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Patient satisfaction is higher when clinicians:  Smiled a lot  Used an expressive tone of voice  Increased eye contact and face  Leaned forward  Gestured (Griffith et al 2003) Listening It is important to actively listen to the patient buy generic hydrochlorothiazide 25 mg online. The important behavioural aspects of effective listening are: S-O-L-E-R  Sit squarely in relation to the patient  Maintain an Open position  Lean slightly towards the client  Maintain Eye contact with the patient  Relax around the patient (Egan 1990) Barriers to effective listening:  Temptation to tell them what to do buy 12.5 mg hydrochlorothiazide overnight delivery, as opposed to letting them share their feelings  Not enough time to listen, share feelings, experiences  A feeling of vulnerability and fear of what the patient may ask (Donoghue and Siegel 2005) Responding to difficult emotions 1) Acute emotional distress Acute stress disorder is present in almost one third of patients after diagnosis (Kangas et al 2007). A distressed patient may be one who is demanding, unable to make decisions or angry (Bylund et al 2006; Knobf 2007). Patients exhibit a range of emotions post diagnosis including, mood changes such as:  Worry  Concerns with body image  Sadness  Sexuality  Anger  Employment  Fear of recurrence  Relationship issues 119 Responses of the clinician to emotional distress  Listen; ask open ended questions and show care, compassion and interest. Clinicians meeting anger may feel threatened, become defensive or, indeed, angry in response. These reactions are generally considered unhelpful as they are likely to result in an escalation of the patients anger (Cunningham, 2004). Develop a shared understanding of the experience, and develop shared goals from this point. After being told their diagnosis, approximately 20% of patients deny they have cancer; 26% partially suppress awareness of implementing death and 8% demonstrate complete denial (Greer, 1992). Strategies and communication skills for clinicians  Exclude misunderstanding or inadequate information  Determine whether denial requires management  Explore emotional background to fears  Provide information tailored to the needs of the patient and clarify goals of care  Be aware of cultural and religious issues  Monitor the shifting sand of denial as the disease progresses  Aim to increase a person’s self esteem, dignity, moral and life meaning (Greer 1992; Watson et al 1984; Erbil et al 1996; Schofield et al 2003) Useful Link for communication skills in cancer care: http://pro. Other Programmes to Support Cancer Patients Travel2Care scheme This scheme helps patients who are suffering from genuine financial hardship with travel costs due to travelling to a cancer centre. Care to drive programme Care to Drive is a volunteer-led transport initiative in which the Irish Cancer Society recruits and trains volunteers to drive patients to and from their chemotherapy appointments. Tax relief can also be claimed back on travelling costs for insured cancer patients. Dengue Fever 1 Introduction Dengue has a wide spectrum of clinical presentations, often with unpredictable clinical evolution and outcome. Reported case fatality rates are approximately 1%, but in India, Indonesia and Myanmar, focal outbreaks away from the urban areas have reported case- fatality rates of 3-5%. To observe for the following Danger signs and report immediately for hospital admission • Bleeding: - red spots or patches on the skin - bleeding from nose or gums - vomiting blood - black-coloured stools - heavy menstruation/vaginal bleeding • Frequent vomiting • Severe abdominal pain • Drowsiness, mental confusion or seizures • Pale, cold or clammy hands and feet • Difficulty in breathing Out -patient laboratory monitoring- as indicated • Haematocrit • White cell count • Platelet count 5. If not tolerated, start intravenous isotonic fluid therapy with or without dextrose at maintenance. If the haematocrit remains the same, continue with the same rate for another 2–4 hours and reassess. If the vital signs/haematocrit is worsening increase the fluid rate and refer immediately. Start with 5–7 ml/kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response. If the haematocrit remains the same or rises only minimally, continue with the same rate (2–3 ml/kg/hr) for another 2–4 hours. If the vital signs are worsening and haematocrit is rising rapidly, increase the rate to 5–10 ml/kg/hour for 1–2 hours.

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When diaphragm contracts hydrochlorothiazide 12.5mg on line, abdominal contents are pushed downward and the ribs are lifted upward and outward order hydrochlorothiazide 12.5mg amex. Compliance of lung and chest wall are inversely correlated with their elastic properties (elastance) Changes in lung compliance: Increase in lung compliance may occur due to loss of elastic fibers (e. Surfactant is lacking in premature infants, causing neonatal respiratory distress syndrome. Intrapleural and alveolar pressure are given in reference to atmospheric pressure Rest. Intrapleural pressure is negative (~ -5cmH2O) because opposing forces of lungs trying to collapse and chest wall trying to expand creates negative pressure in intrapleural space. The expanding force on the 238 lungs and airways at rest is + 5cmH2O (alveolar or airway pressure minus intraplural pressure) Inspiration. The reason is as lung volume increases, elastic recoil strength of lungs increases. The two effects together cause intrapleural pressure to be more negative (~ -8cmH2O). Alveolar pressure becomes positive (higher than atmospheric) because the elastic forces of the lung compress air in the alveoli. Following expiration, volume in the lung decreases and intrapleural pressure returns to its resting volume (i. Refers to energy expended to: • Expand elastic tissues of chest wall and lungs (compliance work) • Overcome viscosity of inelastic structures of chest wall and lungs (tissue resistance work). Alveolar gas exchange Gas exchange in the respiratory system refers to diffusion of oxygen and carbon dioxide in the lungs and in the peripheral tissues. Oxygen is transferred from alveolar gas into pulmonary capillary blood and, ultimately it is delivered to the tissues, where it diffuses from systemic capillary blood into the cells. Carbon dioxide is delivered from the tissues 239 to venous blood, (to pulmonary capillary blood), and is transferred to alveolar gas to be expired. Dalton’s law of partial pressure states that each gas contributes to the total pressure in direct proportion to its relative concentration. Henry’s law states that the actual concentration of dissolved gas in a liquid is equal to the partial pressure of the gas in contact with the liquid multiplied by the solubility coefficient of the gas in that particular liquid. Rate of transfer by diffusion is directly proportional to driving force, diffusion coefficient and surface area available for diffusion, but inversely proportional to thickness of membrane barrier. Total gas concentration in solution = dissolved gas + bound gas + modified gas Dissolved gas: For a given partial pressure, the higher the solubility of gas the higher the concentration in solution. PaO2 (practical pressure of O2 is arterial system) is slightly less than 100 mmHg because of physiological shunt. Physiologic shunt refers to the fraction of pulmonary blood flow that bypasses the alveoli, therefore is not arterialized. If shunt is small, then A-a is small (normal), If abnormal, A-a difference increases.

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The renal columns are connective tissue extensions that radiate downward from the cortex through the medulla to separate the most characteristic features of the medulla order 12.5mg hydrochlorothiazide with amex, the renal pyramids and renal papillae hydrochlorothiazide 25mg with visa. The papillae are bundles of collecting ducts that transport urine made by nephrons to the calyces of the kidney for excretion. The renal columns also serve to divide the kidney into 6–8 lobes and provide a supportive framework for vessels that enter and exit the cortex. Emerging from the hilum is the renal pelvis, which is formed from the major and minor calyxes in the kidney. The renal arteries form directly from the descending aorta, whereas the renal veins return cleansed blood directly to the inferior vena cava. Nephrons and Vessels The renal artery first divides into segmental arteries, followed by further branching to form interlobar arteries that pass through the renal columns to reach the cortex (Figure 25. The interlobar arteries, in turn, branch into arcuate arteries, cortical radiate arteries, and then into afferent arterioles. The afferent arterioles form a tuft of high-pressure capillaries about 200 µm in diameter, the glomerulus. The rest of the nephron consists of a continuous sophisticated tubule whose proximal end surrounds the glomerulus in an intimate embrace—this is Bowman’s capsule. After passing through the renal corpuscle, the capillaries form a second arteriole, the efferent arteriole (Figure 25. These will next form a capillary network around the more distal portions of the nephron tubule, the peritubular capillaries and vasa recta, before returning to the venous system. As the glomerular filtrate progresses through the nephron, these capillary networks recover most of the solutes and water, and return them to the circulation. Since a capillary bed (the glomerulus) drains into a vessel that in turn forms a second capillary bed, the definition of a portal system is met. This is the only portal system in which an arteriole is found between the first and second capillary beds. The efferent arteriole is the connecting vessel between the glomerulus and the peritubular capillaries and vasa recta. Cortex In a dissected kidney, it is easy to identify the cortex; it appears lighter in color compared to the rest of the kidney. About 15 percent of nephrons have long loops of Henle that extend deep into the medulla and are called juxtamedullary nephrons. Even then, serial sections and computer reconstruction are necessary to give us a comprehensive view of the functional anatomy of the nephron and its associated blood vessels. The term forming urine will be used hereafter to describe the filtrate as it is modified into true urine. The principle task of the nephron population is to balance the plasma to homeostatic set points and excrete potential toxins in the urine. Renal Corpuscle As discussed earlier, the renal corpuscle consists of a tuft of capillaries called the glomerulus that is largely surrounded by Bowman’s (glomerular) capsule. It transitions onto the glomerular capillaries in an intimate embrace to form the visceral layer of the capsule. Here, the cells are not squamous, but uniquely shaped cells ( podocytes) extending finger-like arms ( pedicels) to cover the glomerular capillaries (Figure 25. These projections interdigitate to form filtration slits, leaving small gaps between the digits to form a sieve. Where the fenestrae (windows) in the glomerular capillaries match the spaces between the podocyte “fingers,” the only thing separating the capillary lumen and the lumen of Bowman’s capsule is their shared basement membrane (Figure 25.

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