the same virus subtype can co-circulate, persist, and reassort in epidemiologically significant ways (Holmes 2005). These major changes in the antigenicity of an influenza virus are called “antigenic shift” (Figure 2). Table 1: Antigenic Shifts and Pandemics* Designation Resulting Pandemic Death Toll 1889 H3N2 Moderate? The new viral strain will eventually reach everywhere, and will infect practically every human being within a period of a few years. Seasonal excess mortality rates due to pneumonia and influenza may remain elevated for many years, as was shown in the A(H3N2)- dominated seasons in the decade after 1968, in persons aged 45–64 years in the United States (Simonsen 2004). Courtesy: National Institute of Allergy and Infectious Disease Global Impact 21 One hallmark of pandemic influenza is a mortality shift towards younger age groups. Half of influenza-related deaths during the 1968 pandemic, and large pro- portions of influenza-related deaths during the 1957 and the 1918 pandemics, oc- curred among persons < 65 years old (Simonson 1998). It was the worst pandemic in history, killing more people than World War I, and it is generally assumed that at least 50 million people died (Johnson 2002). The first wave, which started during the spring of 1918, was highly contagious but not particularly deadly. Symptoms in 1918 were so unusual that, initially, it was misdiagnosed as dengue fever, cholera, or typhoid (Barry 2004). In contrast to subsequent pandemics, most deaths during the 1918 pandemic were among young and healthy persons aged 15 to 35 years old, and 99 % of deaths occurred in people younger than 65 years. According to this investigation, the 1918 virus was not a reassortant virus (like those of the 1957 and 1968 pandemics), but more likely an entirely avian-like virus that adapted to humans. Patients with chronic underlying disease and pregnant women were particularly at risk of developing pulmonary complications (Louria 1957). The mortality impact was not even particularly severe compared to the severe epidemic in 1967–1968 (the last H2N2 epidemic), as well as two severe H3N2 epidemics in 1975–1976, and in 1980–1981 (Simonsen 2004). The death toll has been estimated to have been around 1 million, and in the United States, nearly 50 percent of all influenza-related deaths occurred in the younger population under 65 years of age. Sero-archaeological studies showed that most individuals aged 77 years or older, had H3 antibodies before they were exposed to the new pandemic virus (Dowdle 1999) and that pre-existing anti- H3 antibodies might have protected the elderly (> 77 years old) during the 1968 H3N2 pandemic. Since 1968, there has been only one episode – in 1976 – when the start of a new pandemic was falsely anticipated (Dowdle 1997, Gaydos 2006, Kilbourne 2006). Current Situation Major pandemics have occurred throughout history at an average of every 30 years and there is a general consensus that there will be another influenza pandemic. One possible candidate is the avian H5N1 strain which has become endemic in wild waterfowl and in domestic poultry in many parts of Southeast Asia, and is recently spreading across Asia into Europe and Africa. Recent research has shown that just ten amino acid changes in the polymerase proteins differentiate the 1918 influenza virus sequences from that of avian viruses, and that a number of the same changes Individual Impact 23 have been found in recently circulating, highly pathogenic H5N1 viruses (Taubenberger 2005).

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    States are counseling and/or psychotherapy extra super avana 260mg with visa, and free to choose whether or not to include tobacco 143 diagnosis extra super avana 260 mg cheap, treatment, assessment and cessation benefits for other enrollees. Eight states covered group counseling for all Medicaid  Outpatient rehabilitation services, including enrollees, five covered group counseling only diagnostic and treatment services. States for enrollees in some programs (fee for service providing optional benefits under Medicaid or managed care) and five states covered group often choose this option since it does not counseling for pregnant women only. As of require services to be provided under the 2009, 34 states covered the nicotine patch for all direction of a physician and instead permits Medicaid enrollees, 33 covered bupropion, 32 the delivery of services including mutual covered nicotine gum, 32 covered varenicline, support by community paraprofessionals and 28 covered nicotine nasal spray, 27 covered 138 nicotine inhalers and 25 covered nicotine peers; 144 lozenges. As of 2011, six state Medicaid 139 programs provide comprehensive coverage for  Clinic services; and smoking cessation treatments for all Medicaid 140 enrollees, while five state Medicaid programs  Case management services. Last, states may provide addiction treatment services as part of a Medicaid managed care † 141 Medicare. Medicare covers the their eligibility requirements and benefits, following services, when medically necessary: individuals have substantially different access to care depending on the state in which they live. States  Tobacco cessation counseling from a that opt simply to expand their Medicaid qualified physician or practitioner for all * programs are required to follow the rules and smokers and tobacco cessation medications 157 151 requirements of Medicaid. States also may use a benefits package that is † Annual limits are caps that insurers place on the actuarially equivalent to one of the benchmark plans, benefits an enrollee is entitled to each year. Lifetime limits are caps on results in a cost increase of greater than two percent expenditures, on specific services or both during an in the first plan year and greater than one percent in individual’s lifetime. For some of those allowed visits or length of stay, however, does who were successful in becoming insured, co- not accord with best practices for treating cases insurance and co-payments rendered treatment 164 169 of addiction that are chronic and relapsing. Furthermore, coverage for for addiction treatment benefits were 170 mental health and addiction services varies unaffected. Yet arise from its passage, many limitations remain rather than defining what these services must both in policy and practice. As a result, individual market (“grandfathered”) health 173 care may transition toward outpatient plans. Within limits--the plan must be comparable to a In the years following, addiction treatment benchmark plan: (1) the largest plan by enrollment in admission rates did not increase significantly. If it is deemed unconstitutional and severable, then the prohibitions against excluding patients with pre-existing conditions and charging higher premiums based on a person’s medical history also might be invalidated. In spite of the evidence that risky use of addictive substances is a public health problem and addiction is a disease: *  Most health professionals are not sufficiently trained to educate patients about risky use and addiction, conduct screening and interventions for risky use or diagnose and treat addiction;  Most of those who currently are providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to prove the full range of evidence-based † 1 services to address addiction effectively; and * The term “health professional” as used in this report includes medical professionals (physicians, physician assistants, nurses and nurse practitioners, dentists, pharmacists) and graduate-level clinical mental health professionals (psychologists, social workers, counselors). All health professionals can be trained to educate patients about risky use and addiction and screen for these conditions; brief interventions also can be conducted by appropriately trained health professionals. Diagnosis and treatment requires a trained physician with the exception of psychosocial treatments which can be provided by trained graduate-level clinical mental health professionals working with a managing physician. A nationally representative survey of accountability gap in addiction treatment is the addiction treatment facilities found that one- fact that there are no national standards; instead, quarter of the program directors were not full- there is considerable inconsistency among states time employees; only two of the programs in the regulation of individual treatment surveyed were directed by a physician; 54 providers and of the programs and facilities that percent employed a part-time physician; less * provide addiction treatment services. An older study found that medical addiction, treatment is provided within a highly- professionals and graduate-level counselors each regulated health care system. In contrast, made up only about 17 percent of the full-time patients with the disease of addiction are staff of addiction treatment facilities and that referred to a broad range of providers largely only 12. Another study found that more many of whom the main qualification may be than a third of clinical supervisors lack any type 8 that they themselves have a history of addiction) of graduate degree. Unlike patient care in the mainstream medical system, which is delivered by highly educated The Size and Shape of the and trained professionals, the staff primarily responsible for patient care in addiction Addiction Treatment Workforce treatment facilities is comprised largely of addiction counselors, many of whom while Given the extensive prevalence of addiction in highly dedicated to addiction care have only a the U. The Bureau of Labor significant shortage of qualified addiction 3 Statistics reports that there were 76,600 treatment providers. One study collected from 1996 to 1997, there are 134,000 found that 50 percent of facilities have full-time full-time staff and 201,000 total staff (including counselors on staff who have no degree; 58. May counsel individuals, families or Data on the numbers of professionals who currently groups or engage in prevention programs. This estimate entailed online reviews and updates (using the still falls far short of the estimated minimum of Internet and the Lexis/Nexis database) of publicly- 6,000 full-time addiction medicine specialists available federal and state laws and regulations (in all currently needed to meet addiction treatment 50 states and the District of Columbia) and of 17 professional association Web sites. Even this projection of workforce Columbia’s analysis examined the minimum need in addiction medicine may underestimate licensing and certification requirements to practice in the need in several ways: (1) it does not include each profession in the 50 states and the District of adolescents; (2) it does not include addiction Columbia, and optional certifications. The analysis ‡ involving nicotine; (3) it does not include sought to develop a summary overview of the institutionalized individuals; (4) it assumes that regulatory landscape.

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    Immediately before use discount 260mg extra super avana fast delivery, mix the suspension by inverting the tube several times until the cells are in suspension purchase extra super avana 260mg mastercard. Add one drop of anti- A serum to the tube labeled ‘anti-A’ and one drop of anti- B to the tube labeled anti- B’ 3. Mix the antiserum and cells by gently tapping the base of each tube with the finger or by gently shaking 5. Read the results by tapping gently the base of each tube looking for agglutination or haemolysis against a well- lighted white background. Slide reverse grouping is not reliable as serum antibodies agglutinate most cell samples when centrifuged, and use of test tube enhances the agglutinated reaction. Add one drop of 2-5% A cells to the tube labeled ‘A cells’ and one drop of 2-5% B cells to the tube labeled ‘B cells’. Read the results by tapping gently the base of each tube looking for agglutination or haemolysis against a well- lighted white background. These include: contaminated reagents or dirty glass ware, over centrifugation, incorrect serum: cell ratio, under centrifugation or incorrect incubation temperature, failure to add test specimen or reagents, and the like. If carefully controlled repeat testing yields the same agglutination patterns, the variation can be assigned to one of the following four categories. Missing or weak reacting antibodies Age: testing of infants who have not begun to produce their own antibodies, or who possess antibodies that have been passively acquired from the mother, or during testing of elderly persons whose antibody levels have declined. Hypogamaglobulininemia: in conditions in which hypogamaglobulininemia may be demonstrated, these include lymphomas, leukemias, immunodeficiency disorders, use of 42 immunosuppressive drugs, and following bone marrow transplantation. Resolution: Enhancing reaction in reverse grouping by incubating of patients serum with the red cells at room 0 0 temperature for 15 min or incubation at 16 C or 4 C for 15 min. Missing weak antigens Sub groups of A or B antigens: The A or B antigens may be weakly expressed because of an unusual genotype (i. Blood group specific substances: in conditions like ovarian cyst & carcinomas, blood group specific substance may be of such high concentration is that anti-A & and – B are neutralized when unwashed cells are used. Acquired B antigen: effect of bacterial enzymes & absorption of bacterial polysaccharide on to the red cells of group A or O patients results in B specificity which involve weak B antigen reaction in the forward grouping. Mixtures of blood: Mixture of cell types in recently transfused patients or recipients of bone marrow transplants can produce unexpected reactions in forward typing. Resolution: - Investigating the possibility of sub groups of A&B - Investigating the diagnosis - Washing the patient’s red cells in saline to eliminate the problem with blood group specific substances. Additional antibody Autoantibody: cold autoantibodies can cause spontaneous agglutination of the A and B cells used in reverse grouping. Patients with warm autoimmune hemolytic anemia may have 44 red cells coated with sufficient antibody to promote spontaneous agglutination. Irregular antibodies: Irregular antibodies in some other blood group system may be present that react with antigens on the A or B cells used in reverse grouping. Resolution: 0 - Washing the patient red cells in warm (37 C) saline to establish cold autoantibodies as the cause. Plasma Abnormalities Increased gamma globulin: elevated levels of globulin from certain disease states such as multiple myeloma result in rouleaux formation. Wharton’s jelly: when cord blood is used, reverse grouping may be affected by wharton’s jelly which causes rouleaux. Give a description for grade of agglutination reaction as recommended by the America blood bank society. They 48 immunized guinea pigs and rabbits with blood from the Macacus rhesus monkey, and the antiserum obtained agglutinated not only the red cells of the rhesus monkey but also 85% of humans. They realized that this serum which they called anti-Rh was about detecting an unknown human blood group antigen which, independent of all other blood groups discovered before that time. They used it to type as Rh positive those donors whose red cells were agglutinated by the new antibody and as Rh negative to those whose red cells were not so agglutinated. Levine and Stetson also postulated that the antibody had arisen as the result of immunization of the mother by a fetal antigen which had been inherited from the father. Later work demonstrated that the animal or rabbit anti- Rhesus and human anti-Rh are not the same, and were not detecting the same antigen but the system had already named the human antibody as anti-Rh.

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