Suhagra

By F. Ramon. Arcadia University.

The dose varies with the size order suhagra 100 mg otc, surface area, the age of the child and the nurse has no standard dose as is customary for adult patients. Since the dose is relatively small, a slight mistake in amount of drug given makes a greater proportional error in terms of the amount ordered than with the adult dose. A) Oral administration: Infants will generally accept the medication put into their mouth, provided that it is in a form which they can deadly swallow. The nurse should sit-down and hold infant or if he cannot be removed from his crib, raises him to sitting position or if this is contraindicated elevate his head and shoulders. Medication can be given from medication glass, the tip of teaspoon or rubber-tipped medicine dropper. The child should be told to place the tablet near the back of his tongue and to drink the water, fruit juice, milk offered him in order to wash down the tablet. In younger seriously sick children, tablets crushed and dissolved in water can be given by spoon or through Naso- gastric tube 25 Pediatric Nursing and child health care B) Intramuscular Injections: The procedure of using an intramuscular injection is the same as for the adults. The needle used for intramuscular injection must be long enough so that the medication should be given deeply into the muscle tissue in order to be absorbed properly. C) Intravenous Administration: When a patient’s gastrointestinal tract can not accept food, nutritional requirements are often met intravenously. Parental administration may include high concentrations of glucose, protein or fat to meet nutritional requirements. Many medications are delivered intravenously, either by infusion or directly into the vein. The ability to gain access to the venous system for administering fluid and medications is an expected nursing skill in many settings. They are responsible for selecting the appropriate venipuncture site and being proficient in the technique of vein entry. Ideally, both arms and hands should be carefully inspected before a specific venipuncture site is chosen. To prepare for Gavage feedings, the space from the bridge of the infant’s nose to the earlobe to a point halfway between the xiphoid process and the umbilicus is measured against a No 8 or 10 Gavage tube for children over one year measure from the bridge of the nose to the earlobe to the xiphoid process. The tube is marked at this point by a small Kelly clamp or 27 Pediatric Nursing and child health care piece of tape to ensure that it reaches the stomach after it is passed. Although the tube is passed into the stomach, it is occasionally passed into the trachea accidentally, oil left in the trachea could lead to lipoid pneumonia, a complication that a child already burdened with disease may not be able to tolerate. Once you are assured that the catheter is in the stomach, attach a syringe or special feeding funnel to the tube. Be certain that the child’s head and chest are slightly elevated to encourage fluid to flow downward into the stomach. Then feed with funnel or syringe and allow it to flow by gravity into the child’s stomach. When the total feeding has passed through the tube, the tube is reclamped securely and then gently and rapidly withdrawn to reduce the risk of aspiration. If the tube is to be remain in place, it should be flashed with 1 to 5 ml of sterile water and cupped to seal out air. Cardiac arrest follows quickly after respiratory arrest as soon as the heart muscle is affected by the anoxia, which occurs. The outcome for the child will depend to great extent on the speed with which resuscitation is began. The steps for resuscitation can be remembered as “A, B, C, D” where A is for airway, B for breathing and C is for circulation and D is for drug administration. Oxygen administration: Oxygen administration elevates the arterial saturation level by supplying more available oxygen to the respiratory tract. Nursing care must be planned carefully when children are in tents: • The tent should be open as little as possible so that as high an oxygen concentration as possible can be maintained. Most children do not like nasal catheter because it is irritant; assess the nostrils of the infant carefully when using nasal catheter. The pressure of catheter can cause areas of necrosis, particularly on the nasal septum. Administering Enemas: Enemas are rarely used with children unless a part of preoperative preparation or are required for radiological study. The usual amount of enema solution used are as follows: • Infant: less than 250 ml • Preschooler: 250-350 ml • School age child: 300-500 ml • Adolescent: 500 ml 30 Pediatric Nursing and child health care For an infant: • Use a small soft catheter (no 10 to 12 French) in place of an enema tip. This may be true, but such a diagnosis is difficult to prove and should never be made without taking a careful history and performing a proper examination in any child with fever. Young children appear to tolerate fever better than adults but some develop convulsions. If you still do not have a definite cause for the fever, rule out (Malaria, Early measles, Pneumonia, meningitis) A) Features of Febrile convulsions: • Begin between 6 month and 5 years of age • Incidence is 3 % by 5 years of age • Epilepsy develop in 3 % of cases • % are neurologically abnormal • 30 % of cases develop further seizure with fever • Febrile seizures lasting over 30 minutes are more serious • Repeated convulsions may damage the brain. The best treatment is controlling and preventing high fever rather than giving continuous anticonvulsants.

Causes /risk factors - Use of maternal estrogen or progesterone during pregnancy - Hereditary Signs and symptoms - Difculty directing the urinary stream and stream spraying - Chordee - Males with this condition ofen have a downward curve (ventral curvature or chordee) of the penis during an erection - Abnormal spraying of urine - Having to sit down to urinate - Malformed foreskin that makes the penis look “hooded” Investigations - A physical examination can diagnose this condition - A buccal smear and karyotyping - Urethroscopy - cystoscopy - Excretory urography Complications - Difculty with toilet training - Problems with sexual intercourse in adulthood - Urethral strictures and fstulas may form throughout the boy’s life Management - Infants with hypospadias should not be circumcised - For a Minor degree of hypospadias (e discount 100mg suhagra overnight delivery. Te repair may require multiple surgeries 178 Surgery Clinical Treatment Guidelines Chapiter 7: Genito-Urinary Disorders 7 • Relief of the chordee • Urethral reconstruction • In some cases, more surgery is needed to correct fstulas or a return of the abnormal penis curve Recommendations - Surgery is usually done before the child starts school - Surgery can be done as young as 4 months old, better before the child is 18 months old 7. Carcinoma of the Penis Te majority of penis malignancies are squamous cell carcinomas. Impotence Defnition: Persistent inability to obtain and sustain an erection sufcient for sexual intercourse. Causes - Psychological - Neurological causes (spinal cord lesions, myelodisplasia, multiple sclerosis, tabes dorsalis,peripheral neuropathies) - Diabetes mellitus - Endocrine (hypogonadotrophic hypogonadism Klinefelter’s Syndrome or surgical orchidectomy) - Low testosterone levels (prolactin producing tumors) - Vascular (atherosclerosis) - Trauma (perineal, posterior urethra, pelvic fracture leading to arterial injury, uraemicchronic dialysis - Iatrogenic (radical prostatectomy, cystoprostatectomy, neurological surgical procedures,transurethral endoscopic procedures, pelvic irradiation procedures) - Medication (centrally acting agents, anticholinergic agents (antidepressant), anti-androgenic agents (digoxin), hyperprolactinemic agent (cimetidine), sympatholitic agent (methyl dopa) Diagnosis - Detailed history - Physical examination - Length, plaques and deformity of the corporal bodies of penis - Presence or absence of testis - Size and consistency of the penis 180 Surgery Clinical Treatment Guidelines Chapiter 7: Genito-Urinary Disorders 7 - Gynecomastia (endrogene defciency) - Neurological assessment - Sensory function of the penis and perineal skin - Bulbo cavernosus refexe to evaluate the sacral refexes Investigations - Nocturnal penile turnescence (change in penis size during sleep) - Dynamic infusion cavernosometry and cavernosonography (to assess venous/corporal leak) Management Psychological • Treated by trained psychotherapist or sex therapist Medical therapy • Sildenafl(viagra), tadalafl (cialis) • Apomorphine (uprima) • Intracorporal administration of vasoactive substances (papaverine hydrochloride alone or associated with vasodilator like phentolamine, or prostaglandin E1) • Androgen replacement therapy with testosterone • Vacuum suction devices Surgical therapy • Penile prostheses • Vascular surgical techniques like micro surgical anastomosis of inferior epigastric artery to the dorsal penile artery Surgery Clinical Treatment Guidelines 181 Chapiter 7: Genito-Urinary Disorders 7. Urethra Meatal Stenosis Defnition: Is a narrowing of the opening of the urethra, the tube through which urine leaves the body. Causes - Not known - Predisposing factors are age, normally functioning testes, race, geographical location, sexual behavior, diet, alcohol, tobacco (no evidence that they play a part). Bladder Calculi/stones Defnition: Bladder calculi/stones are hard buildups of minerals that form in the urinary bladder. Causes - Calculi from the kidney - Bladder outfow obstruction - Presence of foreign bodies ( e. Bladder Cancer Defnition: Bladder cancer is a cancer that starts in the bladder; 90% is transitional cell carcinoma, 5-7% is squamous cell carcinoma, and 1-2% is adenocarcinoma/urachal carcinoma. Staging helps guide future treatment and follow-up and gives idea on patient prognosis. Cystocele Defnition: Is a medical condition that occurs when the tough fbrous wall between a woman’s bladder and her vagina is torn by childbirth, allowing the bladder to herniate into the vagina. Urinary Incontinence Defnition: Is the involuntary loss of urine Classifcation Classifcation of incontinence according to anatomical abnormality Class Sub- class Causes/risk factors Signs and symptoms Urethral Urethral Involuntary abnormalities incompetence urine loss Incontinence less common in men Urethral afer prostatectomy incontinence or pelvic fracture Bladder Inhibited detrusor Frequency and abnormality contractions by: urgency (urge Neuropathic incontinence) (detrusor hyperrefexia) non neuropathic (detrusor instability Non urinary impaired mobility abnormalities(in Impaired mental elderly patients) function Non urethral Fistula incontinence Ureteral ectopia Classifcation of incontinence according to clinical presentation Stress Ref. Vesico-Ureteric Refux Defnition: A congenital condition from the ureteral bud coming of too close to the urogenital sinus on the mesonephric duct which result in short intravesical length (intramural) of ureter. Urine travels retrograde from the bladder into the ureter and ofen into the kidney. Calculus Calcium stones (Ca oxalate, Ca phosphate) are the most common types in 70% of the cases. Management Palliation • Renal artery embolisation (may stop hematuria) • Chemotherapy (10% response rate) • Hormonal therapy (5% response rate) • Immunotherapy (under review) Surgery • Partial nephrectomy, if small peripheral lesions • Radical nephrectomy (Gerota’s fascia and regional lymphnodes) • Isolated lung metastases should also be removed surgically 7. Pelvi-Ureteric Junctions Defnition: Blockage of the ureter where it meets the renal pelvis. Cause - Congenital from either abnormalities of the muscles itself or crossing vessels. Signs and symptoms - Abdominal mass in the new born - Flank pain and infection in later life Surgery Clinical Treatment Guidelines 195 Chapiter 7: Genito-Urinary Disorders Investigations - Ultrasound - Diuretic renal scan Management - Pyeloplasty (Anderson- Hayne) 7. Tey account for approximately 10% of all renal tumours and approximately 5% of all urotherial tumours. A urethral catheter should be lef in situ for at least 10 days - High fstula (supratrigonal): Suprapubic approach 7. Posterior Urethral Valves Defnition: Obstructive urethral lesions usually diagnosed in male newborns and infants. Cause and Risk factors - Congenital Signs and symptoms - Assymptomatic till adolescence or childhood in incomplete valves - Urinary retention - Weak stream - Dysuria (infection) - Able to pass catheter without difculty Investigations - Urinalysis - Ultrasound scan - Voiding cyctogram (dilatation of the urethra above the valves) Management - Detect and treat early to avoid renal failure - Suprapubic catheter - Transurethral resection Surgery Clinical Treatment Guidelines 199 Chapiter 7: Genito-Urinary Disorders 7. Urethral Stricture Defnition: Congenital narrowing of the urethra Cause - Duplication of the urethra. Causes - Idiopathic - Predisposing factors: age, normally functioning testes, sexual behavior, diet, alcohol, tobacco (no evidence that they play a part) 200 Surgery Clinical Treatment Guidelines Chapiter 7: Genito-Urinary Disorders 7 Signs and symptoms - Nocturia - Urinary urgency and frequency - Acute urinary retention - Urinary tract infections - Renal failure - Urinary stones - Haematuria Management Conservative management Medical therapy • Alpha Blockers: e. Adenocarcinoma Defnition: Adenocarcinoma is a cancer originating in glandular epithelial tissue. Epithelial tissue includes, but is not limited to, skin, glands and a variety of other tissue that lines the cavities and organs of the body. It is of two forms, transitional cell carcinoma (> 90%) and squamous cell carcinoma (5-7%). Causes/Risk factors - Cigarette smoking - Chemical exposure at work (carcinogens - dye workers, rubber workers, aluminum workers, leather workers, truck drivers, and pesticide applicators) - Chemotherapy (e. Renal Cell Carcinoma Defnition: Renal cell carcinoma is a type of kidney cancer that starts in the lining of the kidney tubules. Burns Defnition: Burns are skin and tissue damage caused by exposure to or contact with temperature extremes, electrical current, a chemical agent or radiation. Electrical Burns Defnition: Electrical burns are body injuries caused by electrical current itself. Te current generates intense heat along its path through the body, which can lead to severe muscle, nerve and blood vessel damage.

C) Current national data on regional differences in The concentration of spending for addiction the proportion of individuals in need of † treatment in public programs suggests that addiction treatment are not available cheap suhagra 100 mg with amex. However, insurance across the board does not adequately other research indicates that the disparity cover costs of intervention and treatment, with between the number of people who need costly health and social consequences falling to addiction treatment and the number who receive ‡ government programs. National data indicate it varies substantially among states and regions 45 that those with private insurance are three to six of the country, with southern and southwestern times less likely than those with public insurance states having the largest estimated treatment § 52 to receive specialty addiction treatment. It is not possible to understood, possible explanations include determine from these data why treatment access variations among states in funding of treatment differed based on insurance type since the study services, including differences in coverage of the could not take into account important factors such as costs of these services in state managed care 48 individual characteristics and circumstances that may systems. One study found that only 21 percent relate both to type of insurance and likelihood of of the variation among states in the percent who treatment access (e. Therefore, the estimates reported in the federal, state and local categories are exclusive of the estimates of public funds spent through Medicare and Medicaid programs. E Expenditures by Providers and Components of Public Addiction Types of Services Treatment Spending (Total $22. I tried the emergency room; many times to get help for my addiction but due to the lack of insurance and money, was 56 denied. H Admissions to Publicly-Funded Addiction * While some addiction treatment programs may Treatment by Primary Substance address nicotine, they do not report these services in and Multiple Substances their treatment admission data. The number of patients in these facilities whose treatment is not admissions to addiction treatment; therefore, data publicly funded is unknown. K Of all the admissions to publicly-funded Sources of Referral to Publicly-Funded addiction treatment in 2009, 44. The fact Community sources of referral also include government agencies that provide aid in the areas of that the largest proportion of referrals to poverty relief, unemployment, shelter or social addiction treatment comes from the criminal welfare and referrals from defense attorneys. Referrals to treatment programs from health care § Addiction service providers are those programs, providers include those from physicians (including clinics or health care providers whose principal psychiatrists) or other licensed health professionals, objective is treating patients with addiction, or where or from a general hospital, psychiatric hospital, a program’s services are related to substance use mental health program or nursing home. The continuous treatment episode from the initiation of a data reported here do not include referrals to new treatment episode, some transfers may be detoxification programs. L) Available data on treatment venues to which referrals are made distinguish between intensive and non-intensive services provided in non- Figure 7. L Admissions to Different Types of residential settings and between short- and Treatment Service Venues longer-term services provided in residential 70 P settings: E 63. Intensive services are those T Non- Intensive Non- Short-Term Longer-Term that last at least two or more hours per day Intensive/Non- Residential Residential Residential for three or more days per week. The highest completion rates Non- Residential Residential were from venues to which there were the least Residential referrals: Total 63. M Percent of Treatment Admissions and Completions by Different Types of Treatment Service Venues, 2008 P Admissions 73. The general completion rate among all discharges (regardless of whether they were linked to admission data) was 42. The treatment completion rate for Variations in Treatment Completion by admissions involving multiple substances was 79 Source of Referral 38. Admissions to addiction treatment for which the Variations in Treatment Completion by Key source of referral was an employer were the Patient Characteristics most likely to complete treatment (57. No significant and individual sources--including concerned age-related differences in treatment completion family members, friends and the self-referred-- 80 were found. Concern about potential loss of complete treatment than were whites or blacks a job or criminal sanctions might help account (46. However, what is commonly viewed as denial might also be characterized as Existing data do not provide an explanation for a misunderstanding of the disease. As is the these differences and no data are available on case for seeking treatment for other health treatment needs and outcomes by funding source conditions such as diabetes, hypertension or 89 and type of service provided. Possible heart disease, most cases of denial that serve as contributing factors, however, might include that barriers to treatment access actually involve privately-funded admissions are likelier to cases in which a person with symptoms of involve less severe cases of addiction, those with addiction does not recognize that he or she has a 90 private resources may have greater access to treatable disease, underestimates the severity 91 effective support services or quality care, or of the disease or does not believe that the 92 those with private insurance may be less likely symptoms can be allayed through treatment. Continuing to misuse substances despite the associated harms is a In addition to the limited private sector coverage 94 defining symptom of the disease of addiction of addiction treatment and the lack of treatment and in many cases results from the changes that referrals from the health care system, many addictive substances produce in the structure and other barriers stand in the way of individuals function of the areas of the brain that control accessing and completing addiction treatment. Other not get the help they need is that they refuse to factors having to do with treatment quality are admit to having a problem or that they do not discussed in Chapter X. Another study found that all addictive substances including nicotine into between eight and 16 percent of people who had standard treatment protocols. Negative Public Attitudes and Behaviors Toward People with Addiction The most frequently-mentioned barrier to accessing treatment for addiction involving Related to widespread misunderstanding of the alcohol and drugs other than nicotine is not disease of addiction is the stigma attached to it-- ‡ 99 being ready to stop using these substances. A the well documented, strong disapproval of or study of current smokers in Wisconsin found discrimination against those with the disease-- that the main barriers to quitting that participants and the fear of repercussions which prevent reported were not being ready to stop smoking 103 people with addiction from getting help. Another way of people looking for needed addiction national survey found that two-thirds (67 102 treatment. Stigma was defined for respondents as “something § Met clinical diagnostic criteria for addiction that detracts from the character or reputation of a involving alcohol or drugs other than nicotine.