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Most studies B have focused on its effects on hip and knee osteoarthritis cheap slimex 10mg without a prescription weight loss pills contrave, but it may offer beneﬁts for the back as well buy slimex once a day weight loss pills real reviews. The active component is salicin purchase slimex with paypal weight loss percentage calculator, which is similar to aspirin buy discount slimex 10mg line weight loss pills that actually work fast, only it is better tolerated. To prevent injuries, exercise to increase strength and ﬂexibility, use proper lifting techniques, and use proper form for sitting and standing. While it can be embarrassing and annoying, bad breath is not just a cosmetic problem—it can signify an underlying health problem. Approximately 90 percent of cases of bad breath originate from problems in the mouth. Poor oral hygiene (not brushing or ﬂossing regularly or properly) allows bac- B teria to grow and feed on food particles in the mouth. Bacteria emit sulphur gases, which not only cause bad breath, but also damage the tissues in the mouth, leading to inﬂammation of the gums (periodontitis). If left untreated, the bacteria continue to grow and cause gum recession, tooth decay, and even worse-smelling breath. The ancient Greeks chewed tree resin and the Mayans chewed chicle (sap from sapo- dilla tree) to keep their breath fresh. Curtis made and sold the ﬁrst commercial chewing gum called the State of Maine Pure Spruce Gum. When brushing, don’t forget to brush your tongue as it can trap large amounts of bacteria. If the cause of bad breath is a lung, throat, or mouth infection, an antibiotic may B be prescribed. If it is due to constipation and poor digestion, which can lead to the release of toxins into the breath, a laxative and/or ﬁbre supplement may be recom- mended. Foods to avoid: • Foods that move slowly through your digestive tract are more likely to cause constipation and bad breath, such as red meat, fried foods, and processed foods. Odours are transferred to the lungs and expelled by our breath and continue until the food is eliminated. Lifestyle Suggestions • Brush your teeth after meals to remove food particles, especially after drinking coffee or eating sulphur-containing foods such as milk products, ﬁsh, eggs, and meat. Look for products that con- tain zinc (reduces sulphur compounds in the mouth), or tea tree or eucalyptus oil, which have antibacterial and antiseptic properties. Top Recommended Supplements Chlorophyll: A component of green plants, chlorophyll helps neutralize odour. Coenzyme Q10: A deﬁciency of coenzyme Q10, an antioxidant that is important for gum health, has been linked to gum disease, and studies have found that it can help promote healing of the gums. Probiotics: Friendly bacteria that help to reduce formation of bad bacteria that cause bad breath. Complementary Supplement Vitamin C: Essential for healthy gums and teeth; levels may be deﬁcient in those with gum disease and in smokers. Chew gum with xylitol and/or peppermint and take supplements of chlorophyll, coenzyme Q10, and probiotics for gum health. Normally the urine is sterile and does not contain any bacteria, viruses, or fungi. However, an infection can develop when these bugs en- ter the urethra (the tube that carries urine out of the body) and travel up into the bladder. This leads to inﬂammation of the bladder (cystitis) and unpleasant urinary B symptoms. If a bladder infection is not treated properly, it can spread to the kidneys and become very serious. This is often due to a structural abnormality in the urethra or bladder affecting the ﬂow of urine. Infections of the bladder are the second most common infection in women and the most common complication of pregnancy. When urine is left to stagnate in the bladder, the risk of developing infec- tion increases. While necessary, there are various drawbacks to the use of antibiotics, including side effects such as diarrhea, stomach upset, and yeast overgrowth. Overuse of anti- biotics causes resistance—the bugs become stronger than the drugs, leaving people vulnerable to attack by bacteria. To relieve the pain and burning, a drug called phenazopyridine (Pyridium) may be prescribed. This is given for two to three days; it contains a dye and will cause discolouration of the urine and feces. Dietary Recommendations Foods to include: • Drink eight or more glasses of water daily to help ﬂush bacteria out of your bladder. You can sweeten it with stevia, which is a natural, low-calorie plant-based sweetener. Juice cocktails are an alternative that offer better taste and toler- ability, but contain less juice and have added sugar; drink three 16 oz. Foods to avoid: • Caffeine has diuretic properties, which promote ﬂuid loss, making the urine more concen- trated. Wear cotton un- derwear, which allows the skin to breathe; change clothing promptly after swimming. Top Recommended Supplements Cran-Max: Studies show that it prevents bladder infections and may also be effective in treating early bladder infections if taken at the ﬁrst sign of symptoms. Vitamin C: Acidiﬁes urine, making it more difﬁcult for bacteria to grow; inhibits the growth of E. Complementary Supplements Oil of oregano: Has antibacterial properties, and is available in capsules or liquid. Probiotics: Support immune function, help ﬁght off infections, and are essential for those on antibiotics because they restore the friendly bacteria destroyed by antibiotics. Acute bronchitis most commonly occurs follow- ing a respiratory infection, such as a cold or ﬂu. It can also develop due to exposure to cigarette smoke or pollution, or in those who have gastroesophageal reﬂux disease due to backﬂow of acids into the lungs. Acute bronchitis caused by a viral infection B often clears up on its own in a week or two without lasting effects. Long-term exposure to lung irritants (particularly cigarette smoke) can lead to continual inﬂammation and thickening of the lining of your bronchial tubes, which is called chronic bronchitis. People with chronic bronchitis have a persistent productive cough and shortness of breath. If you have a cold or ﬂu and symptoms persist beyond a few weeks, consult with your doctor.
Intermittent release of negative pressure during suctioning has no advantage (Czarnik et al buy discount slimex online hoodia gordonii 8500 mg weight loss 90 pills. Disconnection from ventilation and negative pressure from suction can cause hypoxia through ■ removal of oxygen supply ■ removal of oxygen-rich air from airways ■ alveolar collapse cheap slimex 10 mg without a prescription weight loss in a month. Suction passes should therefore be as brief as possible (maximum 15 seconds) order slimex 15mg mastercard weight loss testimonials, with rapid reconnection of ventilation purchase 15 mg slimex with visa weight loss 20 lbs. Nurses are recommended to hold their own breath during each pass: when they need oxygen, so will their patient. Hypoxia from bronchoconstriction (sympathetic stress response) usually follows endotracheal suction. Although Wood’s review (1998) found no proven benefit to routine preoxygenation, evidence is sparse, and failure to preoxygenate is probably more dangerous than routine preoxygenation. Many ventilators include time-limited control for delivery of 100 per cent oxygen; using these prevents inadvertent delivery of toxic levels continuing after stabilisation. If FiO2 is increased manually, it should be returned to baseline levels once PaO2 is restored. Catheters Removing oral secretions is easiest and safest with Yankauer catheters; angling the head to enable drainage of secretions into the cheek avoids trauma to the delicate soft palate. Endotracheal (soft) catheters should remove the maximum amount of secretions in the quickest possible time with minimal trauma. The practice of reusing disposable catheters for more than one pass seems to be based on anecdotal evidence that infection risks are not increased. Without substantive evidence, nurses reusing catheters should consider their professional accountability, and the legal liabilities of reusing equipment labelled by manufacturers as single-use (de Jong 1996). Using clean (rather than sterile) gloves for suction similarly appears based on anecdotal claims that infection rates are not significantly increased. Gloves of any sort protect (universal precautions) nurses, and clean gloves are both quicker to put on and cheaper; with gloved hands not touching catheter tips, infection risks appear small, but any substantive evidence to support this is lacking (Odell et al. Ventilation continues during catheter insertion and so catheters should be advanced more carefully to reduce trauma (passes should not be slowed so much that patient discomfort is increased). Concerns that they create reservoirs for microbial colonisation appear to be unfounded (Adams et al. Nurses’ concerns that closed circuit catheters may be more difficult to manipulate (Graziano et al. Closed circuit systems can be cost effective if they replace sufficient numbers of disposable items. Most manufacturers recommend replacement after 24 hours; Quirke (1998) found 48-hour changes safe and suggests that further research may support weekly changes; however, staff should remember their legal liability if flouting manufacturer’s recommendations. Widespread practice of saline instillation to loosen secretions has little support beyond anecdotal literature. Mucus is not water soluble and so will not easily mix with saline; encrustations on dentures can be difficult to remove after soaking overnight, and a few seconds contact with saline seems unlikely to significantly loosen airway encrustations. Ackerman (1993) found saline instillation reduced PaO2, possibly from bronchospasm or creating a fluid barrier to gas perfusion. However Ackerman’s methodology alternated use and non-use of saline in the same patients, ignoring possible late complications of consolidation through inadequate removal of mucus. Temperature differentials between cold fluids and airways may trigger bronchospasm so that warming fluids (from hand heat) may reduce complications (Gunderson & Stoeckle 1995). There may be individual cases where saline is indicated, but what those indications currently are remains unclear. Substantial research evidence is needed before saline instillation can be recommended. Nebulisation produces smaller droplets which should reach distal bronchioles, but Asmundsson et al. Hyperinflation Hyperinflation (‘bagging’, to loosen secretions) can be achieved with manual (‘rebreathe’) bags or through most modern ventilators (e. Muscle recoil following hyperinflation mimics the cough reflex and so loosens secretions. It also potentially ■ removal raises intrathoracic pressure ■ removal reduces cardiac return ■ causes (mechanical) vagal stimulation (resulting in bradycardia) ■ causes barotrauma. Manual rebreathe bags are available in various sizes; adult systems should include ■ pressure escape valves ■ oxygen reservoirs if patients normally receive high concentration oxygen ■ 2-litre bags (ideal hyperinflation volume is 1. Relative merits of manual and mechanical hyperinflation remain debated (Robson 1998), but ventilator-controlled hyperinflation leaves nurses’ hands free while ensuring hyperinflation volume is both controlled and measured (limiting barotrauma). Children’s tracheas are smaller and so where 1 mm of oedema might cause slight hoarseness in adults, it would obstruct three-quarters of a child’s airway (Marley 1998). Despite the frequency and long history of mechanical ventilation, many dilemmas of nursing management remain unresolved, influenced more by tradition or small-scale (often inhouse) studies than substantial research and meta- analysis. No aspect of airway management should be considered routine; as with all other aspects of care, frequent assessment enables the individualisation of care in order to meet the patient’s needs. Overviews are usually best obtained from books, but many articles usefully pursue aspects in detail. Wood (1998) provides an extensive literature review on dilemmas of endotracheal suction. Reviewing literature for developing departmental guidelines, McKelvie (1998) gives a reliable overview. Identify those effects that you have observed in your own clinical practice and those from the literature. Lighter sedation ■ enables patients to remain semiconscious, thus reducing psychoses while promoting autonomy ■ reduces hypotensive and cardioinhibitory effects caused by most sedatives Light sedation is a narrow margin between over- and under-sedation. The focus is therefore a nursing one rather than pharmacological, although some widely used sedatives are described. Neuromuscular blockade, once a common adjunct of sedation therapy, is also mentioned. Shelly (1998) stresses that comfort (in its widest sense) can be achieved through sedation. Sedation is now usually only necessary for ventilation if patients have: ■ tachypnoea, which will cause exhaustion ■ discomfort from artificial ventilation (usually from oral endotracheal tubes; also for brief procedures such as cardioversion and bronchoscopy). There are some specific pathologies, such as intracranial hypertension, where sedation is therapeutic. Some authors suggest that potential line displacement justifies sedation (Shelly 1994). Amnesia prevents recall of often horrific procedures, but inability to recall experiences, however horrific, may cause greater psychological trauma (Perrins et al. Prolonged benzodiazepine use causes receptor growth and down-regulation (tolerance), necessitating higher doses (Eddleston et al. Endorphins (endogenous opiates) contribute to sedative effects of critical illness. Midazolam is largely hepatically metabolised and renally excreted, so failure of these organs may cause accumulation of active metabolites (especially with older people, who usually have reduced renal clearance); causing unpredictable increases in half-life with critical illness (Bion & Oh 1997). Being relatively cheap, midazolam is still used by many units for prolonged sedation.
It should be noted that an individual who is suffering from early or late asphyxiation may well struggle more in an attempt to breathe purchase slimex on line weight loss 21 day fix extreme, and cost of slimex weight loss water, during a restraint buy 10mg slimex with mastercard weight loss while breastfeeding, this increased level of struggling may be perceived by police offic- ers as a renewed attempt to escape order slimex mastercard weight loss for 0 positive, resulting in further restriction of move- ment and subsequent exacerbation of the asphyxial process. Officers must be taught that once restrained, these further episodes of struggling may signify imminent asphyxiation and not continued attempts to escape, that they may represent a struggle to survive, and that the police must be aware of this and respond with that in mind. Since these matters were first brought to forensic and then public atten- tion and training and advice to police officers concerning the potential dan- gers of face down or prone restraints, especially if associated with any pressure to the chest or back improved, there has been a decrease in the number of deaths during restraint. However, even one death in these circumstances is too many, and it is hoped that by medical research, improved police training, and increased awareness of the dangers of restraint that these tragic deaths can be prevented. Positional asphyxiation in adults: a series of 30 cases from the Dade and Broward County, Florida, medical examiners offices from 1982 to 1990. Effects of positional restraint on oxygen saturation and heart rate following exercise. The effect of simulated restraint in the prone position on cardiorespiratory function following exercise in humans. The effect of breath holding on arterial oxygen saturation following exercise in man. All these fac- tors can be affected by drugs and alcohol, greatly increasing the risk of acci- dents. Many medical conditions (and their treatments) may impair fitness to drive and are considered first. In many jurisdictions, including Canada, Australia, and the United Kingdom, it is the motorist’s responsibility to inform the licensing authority of any relevant medical conditions. Similar requirements generally apply in the United States, except that six states (California, Delaware, Nevada, New Jersey, Oregon, and Penn- sylvania) require physicians to report patients with seizures (and other condi- tions that may alter levels of consciousness) to the department of motor vehicles (1). Drivers have a legal responsibility to inform the licensing authority of any injury or medical condition that affects their driving ability, and physicians should take great pains to explain this obligation. Occasionally, especially when dealing with patients suffering from dementia, ethical responsibilities may require doctors to breach confidentiality and notify patients against their will or without their knowledge (2); this situation is discussed in Subheading 2. When in doubt about the appropriate course of action, physicians should consult the appropriate guidelines. In Australia, the Austroads Guidelines for Assessing Fitness to Drive provides similar information (4). In the European Union, where Euro- pean Community directives have developed basic standards but allow dif- ferent countries to impose more stringent requirements, there is still variation from country to country. The situation is even more complicated in the United States, where each state sets its own rules and where federal regulations for commercial vehicles apply as well. Often, much of the required regulatory information can be acquired via the Internet or from organizations and foun- dations representing patients who have the particular disease in question. It should be assumed that all adults drive; drivers with disabilities should be given special consideration and may require modification of their vehicle or have certain personal restrictions applied. Cardiovascular Diseases Several studies have demonstrated that natural deaths at the wheel are fairly uncommon and that the risk for other persons is not significant (5,6). Even so, requirements for commercial drivers are generally much more rigid than for individuals, and in the United States, the Federal Highway Adminis- tration prohibits drivers with angina or recent infarction from driving. Restrictions for noncommer- cial car driving after first acute myocardial infarction are 4 weeks in United Kingdom but only 2 weeks in Australia. In general, ischemia itself is not considered an absolute disqualification, provided treadmill stress testing demonstrates that moderate reserves are present (7). Similarly, individuals with controlled hy- pertension are usually considered fit to drive, although physicians, no matter what country they are in, must give serious thought to just what sort of medi- cation is used to control hypertension; clonidine, methyldopa, reserpine, and prazosin can produce somnolence and/or impair reflex responses. Patients with dysrhythmias treated with medication or with the implan- tation of a defibrillator/pacemaker present a special set of problems (8). The tendency in the United States has been to treat such individuals as if they were epileptics (i. Until recently, that period was 6 months in a majority of jurisdictions but is increasingly Traffic Medicine 353 being shortened to 3 months in many locations. In the United Kingdom, patients with implantable cardioverter defibrillators are permanently barred from hold- ing a group 2 license but may hold a group 1 license, providing the device has been implanted for 6 months and has not administered therapy (shock and/or symptomatic antitachycardia pacing) (3). Epilepsy Epilepsy is the most common cause of collapse at the wheel, accounting for approx 30% of such incidents. In the United Kingdom, epilepsy is a pre- scribed disability (along with severe mental impairment, sudden attacks of disabling giddiness, and inability to meet eyesight requirements), and car driv- ing is not allowed for at least 1 yr after a seizure. All 50 of the United States restrict the licenses of individuals with epilepsy if their seizures are not well controlled by medication. Most states require a 6-months seizure-free period and a physician’s statement con- firming that the individual’s seizures have, in fact, been controlled and that the individual in question poses no risk to public safety. The letter from the physician is then reviewed by a medical advisory board, which may or may not issue a license. In the United States, even if the patient, at some later date, does have a seizure and cause an accident, the physician’s act of writing to the board protects him or her from liability under American law, provided the letter was written in good faith. Withdrawal of antiepileptic medication is associated with a risk of seizure recurrence. One study showed that 41% of patients who stopped treatment slowly developed a recurrence of seizures within 2 years, compared with only 22% of patients who continued treatment (9). The legal consequences of discontinuing medication without a physician’s order can be devastating. Patients who stop taking antiseizure medication and then cause an accident may face future civil liability and possibly even criminal charges if they cause physical injury (10). Of course, rules vary from country to country but, in general, a patient with seizures who does not inform the appropriate regulatory agency may face dire consequences (including the legitimate refusal of the insurance carrier to pay for damages). Diabetes Diabetes may affect the ability to drive because of loss of consciousness from hypoglycemic attacks or from complications of the disease itself (e. In January 1998, the British government introduced new restrictions on licensing of people with insulin-dependent diabetes (11). These 354 Wall and Karch restrictions were based on the second European Union driver-licensing direc- tive (91/4389), and under most interpretations of the law, they prevent insu- lin-treated diabetics from driving light goods and small passenger-carrying vehicles. In response to concerns expressed by the diabetic community in Brit- ain, the British Diabetic Association commissioned a report that found little evidence to support the new legislation. Regulations were therefore changed in April 2001 to allow “exceptional case” drivers to apply to retain their enti- tlement to drive class C1 vehicles (3500–7500 kg lorries) subject to annual medical examination. In the United States, the situation varies from state to state, but in many states, individuals with diabetes are subject to restrictive licensing policies that bar them from driving certain types of motor vehicles (12,13). However, the risk of hypoglycemia differs greatly among insulin-requiring diabetics, and today most insulin-dependent diabetics use self-monitoring devices to warn them when their blood glucose levels are becoming too low. Thus, several states have dropped blanket restrictions and allow for case-by-case evalua- tions to determine medical qualifications for diabetics. In some states, physi- cians are specifically required to notify authorities of the patient’s diabetic conditions, but in all states, it is the patient’s responsibility to do so. As with patients with seizure, failure to notify may expose the patient to both civil and criminal liability. Vision and Eye Disorders The two most important aspects of vision in relation to driving are visual acuity and visual fields.