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To conserve patient’s energy and maintain current health status Basic Nursing Art 22 Anesthetic bed: is a bed prepared for a patient recovering from anesthesia ⇒ Purpose: to facilitate easy transfer of the patient from stretcher to bed Amputation bed: a regular bed with a bed cradle and sand bags ⇒ Purpose: to leave the amputated part easy for observation Fracture bed: a bed board under normal bed and cradle ⇒ Purpose: to provide a flat buy avana 100mg line, unyielding surface to support a fracture part Cardiac bed: is one prepared for a patient with heart problem ⇒ Purpose: to ease difficulty in breathing General Instructions 1 purchase avana 200 mg otc. Linen for one client is never (even momentarily) placed on another client’s bed 5 cheap avana 50 mg fast delivery. Soiled linen is placed directly in a portable linen hamper or a pillow case before it is gathered for disposal 6. Soiled linen is never shaken in the air because shaking can disseminate secretions and excretions and the microorganisms they contain Basic Nursing Art 23 7. When stripping and making a bed, conserve time and energy by stripping and making up one side as completely as possible before working on the other side 8. To avoid unnecessary trips to the linen supply area, gather all needed linen before starting to strip bed 9. Make a vertical or horizontal toe pleat in the sheet to provide additional room for the clients feet. Vertical - make a fold in the sheet 5-10 cm 1 to the foot Horizontal – make a fold in the sheet 5-10 cm across the bed near the foot 10. While tucking bedding under the mattress the palm of the hand should face down to protect your nails. Bed spread Note • Pillow should not be used for babies • The mattress should be turned as often as necessary to prevent sagging, which will cause discomfort to the patient. Closed Bed • It is a smooth, comfortable, and clean bed that is prepared for a new patient Basic Nursing Art 24 Essential Equipment: • Two large sheets • Rubber draw sheet • Draw sheet • Blankets • Pillow cases • Bed spread Procedure: • Wash hands and collect necessary materials • Place the materials to be used on the chair. Turn mattress and arrange evenly on the bed • Place bottom sheet with correct side up, center of sheet on center of bed and then at the head of the bed • Tuck sheet under mattress at the head of bed and miter the corner • Remain on one side of bed until you have completed making the bed on that side • Tuck sheet on the sides and foot of bed, mitering the corners • Tuck sheets smoothly under the mattress, there should be no wrinkles • Place rubber draw at the center of the bed and tuck smoothly and tightly • Place cotton draw sheet on top of rubber draw sheet and tuck. The rubber draw sheet should be covered completely • Place top sheet with wrong side up, center fold of sheet on center of bed and wide hem at head of bed • Tuck sheet of foot of bed, mitering the corner • Place blankets with center of blanket on center of bed, tuck at the foot of beds and miter the corner • Fold top sheet over blanket Basic Nursing Art 25 • Place bed spread with right side up and tuck it • Miter the corners at the foot of the bed • Go to other side of bed and tuck in bottom sheet, draw sheet, mitering corners and smoothening out all wrinkles, put pillow case on pillow and place on bed • See that bed is neat and smooth • Leave bed in place and furniture in order • Wash hands B. Occupied Bed Purpose: to provide comfort, cleanliness and facilitate position of the patients Essential equipment: • Two large sheets • Draw sheet • Pillow case • Pajamas or gown, if necessary Procedure: • If a full bath is not given at this time, the patient’s back should be washed and cared for • Wash hands and collect equipment • Explain procedure to the patient • Carry all equipment to the bed and arrange in the order it is to be used • Make sure the windows and doors are closed • Make the bed flat, if possible • Loosen all bedding from the mattress, beginning at head of the bed, and place dirty pillow cases on the chair for receiving dirty linen Basic Nursing Art 26 • Have patient flex knees, or help patient do so. With one hand over the patient’s shoulder and the shoulder hand over the patient’s knees, turn the patient towards you • Never turn a helpless patient away from you, as this may cause him/her to fall out bed • When you have made the patient comfortable and secure as near to the edge of the bed as possible, to go the other side carrying your equipment with you • Loosen the bedding on that side • Fold, the bed spread half way down from the head • Fold the bedding neatly up over patient • Roll dirty bottom sheet close to patient • Put on clean bottom sheet on used top sheet center, fold at center of bed, rolling the top half close to the patient, tucking top and bottom ends tightly and mitering the corner • Put on rubber sheet and draw sheet if needed • Turn patient towards you on to the clean sheets and make comfortable on the edge of bed • Go to the opposite side of bed. Taking basin and wash cloths with you, give patient back care • Remove dirty sheet gently and place in dirty pillow case, but not on the floor • Remove dirty bottom sheet and unroll clean linen • Tuck in tightly at ends and miter corners • Turn patient and make position comfortable • Back rub should be given before the patient is turned on his /her back • Place clean sheet over top sheet and ask the patient to hold it if she/he is conscious Basic Nursing Art 27 • Go to foot of bed and pull the dirty top sheet out • Replace the blanket and bed spread • Miter the corners • Tuck in along sides for low beds • Leave sides hanging on high beds • Turn the top of the bed spread under the blanket • Turn top sheet back over the blanket and bed spread • Change pillowcase, lift patient’s head to replace pillow. Loosen top bedding over patient’s toes and chest • Be sure the patient is comfortable • Clean bedside table • Remove dirty linen, leaving room in order • Wash hands Study Questions 1. Bath (Bathing and Skin Care) It is a bath given to a patient in the bed who is unable to care for himself/herself. Cleansing bath: Is given chiefly for cleansing or hygiene purposes and includes: • Complete bed bath: the nurse washes the entire body of a dependent patient in bed • Self-help bed bath: clients confined to bed are able to bath themselves with help from the nurse for washing the back and perhaps the face • Partial bath (abbreviated bath): only the parts of the client’s body that might cause discomfort or odor, if neglected are washed the face, hands, axilla, perineum and back (the Basic Nursing Art 29 nurse can assist by washing the back) omitted are the arms, chest, abdomen. Also used for therapeutic baths • Shower: many ambulatory clients are able to use shower • The water should feel comfortably warm for the client • People vary in their sensitivity to heat generally it should be o o 43-46 c (110-115 f) • The water for a bed bath should be changed at least once Before bathing a patient, determine a. The bed linen required Note: when bathing a client with infection, the caregiver should wear gloves in the presence of body fluids or open lesion. Principles • Close doors and windows: air current increases loss of heat from the body by convection • Provide privacy – hygiene is a personal matter & the patient will be more comfortable • The client will be more comfortable after voiding and voiding before cleansing the perineum is advisable • Place the bed in the high position: avoids undue strain on the nurses back Basic Nursing Art 30 • Assist the client to move near you – facilitates access which avoids undue reaching and straining • Make a bath mitt with the washcloth. It retains water and heat better than a cloth loosely held • Clean the eye from the inner canthus to the outer using separate corners of the wash cloth – prevents transmitting micro organisms, prevents secretions from entering the nasolacrmal duct • Firm strokes from distal to proximal parts of the extremities increases venous blood return Purpose: o To remove transient moist, body secretions and excretions, and dead skin cell o To stimulate circulation o To produce a sense of well being o To promote relaxation, comfort and cleanliness o To prevent or eliminate unpleasant body odors o To give an opportunity for the nurse to assess ill clients o To prevent pressure sores Two categories of baths given to clients o Cleansing o Therapeutic A. Bed Bath Equipment • Trolley • Bed protecting materials such as rubber sheet and towels • Bath blanket (or use top linen) • Two bath towels • Clean pajamas or gown • Additional bed linens Basic Nursing Art 31 • Hamper for soiled cloths 0 0 • Basin with warm water (43-46 c for adult and 38-40 c for children) • Soap on a soap dish • Hygienic supplies, such as, lotion, powder or deodorants (if required) • Screen • Disposable gloves Procedures 1. Prepare the patient unit • Close windows and doors, use screen to provide privacy. Make a bath mitt with the washcloth, so it retains water and heat than a cloth loosely held 4. Assist the patient with grooming • Apply powder lotion or deodorants (of pt uses) • Help patient to care for hair, mouth and nails. Recomfort the patient • Change linen if soiled • Arrange the bed • Put pt in comfortable position • Remove the screen 6. Give proper care of materials used for bathing • Document and report pertinent data • Observation of the skin condition • General appearance or reaction of the pt • Type of bath give Report any abnormal findings to the nurse in charge B. Therapeutic Baths • Are usually ordered by a physician • Are given for physical effects, such as sooth irritated skin or to treat an area (perineum) • Medications may be placed in the water • Is generally taken in a tub 1/3 or ½ full, about 114 liters (930’gal) • The client remains in the bath for a desired time, often 20-30 min • If the clients back, chest and arms are to be treated, immerse in the solution o • The bath temperature is generally included in the order, 37. Saline: 4 ml (1Tsp) NaCl to 500 ml (1 pt) water • Has a cooling effect • Cleans • Decrease skin irritation 2. Potassium permanganate (Kmno4): available in tablets, which are crushed, dissolved in a little water, and added to the bath • Cleans and disinfects • Treats infected skin areas Oatmeal (Aveeino) and cornstarch can also be used Back Care (massage): includes the area from the back and shoulder to the lower buttocks Purpose • To relieve muscle tension • To promote physical and mental relaxation • To improve muscle and skin functioning • To relieve insomnia • To relax patient • To provide a relieve from pain • To prevent pressure sores (decubitus) Procedure 1. Massaging the back • Pour small amount of lotion (oil) on your palm and rub your palms together to warm the lotion (oil) before massaging. Basic Nursing Art 35 • Complete the back rub using long, firm strokes up and sown the back. Petrissape: kneading and making large quick pinches of the skin, tissue, and muscle • Clean the back first • Warm the massage lotion or oil before use by pouring over your hands: cold lotion may startle the client and increase discomfort 1. Effleurage the entire back: has a relaxing sedative effect if slow movement and light pressure are used 2. Petrissape first up the vertebral column and them over the entire back: is stimulating if done quickly with firm p Basic Nursing Art 36 • Assess: signs of relaxation and /or decreased pain (relaxed breathing, decreased muscles tension, drowsiness, and peaceful affect) ⇒ Verbalizations of freedom from pain and tension ⇒ Areas or redness, broken skin, bruises, or other sings of skin breakdown Note • The duration of a massage ranges from 5-20 minutes • Remember the location of bony prominence to avoid direct pressure over this areas • Frequent positioning is preferable to back massage as massaging the back could possibly lead to subcutaneous tissue degeneration. Mouth Care Purpose • To remove food particles from around and between the teeth • To remove dental plaque to prevent dental caries • To increase appetite • To enhance the client’s feelings of well-being • To prevent sores and infections of the oral tissue • To prevent bad odor or halitosis • Should be done in the morning, at night and after each meal • Wait at least for 10 minutes after patient has eaten Equipments • Toothbrush (use the person’s private item. If patient has none use of cotton tipped applicator and plain water) • Tooth paste (use the person’s private item. If patient has none of use cotton tipped applicator and plain water) • Cup of water Basic Nursing Art 37 • Emesis basin • Towel • Denture bowel (if required) Procedure 1. Prepare the pt: • Explain the procedure • Assist the patient to a sitting position in bed (if the health condition permits). Brush the teeth • Moisten the tooth with water and spread small amount of tooth paste on it • Brush the teeth following the appropriate technique. Brushing technique • Hold the brush against the teeth with the bristles at up degree angle. Give pt water to rinse the mouth and let him/her to spit the water into the basin. Recomfort the pt Basic Nursing Art 38 • Remove the basin • Remove the towel • Assist the patient in wiping the mouth • Reposition the patient and adjust the bed to leave patient comfortably 5. Normal solution: a solution of common salt with water in proportion of 4 gm/500 cc of water 2. Move the floss up and down between the teeth from the tops of the crowns to the gum 3. A fracture, the slipper or low back pan Advantage ⇒ Has a thinner rim than as standard bed pan ⇒ Is designed to be easily placed under a person’s buttocks Disadvantage ⇒ Easier to spill the contents of the fracture pan Basic Nursing Art 40 ⇒ Are useful for people who are a. The pediatric bedpan • Are small sized • Usually made of a plastic Offering and Removing Bed Pan • If the individual is weak or helpless, two peoples are needed to place and remove bed pans • If a person needs the bed pan for a longer time periodically remove and replace the pan to ease pressure and prevent tissue damage • Metal bed pans should be warmed before use by: o Running warm water inside the rim of the pan or over the pan o Covering with cloth • Semi-Fowler’s position relieves strain on the client’s back and permits a more normal position for elimination Improper placement of the bedpan can cause skin abrasion to the sacral area and spillage o Place a regular bed pan under the buttocks with the narrow end towards the foot of the bed and the buttocks resting on the smooth, rounded rim o Place a slipper (fracture) pan with the flat, low end under the client’s buttocks o Covering the bed pan after use reduces offensive odors and the clients embarrassment Basic Nursing Art 41 If the client is unable to achieve regular defecation help by attending to: 1. Timing – do not ignore the urge to defecate • A patient should be encouraged to defecate when the urge to defecate is recognized • The patient and the nurse can discuss when mass peristalsis normally occurs and provide time for defecation (the same time each day) 3. Nutrition and fluids For a constipated client: increase daily fluid intake, drink hot liquids and fruit juices etc For the client with diarrhea – encourage oral intake of foods and fluids For the client who has flatulence: limit carbonated beverages; avoid gas- forming foods 4. Exercise • Regular exercise helps clients develop a regular defecation pattern and normal feces 5. Positioning • Sitting position is preferred 3 Measures to assist the person to void include: • Running water in the sink so that the client can hear it • Warming the bed pan before use • Pouring water over the perineum slowly • Having the person assume a comfortable position by raising the head of the bed (men often prefer to stand) • Providing sufficient analgesia for pain Basic Nursing Art 42 • Having the person blow through a straw into a glass of water – relaxes the urinary sphincter Perineal Care (Perineal – Genital Care) Perineal Area: • Is located between the thighs and extends from the top of the pelvic bone (anterior) to the anus (posterior) • Contains sensitive anatomic structures related to sexuality, elimination and reproduction Perineal Care (Hygiene) • Is cleaning of the external genitalia and surrounding area • Always done in conjunction with general bathing Patients in special needs of perineal care • Post partum and surgical patients (surgery of the perineal area) • Non surgical patients who unable to care for themselves • Patients with catheter (particularly indwelling catheter) Other indications for perineal care are: 1. Excessive secretions or concentrated urine, causing skin irritation or excoriation 4. Care before and after some types of perineal surgery Purpose • To remove normal perineal secretions and odors • To prevent infection (e. Patient preparation • Give adequate explanation • Provide privacy • Fold the top bedding and pajamas (given to expose perineal area and drape using the top linen. Cleaning the genital area • Put on gloves For Female • Remove dressing or pad used • Inspect the perineal area for inflammation excoriation, swelling or any discharge. In case of post partum or surgical pt • Clean by cotton swabs, first the labia majora then the skin folds between the majora and minora by retracting the majora using gauze squares, clean from anterior to posterior direction using separate swab for Basic Nursing Art 44 each strokes. In case of non-surgical pts • Wash or clean the genital area with soapy water using the different quarters of the washcloth in the same manner. Female Perineum • Is made up of the vulva (external genitalia), including the mons pubis, prepuce, clitoris, urethral and vaginal orifices, and labia majora and minora • The skin of the vaginal orifice is normally moist • The secretion has a slight odor due to the cells and normal vaginal florae • The clitoris consists of erectile tissues and many nerves fibers. Is very sensitive to touch Care • Convenient for a woman to be on a bed pan to clean and rinse the vulva and perineum • Secretion collects on the inner surface of the labia • Use on hand to gently retract the labia • Use a separate section of wash cloth for each wipe in a downward motion (from urethra to back perineum) • Then clean the rectal area Note • Following genital or rectal surgery, sterile supplies may be required for cleaning the operative site, E. Hair care includes combing (brushing of hair), washing/shampooing of hair and pediculosis treatment. Equipments • Comb (which is large with open and long toothed) • Hand mirror • Towel • Lubricant/oils (if required) Procedure 1. Comb the hair by dividing the hair • Hold a section of hair 2-3 inches from the end and comb the end until it is free from tangles. Documentation Shampooing/Washing the Hair of Patient Confined to Bed Purpose • Stimulate blood circulation to the scalp through massaging • Clean the patients hair so it increase a sense of well-being to the pt Equipments • Comb and brush • Shampoo/soap in a dish • Shampoo basin • Plastic sheet • Two wash towels • Cotton balls • Water in basin and pitcher • Receptacle (bucket) to receive the used water • Lubricants/oil as required Procedure 1. Prepare the patient • Assist patient to move to the working side of the bed • Remove any hair accessories (e. Shampooing/washing the hair • Wet the hair thoroughly with water • Apply shampoo (soap) to the scalp. Documentation and reporting Pediculosis Treatment Purpose • To prevent transmission of some arthropod born diseases • To make patient comfortable Definition Pediculosis: infestation with lice Lice: • Are small, grayish white, parasitic insects that infest mammals • Are of three common kinds: ¾ Pediculose capitis: is found on the scalp and tends to stay hidden in the hairs ¾ Pediculose pubis: stay in pubic hair ¾ Pediculose corporis: tends to cling to clothing, suck blood from the person and lay their eggs the clothing suspect their presence in the clothing if: a. There are hemorrhagic spots in the skin where the lice have sucked blood Head and body lice lay their eggs on the hairs then eggs look like oval particles, similar to dandruff, clinging to the hair.

Turbulent blood flow If the velocity of flow is very high cheap avana 50mg free shipping, or if the blood has to pass an obstruction vessel discount 200 mg avana, flow becomes turbulent so that eddy currents are formed order 100mg avana overnight delivery. Cross-sectional area and flow velocity The mean velocity of blood flow is inversely proportional to the cross-sectional area provide that the total volume of fluid flowing through each segment is constant. Blood volume distribution & blood pressure Blood volume is very unevenly distributed through the various vascular segments even though the volume flowing through is relatively constant. Thick, elastic arteries and arterioles contain 18%, capillaries hold only 3-4 percent of blood volume, while the heart contains about 7% blood pressure is almost inversely proportional to volume distribution and vascular resistance. There is little change in pressure in large arteries, but resistance increases rapidly in small arteries, causing the pressure to drop to about 70 mm Hg at the beginning of the arterioles. The arterioles have the greatest resistance of the systemic circulation, so that by the time blood reaches the capillaries, pressure has dropped to about 30 mmHg. Direct methods 1 Mercury manometer The principle behind manometry is that the vertical column of manometer fluid exerts a downward Pressure which opposes the blood pressure. When the column reaches a stable height (h), the blood pressure must be equal to the pressure at the bottom of the column, namely ρgh (fluid density ρx force of gravity g x h). Electronic pressure transducer To record the pressure wave form, a fast-responding electronic pressure transducer is needed. The transducer contains a metal diaphragm which deforms slightly when arterial pressure is applied to it via a catheter. The deformation of the diaphragm alters the resistance of a wire Connected to it and the resistance is recorded. Indirect methods Auscultator method (sphygmomanometry) The mercury manometer is used in medical practice throughout the world to measure human blood pressure, by an indirect method called sphygmomanometry. Auscultation of the brachial artery at the antecubital fossa (inner aspect of elbow) with a stethoscope therefore reveals no sound at this stage. As long as this pressure is higher than systolic pressure, the brachial artery remains collapsed and no blood whatsoever flows into the lower artery during any part of the pressure cycle. The transient spurt of blood vibrates the artery wall downstream and creates a dull tapping noise called Korotkoff sound. The jet causes turbulence in the open vessel beyond the cuff, and this sets up vibrations heard through the stethoscope). The sound, this time, has less of the tapping quality but more of a rhythmic harsher quality. Therefore, the sounds suddenly change to a muffled quality and usually disappear entirely. Direct versus indirect methods Several investigators have compared the pressure readings obtained from a cannula inserted into the brachial artery in one arm with the recordings obtained in the other by the auscultatory method. Normal values Many attempts have been made to define normal values for blood pressure but all such efforts have been unsatisfactory. For an adult under certain conditions he would be right, but it is quite wrong to adopt 120/80 mmHg as the normal standard for a resting child, a pregnant woman in midterm or an elderly man. It is not equal to the average of systolic and diastolic pressure because the pressure remains nearer to the diastolic pressure than to the systolic pressure during the greater part of the cardiac cycle. If heart rate increases, the relative amount of time the heart spends in diastole decreases. The increase in pulse pressure is especially striking and iscaused by reduced arterial compliance. Reduced compliance is due to arteriosclerosis (hardeningof the arterioles by fibrosis and calcinosis), and is universal accompaniment to ageing. Conversely, pressure is reduced in the arteries above the heart level and is only 60mmHg or so in human brain during standing. Indirect effect Upon moving from lying to standing, arterial pressure changes at heart level due to changes in cardiac output and peripheral resistance. A transient fall in aortic pressure (which can produce a passing dizziness) is followed by a small but sustained reflex rise. Compared with the relaxed states, while attending a meeting often raise it by 20mmHg. The pressor effect of stress is particularly harmful to patients with ischemic heart disease. Valsalva maneuver: Valsalva maneuver, a forced expiration against a closed or narrowed glottis, causes a complex sequence of pressure changes. Pregnancy: In pregnancy blood pressure gradually falls and reaches a minimum at approximately 6 months. Veins don’t show distensibility are filled; they contain 3- times blood volume than in that of arteries. Veins have more capacity arteries expand and recoil, store pressure during systole of the heart and release it during cardiac diastole -the pressure stores. Capacitance vessels: act as blood reservoirs - veins & venules Regulation of flow through blood vessels Blood vessel caliber, an important factor in the determination of resistance and capacitance, is actively regulated by neural and humoral mechanisms and passively affected by the pressure within it. Vasomotor refers to rhythmic oscillating changes in the caliber of the arterioles, metarterioles, and precapillary sphincters resulting from vasoconstriction or vasodilatation and venomotion. Neural control of vasomotor tone Vasomotor tone is the continuous, low-level activity of vascular smooth muscle fibers that maintain the tension of the vascular walls. It varies in different tissues, and is mainly dependent upon the rate of impulses from the sympathetic nerve fibers to the muscle cells. This tone is higher in skeletal muscles and splanchnic area blood vessels and 193 least in the heart, brain, and kidney. Vasomotor tone is the tension basically to maintain arterial blood pressure; increase in tone increases blood pressure; decrease in tone lowers blood pressure. In order to maintain an adequate coronary and cerebral blood flow while supplying extra blood to the muscles during heavy exercise, blood pressure must be maintained or increased and blood shifted from the splanchnic and renal areas to the active muscles by changes in the resistance of these vascular beds. Sympathetic regulation of vasomotor & venomotor tone Postganglionic sympathetic fibers from the thoracolumbar sympathetic ganglia provide innervation to all blood vessels, though the density of innervations varies in different tissues. Sympathetic fibers innervate smooth muscles in the principal arteries, small arteries, and terminal arterioles in to tissues. Precapillary arterioles and metarterioles in skeletal muscles are also well innervated by sympathetic nerves. Vasoconstriction allows movement of large amount of blood towards the heart in emergencies, such as hemorrhage. Only very few blood vessels are innervated by the parasympathetic, hence this system is less potent. Norepinephrine Stimulation of Alpha Receptors Norepinephrine released from most postganglionic sympathetic fibers reacts with alpha receptors in the skin, Splanchnic area, skeletal muscle, & kidneys to cause a strong vasoconstriction. The blood vessels of the heart and brain lack alpha receptors, consequently nor epinephrine is ineffective in these tissues. Epinephrine stimulation of beta receptors Epinephrine is released into the circulation after sympathetic stimulation of the adrenal medulla and it acts on beta receptors present in the blood vessels of the heart and 194 brain, causing vasodilatation, ensuring that these vital organs are not deprived of blood during stressful situations that induces vasoconstriction elsewhere. Cholinergic sympathetic vasodilation The blood vessels of the skeletal muscles also receive sympathetic cholinergic postganglionic fibers stimulating cholinergic receptors, resulting in vasodilatation, just prior to strenuous exercise, shunting blood to the muscles that will be most active. Parasympathetic regulation of vasomotor activity Postganglionic cholinergic parasympathetic fibers appear to be significant in few tissues; the genital erectile tissues (penis and clitoris) and clitoris glands, such as the salivary glands, where acetylcholine evokes production of vasodilator bradykinin, Local regulation of blood flow The regulation of blood flow thorough the microcirculation is influenced by neural factors as well as some provocative substances that modify vasomotor tone. Some of these vasoactive substances reach the tissues through the circulating blood and others are locally produced by the tissues themselves. Together the neural and vasoactive factors balance vasoconstrictor and vasodilation in specific vascular beds. Hormonal substances Epinephrine & Norepinephrine Norepinephrine though present in small concentration is generalized vasoconstrictor; its effect is more important as a neurotransmitter at nerve endings. Epinephrine act either as a vasoconstrictor or as vasodilator depending on their concentration, the previous vasomotor tone, and the specific receptors present on the smooth muscle cells of a particular region. It is vasodilator in the skeletal muscle and liver and the heart, elsewhere it has a vasoconstrictor effect. Damaged tissues produce histamine, which are an amine and a very potent vasodilator substance. In damaged tissues histamine causes vasodilatation and a marked increase in capillary permeability and tissue edema. Many tissues, such as brain and the gastrointestinal tract release different peptides, such as glucagons. Another peptide bradykinin is very potent vasodilator and also increases capillary permeability. Bradykinin also cause release of local prostaglandin that act either as vasodilator or as vasoconstrictor. Serotonin, released by activated platelets, is a vasoconstrictor that also releases nor epinephrine from sympathetic nerve endings. Locally produced vasoactive substances Almost all of them are vasodilators, produced by actively metabolizing tissues, which themselves ensure increased blood flow in active tissues. These substances include: hydrogen, and potassium ions, inorganic phosphate, carbon dioxide, some intermediates of the kreb’s cycle. Myogenic control of blood flow The smooth muscles present in the walls of the terminal arterioles of the microcirculation respond to changes in vascular pressure by vasomotion. Vascular distention induced by increased pressure in the arteriole, and increases their tone, resulting in vasoconstriction. Conversely, decreased arteriolar pressure is followed by relaxation of the smooth muscles and a consequent vasodilatation. The fine tuning regulation of blood flow depends upon different combinations of humoral and local vasoactive substances, changes in the proportion of vasoconstriction and vasodilatation, and balance between sympathetic and parasympathetic activity, plus the myogenic responses to changes in arterial blood pressure. Autoregulation assures relatively adequate blood flow even when large fluctuations in blood pressure occur. An increase in blood pressure briefly increases blood flow through the tissues, but it will also rapidly remove tissue vasodilators and increase the oxygen supply. A fall in blood pressure transiently decreases blood flow, increases metabolic and humoral accumulation of metabolic vasodilators, decreases oxygen content, and initiates the myogenic response of vasodilation.

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Systematic reviews have reported that although these diets may be more effective than comparison diets over the short-term buy avana 200 mg line, there is little published evidence from studies in people without diabetes showing beneft over the longer term [44 50mg avana mastercard, 137] discount avana 50mg fast delivery. Concern has been expressed about the potential adverse effects of these diets, especially on cardiovascular risk, but there remains no evidence of harm over the short term [137]. Meal replacements Meal replacements consist of liquid shakes, soups or bars designed to be eaten in place of one or two meals daily. A meta-analysis reported that partial meal replacements produced greater weight loss than a reduced energy diet over the short term (six months) [139]. Commercial diet programmes There is an absence of published evidence for the effect of commercial weight loss programmes in people with diabetes. These programmes utilise a variety of interventions including group therapy, dietary advice and physical activity. Physical activity Physical activity in isolation is not an effective strategy for weight loss in people with Type 2 diabetes [140] unless 60 minutes per day is undertaken [141]. However, evidence shows that a combination of diet and physical activity results in greater weight reduction than diet or physical activity alone [142]. Physical activity does have positive effects on cardiovascular risk and leads to signifcant reductions in diastolic blood pressure, triglycerides, fasting glucose [143] and glycated haemoglobin [140, 144]. In terms of dietary strategies for weight loss, encouraging the individual to adopt their diet of choice may well improve outcomes. The exact proportion of energy that should be derived from fat is less clear, and studies with percentages of energy from unsaturated fat of up to between 35 and 40 per cent, have resulted in benefcial effects on lipid profles, blood pressure and weight that equal or are greater than low fat approaches [118, 134, 150]. Although there is some conficting evidence and concerns of potential adverse effects of fsh oils and fsh oil supplementation on lipid profles, there is evidence of the benefcial effects on reducing triglyceride levels for those with elevated blood triglycerides [157]. A Cochrane review confrmed that in this subgroup of patients, n-3 supplementation did not result in any adverse effects and may be a useful therapeutic strategy [158]. Studies suggest further benefts from lower levels (3g per day); to achieve this goal would require signifcant effort from the food industry [160]. The improvements observed in Mediterranean-style diets are in addition to the effect of any weight loss and are seen in both people with and without diabetes [153, 161, 162]. Alcohol Evidence suggests that more than two alcoholic drinks per day increases blood pressure and that drinking outside of meals may have more impact on hypertension [167, 168]. A signifcant loss of 10 per cent of body weight over 18 months has shown long-lasting benefts for blood pressure in Type 2 diabetes; despite some weight regain [171]. Physical activity Increased physical activity is associated with reductions in cardiovascular risk in both Type 1 and Type 2 diabetes [88, 106, 173]. The most recent recommendation from the American Dietetic Association [174] suggests that maximum beneft is obtained from undertaking moderate aerobic activity at least three times weekly (a total of 150 minutes per week) together with resistance training at least twice weekly. The goal of treatment is to relieve hypoglycaemic symptoms and limit the risk of injury, while avoiding over-treating. Glucose is the preferred treatment for hypoglycaemia with a 10g and 20g dose of oral glucose increasing blood glucose levels by approximately 2mmol/l and 5mmol/l respectively. The glycaemic response of a food used to treat hypoglycaemia is directly related to its glucose content, and as fruit juice and sucrose only contain half the amount of carbohydrate as glucose, a larger portion would be needed to produce the same effect [178]. Glucose levels often begin to fall approximately 60 minutes after glucose ingestion hence the practice of introducing a follow-on carbohydrate snack despite the lack of robust supporting evidence. One small study has shown that a follow-on snack providing a more sustained glucose release may be useful to prevent the re-occurrence of the hypoglycaemic episode [179]. Treatment regimens and individual circumstances vary, and although glucose is recommended as a frst-line treatment for any hypoglycaemic episode, taking extra starchy carbohydrate may be necessary for prolonged hypoglycaemia. Where lifestyle factors, such as exercise or alcohol consumption, may contribute to hypoglycaemia, proactive steps can often be taken to minimise any risks. However, the role of specifc nutrition management in the prevention and management of diabetes related complications is not supported by evidence from randomised controlled trials. As nutritional management is part of the package of care used to improve glycaemic control, good practice would be to offer dietetic advice and support to those with diabetes related complications. One systematic review of the effect of dietary protein restriction in diabetic nephropathy concluded that the evidence was not strong enough to justify the use of protein restriction in the management of diabetic nephropathy [180]. However, this review does recommend that some people may respond to low protein diets and suggests that a six month trial may be initiated, and continued in those that respond. Evidence-based nutrition guidelines for the prevention and management of diabetes 23 Nutrition recommendations for managing diabetes related complications 6. If an individual needs an amputation, their nutritional status should be assessed and reviewed appropriately, as with all surgical procedures, nutritional support should be offered to those in a poor nutritional state. Although the evidence is weak, a recent review highlighted that dietary recommendations should rely on measures that promote gastric emptying or at a minimum do not retard emptying. Artifcial (post-pyloric) feeding should be offered when nutritional status continues to decline because of gastroparesis [184]. However, as the management of glycaemic control is important, dietary review and counselling should again be offered as part of the package of care. There is very little published evidence for nutrition support in people with diabetes either in hospital or in the community and the same applies to end of life care. Nutrition management should be in partnership with the patient and the multi-disciplinary diabetes team with the aim of improving care and optimising glucose control. Hyperglycaemia is common in hospitalised patients and an important marker of poor clinical outcome and mortality in patients. Optimising glucose control is paramount and is associated with better outcomes in conditions including accidental injury, stroke and critical illness, where hyperglycaemia predicts worse outcomes. When feeding enterally, either standard or diabetes specifc formula may be used but care should be taken not to over-feed as it may exacerbate hyperglycaemia [184]. There is no evidence for the most effective mode of long-term nutritional support for people with diabetes [184], but a systematic review of 23 short-term studies have shown that diabetes specifc formulae (containing high proportions of monounsaturated fatty acids, fructose and fbre) signifcantly reduce postprandial blood glucose levels and reduced insulin requirements with no deleterious effect on lipid levels [184]. Patients requiring parenteral nutrition should be treated with standard protocols and covered with adequate insulin to maintain normoglycaemia. Evidence-based nutrition guidelines for the prevention and management of diabetes 25 Additional considerations End of life care is an important consideration. The aims of nutrition advice for these individuals are different as the risk of macro- and microvascular complications are no longer relevant. The main emphasis should be on the avoidance of symptoms due to hyper and hypoglycaemia, providing short-term symptomatic relief, while respecting the wishes of the individual. There is some evidence that the older person with diabetes may have poorer nutritional status than those without diabetes, both in the community [186] and in hospital [187]. Assessment of nutritional status and support for those who may be malnourished should be available to all elderly people with diabetes. The onset is insidious and glycaemic status varies as it is infuenced by the clinical state of the person. The recommendation for a higher than normal folic acid supplement is based upon the higher incidence of neural tube defects in infants born to women with diabetes. In gestational diabetes there is evidence to suggest that dietary strategies focusing on low glycaemic index carbohydrates may offer improved glycaemic control [193]. Although it has been suggested that nutritional supplements might reduce this risk, there is no evidence to support this viewpoint [194, 195]. Recommendations for postnatal care • Women who are breastfeeding and managing their diabetes with insulin should decrease their insulin dose, consume additional carbohydrate, test more frequently and have hypoglycaemia treatment close to hand. Breastfeeding may precipitate hypoglycaemia and requires increased frequency of glucose testing, an increased carbohydrate intake and a reduced insulin dose. However, the protective effects of breastfeeding on the infant and mother, both initially and in terms of chronic disease risk reduction, suggest that where possible it should be encouraged. Gestational diabetes is a strong predictor of future gestational diabetes and Type 2 diabetes, and women should be encouraged to follow a healthy lifestyle and consider weight management if appropriate after giving birth [193]. Therefore, expert opinion suggests lifestyle intervention, as advised for the general diabetes population, should be the primary treatment [202]. Evidence-based nutrition guidelines for the prevention and management of diabetes 29 Additional considerations • Meals and snacks should be made available around appropriate timing of medications. Practitioners should be aware that many people with diabetes may choose to fast for their own personal, spiritual or religious reasons despite being exempt. Little evidence is available on which to make recommendations about fasting and most of it usually focuses on Ramadan [209], so consensus guidelines have been formulated: • Fasting can be safe if a specifc individual care plan is put in place that considers adjustments to timing and dosing of medication, frequent blood glucose monitoring and food and drink choices that are made when breaking the fast. The deliberate omission of insulin to aid weight loss has serious consequences [214] and is referred to as diabulimia in the media. Eating disorders also co-exist with Type 2 diabetes, where binge eating seems to be most prevalent among younger women [215]. Most eating disorder guidelines support a multidisciplinary approach and if healthcare professionals involved with diabetes care feel ill-equipped to deal with patients who have eating disorders [217] they should refer the patient to eating disorder units (see signpost). However, there is no clear evidence of beneft from vitamin or mineral supplementation in people with diabetes (compared with the general population), who do not have underlying defciencies. There are varying degrees of evidence from a range of studies looking into other supplements and functional foods. More robust research is required into micronutrients, supplements and functional foods before further recommendations about safety and effectiveness can be made. Individuals choosing to or considering using supplements or functional foods should be encouraged to discuss their individual needs with a registered dietitian or medical practitioner taking into account safety and risks. Consensus Recommendations for Diabetic Foods • People with diabetes are not advised to purchase ‘diabetic’ foods. Some confectionery, biscuits and bakery products are labelled as ‘diabetic’ and usually contain polyols as a substitute for sucrose. They are available in a variety of high street outlets including supermarkets, pharmacies,health food shops and from the internet. In 2008 a report from the Commission on ‘diabetic’ foods [218] concluded • people with diabetes should be able to meet their dietary needs by appropriate selection from everyday foods.

The lesser tuberosity can be felt lateral to the coracoid pro- • At the wrist the radial artery courses on the radial side of flexor carpi cess generic avana 100 mg with visa. The pulses of both are easily felt at these • Elbow: the medial and lateral epicondyles of the humerus and ole- points buy avana 100mg visa. The deep palmar arch reaches a point approx- importance clinically in differentiating supracondylar fractures of the imately one fingerbreadth proximal to the superficial arch discount 100mg avana overnight delivery. These veins can • Radius: the radial head can be felt in a hollow distal to the lateral be identified in most lean subjects. The The ulnar nerve can usually be rolled as it courses behind the medial dorsal tubercle (of Lister) can be felt on the posterior aspect of the dis- epicondyleaan important point when considering surgical approaches tal radius. The scaphoid bone can • Axillary nerve: winds around behind the surgical neck of the be felt within the anatomical snuffbox (Fig, 40. Surface anatomy of the upper limb 91 41 The osteology of the lower limb Greater trochanter Trochanteric fossa Head Nutrient foramina Intertrochanteric Quadrate tubercle line Intertrochanteric Anterior border Lesser crest Anterior surface trochanter Gluteal tuberosity Lateral surface Medial border Spiral line Posterior surface Posterior border Anterior border Linea aspera Anterior surface Medial border Lateral Posterior surface Popliteal surface surface Medial crest Posterior surface Adductor Posterior border tubercle Fig. It extends from the femoral neck and is rounded, smooth on the postero-inferior aspect of the lateral condyleathe superior and covered with articular cartilage. The head faces medially, upwards and forwards • The fibular notch is situated laterally on the lower end of the tibia for into the acetabulum. The fovea is the central depression on the head to articulation with the fibula at the inferior tibiofibular joint ( fibrous). The medial malleolus Pathological lessening or widening of the angle is termed coxa vara is grooved posteriorly for the passage of the tendon of tibialis posterior. The main functions of the fibula are to provide smooth trochanteric crest, demarcate the junction between the shaft origin for muscles and to participate in the ankle joint. The linea aspera is the crest seen running longitudinally ing characteristic features: along the posterior surface of the femur splitting in the lower portion • The styloid process is a prominence on the fibular head onto which into the supracondylar lines. The medial supracondylar line terminates the tendon of biceps is inserted (around the lateral collateral ligament) at the adductor tubercle. These bear the articular surfaces for articulation with the tibia mon peroneal nerve winds around the neck prior to dividing into at the knee joint. It has anterior, medial femoral aspect is smooth for articulation with the posterior surface of (interosseous) and posterior borders with anterior, lateral and posterior the patella. The posterior aspect of following characteristics: the malleolus is grooved for the passage of the tendons of peroneus • The flattened upper end of the tibiaathe tibial plateauacomprises longus and brevis. The lateral malleolus projects further downwards medial and lateral tibial condyles for articulation with the respective than the medial malleolus. The patella • The intercondylar area is the space between the tibial condyles on • The ligamentum patellae, which is attached to the apex of the patella which can be seen two projectionsathe medial and lateral intercondy- and the tibial tuberosity, is the true insertion of the quadriceps and the lar tubercles. This arrange- The horns of the lateral meniscus are attached close to either side of the ment constitutes the extensor mechanism. It has anterior, medial and lat- • The posterior surface of the patella is smooth and covered with articu- eral borders and posterior, lateral and medial surfaces. It is divided into a large lateral and a smaller medial facet • The anterior border and medial surface of the shaft are subcutaneous for articulation with the femoral condyles. The osteology of the lower limb 93 42 The arteries of the lower limb Superficial epigastric Superficial (to abdominal wall) circumflex Femoral iliac Superficial external pudendal Deep external pudendal Femoral nerve Femoral sheath Femoral vein Lateral circumflex Profunda femoris Medial circumflex Plantar metatarsal artery Anastomosis Perforating Deep plantar arch with dorsal arteries artery Medial Lateral plantar plantar artery artery Gap in adductor magnus Flexor digitorum Abductor accessorius Popliteal hallucis Genicular arteries Soleus arch to knee joint Posterior tibial Fig. Tibialis • Course: the femoral artery commences as a continuation of the ex- anterior and extensor digitorum longus flank the artery throughout its ternal iliac artery behind the inguinal ligament at the mid-inguinal point. Extensor hallucis In the groin the femoral vein lies immediately medial to the artery and longus commences on the lateral side but crosses the artery to lie both are enclosed in the femoral sheath. The femoral artery dorsum of the foot to the level of the base of the metatarsals and then descends the thigh to pass under sartorius and then through the adductor between the two heads of the first dorsal interosseous muscle to gain (Hunter’s) canal to become the popliteal artery. Prior to passing to • Branches: the sole it gives off the 1st dorsal metatarsal branch and via an arcuate • Branches in the upper part of the femoral triangleafour branch the three remaining dorsal metatarsal branches (Fig. Near its origin it gives rise The posterior tibial artery to medial and lateral circumflex femoral branches. These con- • Course: the posterior tibial artery arises as a terminal branch of the tribute to the trochanteric and cruciate anastomoses (see below). It is accompanied by its venae comitantes and supplies The profunda descends deep to adductor longus in the medial com- the flexor compartment of the leg. These circle the femur posteriorly perforating, and supplying, all The artery ultimately passes behind the medial malleolus to divide into muscles in their path. The profunda and perforating branches ulti- medial and lateral plantar arteries under the flexor retinaculum. The mately anastomose with the genicular branches of the popliteal latter branches gain access to the sole deep to abductor hallucis. Posterior to the medial malleolus the structures which can be identifiedafrom front to backaare: tibialis posterior, flexor digitorum The trochanteric anastomosis longus, posterior tibial artery and venae comitantes, the tibial nerve and This arterial anastomosis is formed by branches from the medial and flexor hallucis longus. It lies close to the trochanteric fossa and pro- • Peroneal arteryathis artery usually arises from the posterior tibial vides branches that ascend the femoral neck beneath the retinacular artery approximately 2. It ends by dividing into a The cruciate anastomosis perforating branch that pierces the interosseous membrane and a This anastomosis constitutes a collateral supply. The deep branch runs • Course: the femoral artery continues as the popliteal artery as it between the 3rd and 4th muscle layers of the sole to continue as the passes through the hiatus in adductor magnus to enter the popliteal deep plantar arch which is completed by the termination of the space. The arch gives rise to plantar metatarsal the capsule of the knee joint and then on the fascia overlying popliteus branches which supply the toes (Fig. In the fossa it is the deepest structure, ren- sends branches which join with the plantar metatarsal branches of dering it difficult to feel its pulsations. Atheroma causes narrowing of the peripheral arteries with a con- • Branches: muscular, sural and five genicular arteries are given off. When symptoms are intolerable, pain is present at The anterior tibial artery rest or ischaemic ulceration has occurred, arterial reconstruction is • Course: the anterior tibial artery passes anteriorly from its origin, required. Disease which is limited in extent may be suitable for inter- membrane giving off muscular branches to the extensor compartment ventional procedures such as percutaneous transluminal angioplasty of the leg. The arteries of the lower limb 95 43 The veins and lymphatics of the lower limb From lower abdomen Inguinal lymph nodes From perineum and gluteal region Vein linking great and small saphenous veins Great saphenous vein Popliteal lymph nodes Short saphenous vein Fig. The arrows indicate the direction of lymph flow Superficial epigastric Inguinal ligament Femoral Pubic tubercle artery Edge of saphenous opening Superficial Femoral vein circumflex Deep fascia of thigh iliac Superficial external pudendal Great saphenous vein Fig. Failure of this ‘muscle pump’ to work efficiently, towards becoming varicose and consequently often require surgery. It passes anterior to the medial malleolus, Varicose veins along the anteromedial aspect of the calf (with the saphenous nerve), These are classified as: migrates posteriorly to a handbreadth behind patella at the knee and • Primary: due to inherent valve dysfunction. It pierces the • Secondary: due to impedance of flow within the deep venous circula- cribriform fascia to drain into the femoral vein at the saphenous open- tion. The terminal part of the great saphenous vein usually receives pelvic tumours or previous deep venous thrombosis. They receive lymph from the majority of the superficial tis- below the medial malleolus, in the gaiter area, in the mid-calf region, sues of the lower limb. They in the perforators are directed inwards so that blood flows from receive lymph from the superficial tissues of the: lower trunk below the superficial to deep systems from where it can be pumped upwards level of the umbilicus, the buttock, the external genitalia and the lower assisted by the muscular contractions of the calf muscles. The superficial nodes drain into the deep nodes tem is consequently at higher pressure than the superficial and thus, through the saphenous opening in the deep fascia. In addition they • The small saphenous vein arises from the lateral end of the dorsal also receive lymph from the skin and superficial tissues of the heel and venous network on the foot. The deep nodes over the back of the calf to pierce the deep fascia in an inconstant posi- convey lymph to external iliac and thence to the para-aortic nodes. This can be congenital, due to aberrant lymphatic formation, or acquired The deep veins of the lower limb such as post radiotherapy or following certain infections. In develop- The deep veins of the calf are the venae comitantes of the anterior and ing countries infection with Filaria bancrofti is a significant cause of posterior tibial arteries which go on to become the popliteal and lymphoedema that can progress to massive proportions requiring limb femoral veins. The veins and lymphatics of the lower limb 97 44 The nerves of the lower limb I Anterior superior iliac spine Inguinal ligament Lateral cutaneous External oblique aponeurosis nerve of thigh Femoral nerve Femoral artery Iliacus Femoral vein Femoral canal Psoas tendon Lacunar ligament Pubic tubercle Lateral cutaneous nerve of thigh Pectineus Iliacus Inguinal ligament Femoral nerve Pubic tubercle Nerve to sartorius To pectineus Tensor fasciae latae Pectineus To vastus lateralis Adductor longus Psoas Femoral vein To vastus intermedius Great saphenous vein and rectus femoris Femoral artery Sartorius Saphenous nerve Intermediate To vastus medialis cutaneous nerve Medial cutaneous of thigh nerve of thigh (Skin of front of thigh) (Skin of medial thigh) Rectus femoris Gracilis Obturator externus Pectineus Posterior division Adductor Adductor brevis longus Anterior division Gracilis Deep fascia (Skin of medial leg Branch to and foot) Fig. The latter supply • Course: the majority of the branches of the plexus pass through the sartorius and pectineus. The latter nerve is the only branch to extend • Intra-abdominal branchesathese are described in Chapter 21. Obese patients sometimes describe paraesthesiae over the • Origins: the anterior divisions of the anterior primary rami of lateral thigh. At this point it lies on iliacus, which it supplies, and is situ- • Anterior divisionagives rise to an articular branch to the hip joint ated immediately lateral to the femoral sheath. It branches within the as well as muscular branches to adductor longus, brevis and gra- femoral triangle only a short distance (5 cm) beyond the inguinal liga- cilis. The nerves unite, and are joined by the lumbosacral trunk (L4,5), artery from the lateral to medial side. The nerve • The superior gluteal nerve (L4,5,S1)aarises from the roots of the crosses the posterior tibial artery from medial to lateral in the mid-calf sciatic nerve and passes through the greater sciatic foramen above and, together with the artery, passes behind the medial malleolus and the upper border of piriformis. In the gluteal region it runs below then under the flexor retinaculum where it divides into its terminal the middle gluteal line between gluteus medius and minimis (both branches, the medial and lateral plantar nerves. In the gluteal region it penetrates and supplies gluteus • Sural nerveaarises in the popliteal fossa and is joined by the sural maximus. It pierces the • The posterior cutaneous nerve of the thigh (S1, 2, 3)apasses deep fascia in the calf and descends subcutaneously with the small through the greater sciatic foramen below piriformis. It passes behind the lateral malleolus and under the supply the skin of the scrotum, buttock and back of the thigh up to flexor retinaculum to divide into its cutaneous terminal branches the knee. It sends four motor branches and a cutaneous supply to the region by passing out of the greater sciatic foramen below pirifor- medial 3 /12 digits. It runs forwards in the pudendal plantar artery to the base of the 5th metatarsal where it divides into (Alcock’s) canal and gives off its inferior rectal branch in the superficial and deep branches.

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