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In a two-stage procedure blood sugar rises proven 50 mg precose, a colostomy is constructed at the proximal margin with the distal stump oversewn (Hartmann procedure diabetes insipidus blood sugar levels precose 50 mg low price, as shown) or brought to the outer surface as a mucous fistula diabetes amputation definition precose 50 mg visa. Has no blood in the stool Peritonitis Abscess formation Bleeding Planning and Goals the major goals for the patient may include attainment and maintenance of normal elimination patterns diabetes in dogs statistics buy precose 25 mg otc, pain relief, and absence of complications. An individualized exercise program is encouraged to improve abdominal muscle tone. The nurse encourages daily intake of bulk laxatives such as Metamucil, which helps to propel feces through the colon. Stool softeners are administered as prescribed to decrease straining at stool, which decreases intestinal pressure. Oil retention enemas may be prescribed to soften the stool, making it easier to pass. The nurse records the intensity, duration, and location of pain to determine if the inflammatory process worsens or subsides. Peritonitis can also result from external sources such as injury or trauma (eg, gunshot wound, stab wound) or an inflammation that extends from an organ outside the peritoneal area, such as the kidney. The most common bacteria implicated are Escherichia coli, Klebsiella, Proteus, and Pseudomonas. Other common causes of peritonitis are appendicitis, perforated ulcer, diverticulitis, and bowel perforation. Peritonitis may also be associated with abdominal surgical procedures and peritoneal dialysis. The clinical manifestations of perforation and peritonitis and the care of the patient with peritonitis are presented in the next section. The nurse monitors vital signs and urine output and administers intravenous fluids to replace volume loss as needed. The nurse educates patients who have not been involved in these practices in the past about their importance and refers the patients to appropriate health care providers. Fluid in the peritoneal cavity becomes turbid with increasing amounts of protein, white blood cells, cellular debris, and blood. The immediate response of the intestinal tract is hypermotility, soon followed by paralytic ileus with an accumulation of air and fluid in the bowel. Clinical Manifestations Symptoms depend on the location and extent of the inflammation. The early clinical manifestations of peritonitis frequently are the symptoms of the disorder causing the condition. The pain tends to become constant, localized, and more intense near the site of the inflammation. The affected area of the abdomen becomes extremely tender and distended, and the muscles become rigid. The temperature and pulse rate increase, and there is almost always an elevation of the leukocyte count. Oxygen therapy by nasal cannula or mask can promote adequate oxygenation, but airway intubation and ventilatory assistance occasionally are required. Massive antibiotic therapy is usually initiated early in the treatment of peritonitis. Large doses of a broad-spectrum antibiotic are administered intravenously until the specific organism causing the infection is identified and the appropriate antibiotic therapy can be initiated. Surgical objectives include removing the infected material and correcting the cause. Surgical treatment is directed toward excision (ie, appendix), resection with or without anastomosis (ie, intestine), repair (ie, perforation), and drainage (ie, abscess). The nurse reports the nature of the pain, its location in the abdomen, and any shifts in location. Administering analgesic medication and positioning the patient for comfort are helpful in decreasing pain. The patient is placed on the side with knees flexed; this position decreases tension on the abdominal organs. Accurate recording of all intake and output and central venous pressure assists in calculating fluid replacement. Signs that indicate that peritonitis is subsiding include a decrease in temperature and pulse rate, softening of the abdomen, return of peristaltic sounds, passing of flatus, and bowel movements. The nurse increases fluid and food intake gradually and reduces parenteral fluids as prescribed.

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If the patient has a coexisting peptic ulcer diabetic diet quiz purchase generic precose canada, prescribed antacids and protein feedings are necessary diabetes type 2 foot pain generic precose 50mg with visa. Prune juice diabetes diet for patients purchase 25 mg precose with mastercard, stool softeners diabetes insipidus gland safe precose 25mg, and physical activity, along with increased fluid intake, help to offset constipation, which is common postoperatively. Nursing Management the nursing management of the patient undergoing parathyroidectomy is essentially the same as that of a patient undergoing thyroidectomy. However, the previously described precautions about dehydration, immobility, and diet are particularly important in the patient awaiting and recovering from parathyroidectomy. Although not all parathyroid tissue is removed during surgery in an effort to control the calcium­phosphorus balance, the nurse closely monitors the patient to detect symptoms of tetany (which may be an early postoperative complication). Most patients quickly regain function of the remaining parathyroid tissue and experience only mild, transient postoperative hypocalcemia. In patients with significant bone disease or bone changes, a more prolonged period of hypocalcemia should be anticipated. The nurse reminds the patient and family about the importance of follow-up to ensure return of serum calcium levels to normal (Chart 42-7). A combination of calcitonin and corticosteroids has been administered in emergencies to reduce the serum calcium level by increasing calcium deposition in bone. Other agents that may be administered to decrease serum calcium levels include bisphosphonates (eg, etidronate [Didronel], pamidronate). The patient requires expert assessment and care to minimize complications and reverse the life-threatening hypercalcemia. Medications are administered with care, and attention is given to fluid balance to promote return of normal fluid and electrolyte balance. Medical Management the insidious onset and chronic nature of hyperparathyroidism and its diverse and commonly vague symptoms may result in depression and frustration. An awareness of the course of the disorder and an understanding approach by the nurse may help the patient and family to deal with their reactions and feelings. The recommended treatment of primary hyperparathyroidism is the surgical removal of abnormal parathyroid tissue. In some patients without symptoms and with only mildly elevated serum calcium levels and normal renal function, surgery may be delayed and the patient followed closely for worsening of hypercalcemia, bone deterioration, renal impairment, or the development of kidney stones. Therefore, a fluid intake of 2,000 mL or more is encouraged to help prevent calculus formation. The patient is instructed to report other manifestations of renal calculi, such as abdominal pain and hematuria. Thiazide diuretics are avoided because they decrease the renal excretion of calcium and further elevate serum calcium levels. Because of the risk of hypercalcemic crisis, the patient is instructed to avoid dehydration and to seek immediate health care if conditions that commonly produce dehydration (eg, vomiting, diarrhea) occur. Atrophy of the parathyroid glands of unknown cause is a less common cause of hypoparathyroidism. Pathophysiology Symptoms of hypoparathyroidism are caused by a deficiency of parathormone that results in elevated blood phosphate (hyperphosphatemia) and decreased blood calcium (hypocalcemia) levels. In the absence of parathormone, there is decreased intestinal absorption of dietary calcium and decreased resorption of calcium from bone and through the renal tubules. Decreased renal excretion of phosphate causes hypophosphaturia, and low serum calcium levels result in hypocalciuria. Clinical Manifestations Hypocalcemia causes irritability of the neuromuscular system and contributes to the chief symptom of hypoparathyroidism-tetany. Tetany is a general muscle hypertonia, with tremor and spasmodic or uncoordinated contractions occurring with or without efforts to make voluntary movements. Symptoms of latent tetany are numbness, tingling, and cramps in the extremities, and the patient complains of stiffness in the hands and feet. In overt tetany, the Chapter 42 Assessment and Management of Patients With Endocrine Disorders 1233 Chart 42-7 Home Care Checklist the Patient With Hyperparathyroidism At the completion of the home care instruction, the patient or caregiver will be able to: State present and potential effects of hyperparathyroidism on the body State precipitating factors and interventions for complications State importance of regular follow-up visits with health care provider Describe potential benefits and risks of parathyroidectomy State the purpose, dose, route, schedule, side effects, and precautions of prescribed medications (loop diuretics, phosphate, calcitonin, mithramycin) State the need to contact health care provider before taking over-the-counter medication containing calcium State need to take pain medications on a scheduled basis Describe nonpharmacologic methods of pain management Identify safety hazards and methods of injury prevention Identify areas of activity limitations and impact on lifestyle State need for increased fluid intake and diet low in calcium and vitamin D Patient Caregiver signs include bronchospasm, laryngeal spasm, carpopedal spasm (flexion of the elbows and wrists and extension of the carpophalangeal joints), dysphagia, photophobia, cardiac dysrhythmias, and seizures. The diagnosis of hypoparathyroidism often is difficult because of the vague symptoms, such as aches and pains.

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The rate of heat loss depends primarily on the surface temperature of the skin blood glucose to a1c conversion buy precose discount, which is a function of the skin blood flow diabetes 65 50mg precose amex. Under normal conditions diabetes symptoms hypoglycemia precose 50 mg overnight delivery, the total blood circulated through the skin is approximately 450 mL per minute diabetes prevention testosterone proven 25mg precose, or 10 to 20 times the amount of blood required to provide necessary metabolites and oxygen. Blood flow through these skin vessels is controlled primarily by the sympathetic nervous system. Increased blood flow to the skin results in more heat delivered to the skin and a greater rate of heat loss from the body. In contrast, decreased skin blood flow decreases the skin temperature and helps conserve heat for the body. When the temperature of the body begins to fall, as occurs on a cold day, the blood vessels of the skin constrict, thereby reducing heat loss from the body. Sweating does not occur until the core body temperature exceeds 37°C, regardless of skin temperature. In extremely hot environments, the rate of sweat production may be as high as 1 L per hour. Under some circumstances (eg, emotional stress), sweating may occur as a reflex and may be unrelated to the need to lose heat from the body. Assessment of Integumentary Function 1643 Vitamin Production Skin exposed to ultraviolet light can convert substances necessary for synthesizing vitamin D (cholecalciferol). Vitamin D is essential for preventing rickets, a condition that causes bone deformities and results from a deficiency of vitamin D, calcium, and phosphorus. Before conducting a skin assessment, the nurse needs to be aware of significant changes that occur with aging. The major changes in the skin of older people include dryness, wrinkling, uneven pigmentation, and various proliferative lesions. Cellular changes associated with aging include a thinning at the junction of the dermis and epidermis. This results in fewer anchoring sites between the two skin layers, so that even minor injury or stress to the epidermis can cause it to shear away from the dermis. This phenomenon of aging may account for the increased vulnerability of aged skin to trauma. With increasing age, the epidermis and dermis thin and flatten, causing wrinkles, sags, and overlapping skin folds. Loss of the subcutaneous tissue substances of elastin, collagen, and subcutaneous fat diminishes the protection and cushioning of underlying tissues and organs, decreases muscle tone, and results in the loss of the insulating properties of fat. These vascular changes contribute to the delayed wound healing commonly seen in the elderly patient. Sweat and sebaceous glands decrease in number and functional capacity, leading to dry and scaly skin. Reduced hormonal levels of androgens are thought to contribute to declining sebaceous gland function. Hair growth gradually diminishes, especially over the lower legs and dorsum of the feet. Other functions affected with normal aging include the barrier function of skin, sensory perception, and thermoregulation. Photoaging, or damage from excessive sun exposure, has detrimental effects on the normal aging of skin. A lifetime of outdoor work or outdoor activities (eg, construction work, lifeguarding, sunbathing) without prudent use of sunscreens can lead to profound wrinkling; increased loss of elasticity; mottled, pigmented areas; cutaneous atrophy; and benign or malignant lesions. Recognizing these lesions enables the examiner to assist the patient to feel less anx- Immune Response Function Research findings (Demis, 1998) indicate that several dermal cells (ie, Langerhans cells, interleukin-1­producing keratinocytes, and subsets of T lymphocytes) and three varieties of human leukocyte antigen (ie, protein marker on white blood cells indicating the type of cell) are important components of the immune system. Ongoing research is expected to more clearly define the role of these dermal cells in immune function. Gerontologic Considerations the skin undergoes many physiologic changes associated with normal aging. Chart 55-1 summarizes some skin lesions that are expected to appear as the skin ages. These are normal and require no special attention unless the skin becomes infected or irritated. If indicated, refer for further genetic counseling and evaluation so that family members can discuss inheritance, risk to other family members, availability of genetic testing, and gene-based interventions. Provide support to families with newly diagnosed geneticrelated integumentary conditions.

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The epithelial cells are capable of rapid replication and are completely replaced every 7 days diabetes test to diagnose buy discount precose line. Behind the cornea lies the anterior chamber diabetes symptoms excessive thirst purchase 25 mg precose with amex, filled with a continually replenished supply of clear aqueous humor diabetes mellitus in older dogs discount precose uk, which nourishes the cornea diabetes distress definition precose 25 mg overnight delivery. The iris, or colored part of the eye, is a highly vascularized, pigmented collection of fibers surrounding the pupil. Normal pupils are round and constrict symmetrically when a bright light shines on them. About 20% of the population has pupils that are slightly unequal in size but that respond equally to light. Dilation and constriction are controlled by the sphincter and dilator pupillae muscles. The dilator muscles are controlled by the sympathetic nervous system, whereas the sphincter muscles are controlled by the parasympathetic nervous system. Directly behind the pupil and iris lies the lens, a colorless and almost completely transparent, biconvex structure held in position by zonular fibers. The lens is suspended behind the iris by the zonules and is connected to the ciliary body. The ciliary body controls accommodation through the zonular fibers and the ciliary muscles. The aqueous humor is anterior to the lens; posterior to the lens is the vitreous humor. All cells formed throughout life are retained by the lens, which makes the cell structure of the lens susceptible to the degenerative effects of aging. The lens continues to grow throughout life, laying down fibers in concentric rings. This gradual thickening becomes evident in the fifth decade of life and eventually results in an increasingly dense core or nucleus, which can limit accommodative powers. This aqueous fluid flows from the posterior chamber into the anterior chamber, from which it drains through the trabecular meshwork into the canal of Schlemm. It is a vascular tissue, supplying blood to the portion of the sensory retina closest to it. The ocular fundus is the largest chamber of the eye and contains the vitreous humor, a clear, gelatinous substance, composed mostly of water and encapsulated by a hyaloid membrane. As the body ages, the gel-like characteristics are gradually lost, and various cells and fibers cast shadows that the patient perceives as "floaters. The retina is composed of 10 microscopic layers and has the consistency of wet tissue paper. Viewed through the pupil, the landmarks of the retina are the optic disc, the retinal vessels, and the macula. Three-dimensional cross-section of the disc, a physiologic depression or cup is present centrally, with the retinal blood vessels emanating from it. The retinal tissues arise from the optic disc and line the inner surface of the vitreous chamber. The retinal vessels also enter the eye through the optic nerve, branching out through the retina and forming superior and inferior arcades. In the center of the macula is the most sensitive area, the fovea, which is avascular and surrounded by the superior and inferior vascular arcades. Core curriculum for ophthalmic nursing, American Society of Ophthalmic Registered Nurses. Cones are distributed throughout the retina with their greatest concentration in the fovea. Good visual acuity depends on a healthy, functioning eyeball and an intact visual pathway. This pathway is made up of the retina, optic nerve, optic chiasm, optic tracks, lateral geniculate bodies, optic radiations, and the visual cortex area of the brain. Its purpose is to transmit impulses from the retina to the occipital lobe of the brain. The optic nerve leaves the eye and then meets the optic nerve from the other eye at the optic chiasm. The chiasm is the anatomic point at which the nasal fibers from the nasal retina of each eye cross to the opposite side of the brain. Fibers from the right half of each eye, which would be the left visual field, therefore carry impulses to the right occipital lobe.