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The interdisciplinary team is made up of practitioners from multiple disciplines that function collaboratively to treatment nausea order isordil 10 mg free shipping achieve common objectives medications qt prolongation cheap 10 mg isordil with amex. The team determines specific interventions based on analysis of the assessment information with feedback from all team members including the patient and caregiver(s) medicine 003 buy discount isordil 10mg on line. Interventions are formalized into an individualized plan of care with specific long term goals symptoms wheat allergy buy isordil without prescription, short term objectives. Role of the Provider in the Initial Care Setting the provider in the initial setting of care should develop a problem list that summarizes the patient’s problems. The provider should determine the severity of each identified problem and the impact it will have on the patient’s functional ability and quality of life, so that a baseline can be established against which improvements can be assessed. The provider should also identify problems for which treatment is most urgently recommended. The most urgent treatments may be defined as those treatments expected to result in the greatest improvement when addressing the most severe problems. Although there is evidence that rehabilitation is beneficial for improving community integration and return to work for persons with moderate to severe injuries, this evidence is not available for those with milder injuries. Education should be provided in printed material combined with verbal review and consist of: a. Information and education should also be offered to the patient’s family, friends, employers, and/or significant others. Symptomatic management should include tailored education about the specific signs and symptoms that the patient presents and the recommended treatment. Patients should be provided with written contact information and be advised to contact their healthcare provider for follow up if their condition deteriorates or if symptoms persist for more than 4 6 weeks. The three studies that compared minimal and intensive education interventions found consistent evidence that brief educational and reassurance oriented intervention is as effective as a potentially more intensive and expensive educational model. Mental well being may be improved through stress relief and relaxation, medication, and creating a supportive social network. Social well being may be improved through resolving legal, financial, occupational, or recreational problems. Provide early intervention maximizing the use of non pharmacological therapies: a. Review sleep patterns and hygiene and provide sleep education including education about excess use of caffeine/tobacco/alcohol and other stimulants b. Although rare, the possibility of second impact syndrome must be prevented by altering a concussed patient’s vocational duties when they are high risk for re injury. Exertional testing prior to the return to work or military duty may help to ensure adequate resolution of symptoms in a high stress state or combat environment. Return to activity assessment is based on an inventory of symptoms and their severity and the patient’s job specific tasks. Activity restriction does not imply complete bed rest but rather a restful pattern of activity throughout the day with minimal physical and mental exertion. In individuals who report symptoms of fatigue, consideration should be given to a graded return to work/activity. In instances where there is high risk for injury and/or the possibility of duty specific tasks that cannot be safely or competently completed, an assessment of the symptoms and necessary needs for accommodations should be conducted through a focused interview and examination of the patient. If exertional testing results in a return of symptoms, a monitored progressive return to normal activity as tolerated should be recommended. The purpose of most sport studies is to predict subsequent concussion rather than recovery of symptoms or health outcomes. In the sports arena, there is an opportunity to observe the concussion and continuously monitor the players including access for pre and post injury function assessment. The uniqueness of these characteristics does not allow generalizing the conclusions of sport research to the clinical setting. Return to activity assessment is based on an inventory of symptoms and job specific tasks. Most of the literature regarding criteria for return to activities after concussion has been focused on sports medicine and return to play. Sports organizations have developed return to play guidelines, however these were consensus based. Research evidence supports that a sports specific stepwise return to play program after resolution of symptoms is recommended in sports concussion (Kissick & Johnston, 2005]. Both guidelines use a grading system to assess the injury severity that takes into account the nature and duration of key injury characteristics. Players who sustain this grade of concussion may also return to play after one week of being asymptomatic. Players who sustain this grade of concussion should be sidelined for at least one month, after which they can return to play if they are asymptomatic for one week. Signs and symptoms may occur alone or in varying combinations and may result in functional impairment. Cognitive: attention, concentration, memory, speed of processing, judgment, executive control c. Behavioral/emotional: depression, anxiety, agitation, irritability, impulsivity, aggression. The expected outcome of intervention should be to improve the identified problem areas, rather than discover a disease etiology or “cure. The following recommended interventions focus on initial management of the physical, cognitive and behavioral symptoms. Patients with symptoms that persist despite these initial treatment interventions should be managed using Algorithm C: Follow up Persistent symptoms 5. In the majority of cases, these symptoms are markedly improved or have disappeared within 3 months after the injury. Establishing a thorough medical history, completing a physical examination, and review of the medical record (for specific components for each symptoms see Table B 2 Physical Symptoms Assessment) b. Non pharmacological interventions such as sleep hygiene education, physical therapy, relaxation and modification of the environment (for specific components for each symptoms see Table B 3 Physical Symptoms Treatment) b. Use of medications to relieve pain, enable sleep, relaxation and stress reduction. A consultation or referral to specialists for further assessment should occur when: a. Symptoms cannot be linked to a concussion event (suspicion of another diagnosis) b. Findings indicate an acute neurologic condition that requires urgent neurologic/neuro surgical intervention (see Section 3. Early psychoeducational, supportive, and stress management interventions have been shown to increase rate and extent of recovery from somatic, cognitive and behavioral symptoms. As rapid recovery is expected, patients should always be provided with positive expectations. Comprehensive neuropsychological/cognitive testing is not recommended during the first 30 days post injury. If a pre injury neurocognitive baseline was established in an individual case, then a post injury comparison may be completed by a psychologist but should be determined using reliable tools and test retest stability should be ensured. Several older studies that are included were referenced in the systematic review published by Comper et al. Studies have demonstrated initial cognitive impairments using standardized and valid measuring instrument (Belanger et al. There are a number of effective adjunctive treatments for symptoms, that when used appropriately and cautiously can improve neurological and functional outcome. While there is little empiric evidence, some experts prescribe medications for attention, irritability, sleep, and mood disorders. Considerations in Using Medication for Treatment of Symptoms • Avoid medications that lower the seizure threshold. For suggested classes of medication treatment for specific symptoms, see Tables B 3 and B 5. Medications may be considered for headaches, musculoskeletal pain, depression/anxiety, sleep disturbances, chronic fatigue or poor emotional control or lability. Review and minimize all medication and over the counter supplements that may exacerbate or maintain symptoms b. Initiate therapy with the lowest effective dose, allow adequate time for any drug trials, and titrate dosage slowly based on tolerability and clinical response. Document and inform all those who are treating the person of current medications and any medication changes. These exercises can be general and directed at an overall improvement in cardiopulmonary health, physical strength and power, and overall well being; or focused at specific musculoskeletal, sensory or neuromuscular impairments that limit performance of daily activities.

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Summary of Essential Features and Diagnostic Criteria Usual Course Persistent or recurrent pain in the distribution of the tho Without treatment the pain may decrease in intensity racotomy scar in patients with lung cancer is commonly during the first year post surgery treatment 6th nerve palsy buy generic isordil 10 mg on line, may remain the same symptoms 6 days post iui purchase isordil with paypal, associated with tumor recurrence treatment yeast infection child generic 10mg isordil. Thoracic sympathetic gan the diagnostic procedure of choice to treatment receding gums generic isordil 10 mg amex demonstrate this glia blocks may significantly reduce pain, allodynia, and recurrence. Differential Diagnosis Complications Epidural disease and tumor in the perivertebral region Pain can be compounded by emotional stress and suspi can also produce intercostal pain if there is recurrent cion of recurrence of heart disease. Social and Physical Disability Code Depending on the degree of discomfort, impairment 303. Patients System may benefit from reassurance that this pain does not Peripheral nervous system. Main Features Differential Diagnosis Burning pain across a well circumscribed area defined Ischemic heart pain, costochondritis, hyperesthesia from by the sternum medially, the intercostal junction at T2 or the scar. T3 superiorly, the intercostal junction at T5 or T6 inferi orly, and approximately the nipple line laterally. Site Most frequent in precordium; may be associated with Either symmetrical, more often in the posterior thoracic tachycardia and fear or conviction of heart disease being region, or precordial. Main Features Tension pain is rare in the posterior thoracic region Code compared with tension headache (perhaps one tenth or 31 X. Precordial pain is more common, often associated with tachycardia or a fear of heart disease. Often follows intra abdominal Pain related to the protrusion of an abdominal organ surgery, especially with perforated viscus. Site Associated Symptoms Pain can be related either to the organ herniating or the Fever, malaise, weight loss, hiccoughs. There may be tenderness to Main Features percussion or to palpation of the upper abdomen. White Burning epigastric pain (or retrosternal pain, or both), blood cell count and erythrocyte sedimentation rate may often following eating or lying recumbent. The patient may also complain of chest pain similar to angina, right upper quadrant abdominal pain similar to Usual Course that in cholelithiasis, epigastric pain like that in peptic Treatment with antibiotics with or without surgery usu ulcer disease, abdominal bloating and air swallowing. Radiographic Complications techniques will show evidence of abdominal viscera in Prolonged fever and weight loss. Social and Physical Disability Usual Course May lead to usual effects both of chronic sepsis and Pain typically is intermittent and aggravated by certain chronic pain. Etiology Traumatic and congenital or degenerative weaknesses in Signs and Laboratory Findings the diaphragm are of key etiologic significance, although Patients usually point out their pain with one finger. Gastroscopy, barium swallow, cine esophagoscopy or esophageal manometry may show evidence of increased Summary of Essential Features and Diagnostic Cri or asynchronous esophageal motility. A barium swallow teria may show disordered esophageal contractions with or Epigastric discomfort and esophageal reflux are key without `spasm’ or esophageal dilatation. The cardiac symptoms, with radiographic or endoscopic evidence of sphincter may remain closed until a large amount of extra abdominal organs. In patients with prolonged achalasia the esophagus may Differential Diagnosis contain foreign material, which is undigested food. Eso Angina, cholelithiasis, acid pepsin disease without her phageal manometry will show disordered motility with a nias, and pancreatitis, etc. X6 Abdominal pain cial pressure devices in the esophagus for 24 to 48 hours may pick up very high pressure contractions, which may be related to the pain. It may vary from very occasional to cyclic or be continuous throughout Definition the day. Most pa Attacks of severe pain, usually retrosternal and midline, tients with motility disorders run a benign course with due to a diffuse disorder of the esophageal musculature occasional attacks of pain. Occasionally the symptoms with severe attacks of spasm and/or failure of relaxation progress to the point where the patient has to undergo of the cardiac sphincter. In contrast, patients with achalasia usu ally progress to the point where they require definitive Site treatment. Pain is usually well localized to the midline behind the sternum, between the epigastrium and the suprasternal Complications notch. Patients with System achalasia can develop aspiration pneumonia from re Gastrointestinal system. Age of Onset: occurs in young adults Severe pain may restrict normal activities and be so and middle aged. This is mainly a physiologic rather than a pathologic the bouts are usually infrequent. Summary of Essential Features and Diagnostic Cri Associated Symptoms teria Dysphagia occurs in patients with achalasia of the lower this syndrome consists of short attacks of acute severe esophageal sphincter. There is a sensation of the food retrosternal pain which may be relieved by nitrites, with sticking in the lower part of the esophagus. The diagnosis is made with a of gravity, the weight of the food causes the sphincter to combination of barium swallow appearances and disor open when the patient rises from the chair, and the stick Page 148 dered esophageal motility and normal mucosal appear Code ances on esophagoscopy. X3a Peptic Differential Diagnosis Pericarditis, pulmonary embolism, angina pectoris, dis secting aneurysm, tertiary esophageal contractions in the Reflux Esophagitis with Peptic elderly, and carcinoma of the esophagus. X7 Retrosternal burning chest pain due to acid reflux caus ing inflammation and ulceration. Site System Retrosternal or epigastric pain, depending on the etiol Gastrointestinal system (esophageal mucosa). Main Features Prevalence: common in young adults and middle age Main Features group, starting in third decade. Sex Ratio: more common Prevalence: common, especially in middle aged and in females, especially in the obese or during pregnancy. Pain Qual Time Pattern: bouts of pain occur often after postural ity: burning retrosternal pain, especially at night if lying changes such as bending over or lying down. There may be iron deficiency Aggravating Factors anemia and positive occult blood tests. Certain postures such as bending over, sitting in a slumped position, or lying down; very hot or cold Usual Course drinks; acidic drinks. Esophageal motility stud Social and Physical Disability ies may show a decrease in cardiac sphincter pressure, a Unable to tolerate certain foods, unable to sleep flat in pH probe may detect acid reflux, and the pain may be bed. Pathology Peptic: Dysfunction of cardiac sphincter results in in Usual Course termittent regurgitation of gastric acid contents into In the majority of patients the symptoms persist intermit lower esophagus when intragastric or intra abdominal tently for years. Pathology Changes in the lower esophageal mucosa may vary from Summary of Essential Features and Diagnostic the mildest changes with blunting of the rete papillae to Criteria severe hemorrhage inflammation with ulceration and Burning retrosternal pain from esophageal inflammation. Page 149 Complications Gastric Ulcer with Chest Pain Patients with ulceration may develop a stricture in the region of the ulcer which can cause dysphagia. The diagnosis is made on the history, esophago scopy, and esophageal motility studies. X3d Differential Diagnosis Monilial esophagitis, herpetic esophagitis, foreign body in wall of esophagus, Crohn’s disease. X2d Chronic pain in the loin, sometimes with acute exacerba tions and radiation to the groin. The pain may take the form of a sharp pain or a dull ache, or a combination of the two (the ini Differential Diagnosis tial lancinating pain being followed by a prolonged pe Also includes entrapment in rectus sheath or operative riod of aching pain). Post traumatic pain often has continuous ache although the intensity varies from time to time. The sharp pains usually last for several hours, and Code the subsequent dull ache subsides over a couple of days. X1 Post traumatic Page 150 Aggravating Factors Abdominal Cutaneous Nerve Certain movements, involving alternating flexion and extension of the spine. Segmental pain in the abdominal wall due to cutaneous nerve entrapment in its muscular layers, commonly at Signs the outer border of the rectus sheath or by involvement Tenderness of the affected ribs. Site Laboratory Findings Unilateral in the abdomen, usually confined to a single None diagnostic but a chest X ray, intravenous urogram, dermatome. Main Features Initially there is abdominal wall pain, which is sharp and Complications burning but intermittent. With nerve entrapment in the rectus sheath the pain oc Pathology curs, or is made worse, when the abdominal wall is No histological abnormality identified in ribs. It is as tensed, for example if the patient is asked to raise the sumed that the cause is irritation of an intercostal nerve head and neck off the examining couch. The diagnosis may also Summary of Essential Features and Diagnostic Cri be supported by the response of pain on localized pres teria sure of the fingertip, pencil head, or similar object over Loin pain, either intermittent or continuous and some the tender area. Diagnosis is clinical and the measures in examination assist in determining depends upon exactly reproducing the patient’s pain by which thoracic nerve is trapped and may require injec palpation of the rib. Relief is obtained immediately by injection of local an esthetic into the trigger zone.

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When seating plans are not available and when local or national authorities removed bodies but did not record their location 6mp medications isordil 10mg for sale, clues may often be discovered as to medicine uses safe isordil 10 mg the seating of passengers; for example treatment efficacy order isordil online, a book or handbag found in the compartment on a seat back will suggest a probable location of its owner xerostomia medications that cause discount 10mg isordil free shipping. Fragments of fabric, fused to aircraft structure, compared with clothing removed from bodies may permit deductions about the location of bodies — at least where the bodies came to rest, if not their seat locations. Particular attention should be given to any condition likely to have led to incapacitation in flight or to a deterioration in fitness and performance. The possible cause of incapacitation or lowered efficiency of performance is, theoretically, the range of the diseases of man but, with adequate medical supervision of crews, gross abnormalities are unlikely to be present. Many functional abnormalities, however, are not demonstrable at autopsy — epilepsy being the prime example. Visual and auditory acuity of the crew should also be noted but, again, it will be the essentially negative pathological findings in an accident suspected of having a human factor cause that will focus attention on these systems. However, well documented abnormalities of this sort are scarcely compatible with modern flight crew selection methods or effective working as part of an airline operation. It may be that information obtained from friends, relatives, acquaintances, supervisors, instructors, personal physicians and other observers as to both the recent activities and attitudes of the flight crew and to their long term personal and flying habits, general health and ordinary behaviour may provide information which is of far greater value. Human elements of perception, judgement, decision, morale, motivation, ageing, fatigue and incapacitation are often relatively intangible, yet highly pertinent variables. It should be emphasized that a positive association between any such abnormality discovered and the cause of the accident can seldom, if ever, be better than conjecture. Despite these difficulties, every effort must be made to investigate and report upon such human factors as fully as possible. It may be necessary to include a psychologist familiar with aviation in the Human Factors Group. For example, a deviation from the flight path might suggest a need for an examination for carbon monoxide intoxication; a suspect pressurization system might indicate a need to confirm or exclude hypoxia as a cause of the accident. The itemization of likely toxic causes will simplify and direct the work of the toxicologist. These are the sort of matters that emphasize the need for frequent meetings of the heads of the investigation groups and the need for adequate exchange of information at such meetings. Errors and deficiency of performance may occur whether operations are as planned, whether unexpected conditions develop, or whether emergencies arise. The cause of these errors and performance decrements may be found in: a) errors of perception. These may be related to auditory, visual, tactile or postural stimuli; b) errors of judgement and interpretation. Misjudgement of distances, misinterpretation of instruments, confusion of instructions, sensory illusions, disorientation, lapse of memory, etc. These particularly relate to timing and coordination of neuromuscular performance and technique as related to the movement of controls; Contributing causes of errors and performance deficiency may lie in such areas as: d) attitude and motivation; e) emotional affect; f) perseverance. It is in the evaluation of these potential factors that the Human Factors Group may be of invaluable assistance to the Investigator in Charge. For example, it may be suggested that the pilot was particularly irritable at the time of the flight. However, a replay of the recordings of his in flight transmissions may give far better evidence as to whether this effect was operative at the time of the accident. Essentially the Human Factors Group will be looking for the same type of evidence as that derived from the pathological examination of those killed. Interviews should be properly planned and coordinated through the Investigator in Charge. A medical assessment might differ depending upon whether it was carried out soon after the accident before debriefing by other investigators, or at a later time after interview by others. Before taking such specimens, however, the investigator should ensure that there are no local legal contraindications. The consent of the subject should be obtained and the purpose of the tests explained before they are undertaken. The findings must be collated with their seat position, or location in the aircraft, and adjacent environment so that preventive action such as redesign may be considered. The psychological effects of any accident upon the rescuers should not be forgotten. Adequate, regular debriefing sessions may help prevent the occurrence of Post Traumatic Stress Disorder. Specialists in aviation medicine will be of greatest value when there are many survivors but pathological assistance will be required whenever there are fatalities. The Investigator in Charge must ensure that important investigative information is not sacrificed to meet social and legal desires for rapid identification and disposal of bodies. To this end, he should, if possible, obtain the services of a pathologist familiar with aircraft accident investigation who is capable of coordinating the two interdependent functions of investigation and identification. Coincidentally with this investigation, evidence of medico legal significance as to identification will automatically emerge, particularly if each examination is enhanced by the coordinated efforts of the pathologists, police, odontologists, radiologists, etc. For their part, the head of the Human Factors Group and the Investigator in Charge must ensure that the pathological findings are taken as but part of the investigation as a whole and are fully correlated with evidence adduced within the Group and by other Groups. Experience has shown that this is facilitated and maximum advantage gained if the pathologist attends the periodic briefings by the Investigator in Charge. Reals (eds), Aerospace Pathology, College of American Pathologists Foundation, Chicago, Illinois, 1973. Some of the reasons for a national reference laboratory include the following: a) to ensure standard results across the country, with a high level of expertise; b) to provide rapid response to investigators; c) to offer special tests not performed by other forensic laboratories, but which are required by air accident investigators; d) to work at levels of sensitivity which would pick up sub therapeutic and trace concentrations of analysed compounds; e) to provide forensic analyses on tissue samples in cases where fluids are unavailable; f) to assist in the interpretation of results with respect to a causal, contributory or incidental role in accident occurrence or impact on survivability; g) to undertake special studies as may be required to determine human factor input to the accident; h) to keep a computerized data archive of relevant toxicological, biochemical and pathological findings to detect disease prevalence, drug use or toxin exposure from a national perspective. State of the art methods and instruments should be used by the laboratory to ensure competent screens and specific analyses. The laboratory should participate in national level proficiency testing for quality and quantity control tests of alcohol and common drugs in biological fluids. The verbal reporting time for ethanol, carbon monoxide and hydrogen cyanide should be within five to seven working days after receipt of samples. More demanding tests require more time, but a complete report should be issued after two to five weeks. The major contribution of forensic odontology is assisting the police or other authorities in charge with identification of unknown human remains. Forensic odontology may include further activities as determination of age; tooth mark and bite pattern analysis; physical assault (child abuse); and malpractice. Forensic odontologists synthesize principles, knowledge and competence from many aspects of dentistry with those of other disciplines, as for example forensic pathology/medicine, genetics, anthropology and criminology. This chapter is aimed at presenting an overview of forensic odontology with special emphasis on person identification as it is practiced today in mass disasters. A forensic odontologist with extensive experience in identification work involving foreign nationals should be appointed to the identification commission (the aviation pathology team) responsible for the organization and legal aspects of the identification process. During the investigation, the appointed forensic odontologist should confer with the chairman of the identification commission or the investigator in charge as appropriate. The forensic odontologist is able to contribute both to the accident investigation and to the identification of victims. The odontologist will further ensure availability of instruments and equipment needed and call upon additional staff as required. On the site, the main task of the forensic odontologist is to give a preliminary description of the face and dentition of recovered bodies and otherwise help in the search for bodies or body fragments and assist whenever required. In case of badly burnt or maimed bodies, a preliminary description of the teeth has to be made and dental radiographs taken with portable X ray equipment before handling and transporting the body. The forensic odontologist may even choose to complete the post mortem registration at the scene of the accident. In the aftermath of a disaster with significant numbers of victims, the local police or other approved authorities will contact dentists known to have treated specific missing persons. Forensic odontologists, with or without assistance from other professionals (police, forensic pathologists, etc. Original records including X rays are irreplaceable and may get lost if sent by ordinary mail or released to relatives or other individuals acting on behalf of the victim. Priority ought to be given to photographing faces of the victims before decomposition starts and to planning a system of numbering that follows the victims, their forms and samples throughout the identification process. As the teeth and dental structures are fairly stable under variable conditions, the forensic odontological examination may wait until adequate working conditions are established. Provided working conditions are adequate, several re examinations may be avoided and, in the long run, time may be saved. Essential dental autopsy equipment includes cameras, preferably digital cameras, and portable X ray machines.

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The inflammatory process initiates a Ineffective Health Maintenance cycle of events that affects the regulation of temperature and causes the patient with endocarditis often is treated in the community medications for bipolar disorder purchase isordil pills in toronto. Teaching about disease management and prevention of possible re Expected Outcome: the patient’s body temperature will be within currences of endocarditis is vital symptoms 4dp5dt purchase isordil 10mg line. Fever is • Demonstrate intravenous catheter site care and intermittent usually low grade (below 39 medicine to stop contractions isordil 10 mg amex. Have the patient and/or significant other redemonstrate returns to medicine to reduce swelling order discount isordil online normal within 1 week after initiation of antibiotic therapy. Intermittent antibiotic infusions may be Continued fever may indicate a need to modify the treatment regimen. Appropriate site care Initial blood cultures are obtained before antibiotic therapy is started is necessary to reduce the risk of trauma and infection. Follow up • Explain the actions, doses, administration, and desired and adverse cultures are used to assess the effectiveness of therapy. Identify manifestations to be reported Chapter 31 • Nursing Care of Patients with Cardiac Disorders 945 to the physician. Provide practical information about measures to • the importance of maintaining contact with the physician for reduce the risk of superinfection. Provide educational materials on infective endocarditis from • Teach about the function of heart valves and the effects of endo the American Heart Association. Information helps the members or significant others as appropriate to a drug or substance patient and family understand endocarditis, its treatment, and its ef abuse treatment program or facility. Evidence of heart failure may necessitate modification of the treatment regimen or replacement of infected valves. It usually results ease, heart murmur, or valve replacement before undergoing in from an infectious process, but also may occur as an immunologic vasive procedures. Invasive procedures provide a portal of entry for response, or due to the effects of radiation, toxins, or drugs. A history of valve disease increases the risk for the develop United States, myocarditis is usually viral, caused by coxsackievirus ment or recurrence of endocarditis. Teach how to prevent bleeding from the gums and carditis, much less common, may be associated with endocarditis avoid developing mouth ulcers. Parasitic infec suring that dentures fit properly, and avoiding toothpicks, dental tions caused by Trypanosoma cruzi (Chagas disease) are common in floss, and high flow water devices). Incidence and Risk Factors • Encourage the patient to avoid people with upper respiratory Myocarditis may occur at any age, and it is more common in men infections. It also is a com • If anticoagulant therapy is ordered, explain its actions, adminis mon complication of rheumatic fever and pericarditis. Patients with valve Pathophysiology disease or a prosthetic valve following infective endocarditis may re In myocarditis, myocardial cells are damaged by an inflammatory quire continued anticoagulant therapy to prevent thrombi and em process that causes local or diffuse swelling and damage. Knowledge is vital for appropriate management of anticoagulant agents infiltrate interstitial tissues, forming abscesses. The extent of damage Delegating Nursing Care Activities to cardiac muscle ultimately determines the long term outcome of As appropriate and allowed by designated duties and responsibilities the disease. Viral myocarditis usually is self limited; it may progress, of assistive personnel, the nurse may delegate nursing care activities however, to become chronic, leading to dilated cardiomyopathy. Manifestations the manifestations of myocarditis depend on the degree of myocar Continuity of Care dial damage. Nonspecific mani When preparing the patient with infective endocarditis for home festations of inflammation such as fever, fatigue, general malaise, care, provide teaching as outlined for the nursing diagnosis Ineffective dyspnea, palpitations, arthralgias, and sore throat may be present. In addition, discuss the following topics: nonspecific febrile illness or upper respiratory infection often pre cedes the onset of myocarditis symptoms. Abnormal heart sounds • Although serious and frightening, infective endocarditis can usu such as muffled S, an S, murmur, and pericardial friction rub may 1 3 ally be treated effectively with intravenous antibiotics. In some cases, manifestations of myocardial infarction, • the importance of promptly reporting any unusual manifesta including chest pain, may occur. Myocarditis treatment focuses on resolving the inflammatory pro • Preventing recurrences of infective endocarditis. It protects and cushions the • Cardiac markers, such as the creatinine kinase, troponin T, and heart and the great vessels, provides a barrier to infectious processes troponin I, may be elevated, indicating myocardial cell damage. Acute pericarditis is usually viral and affects men If appropriate, antimicrobial therapy is used to eradicate the infect (usually under the age of 50) more frequently than women. Postmyocardial infarction pericarditis and postcardiotomy suppressive agents (refer to Chapter 13) may be used to minimize the (following open heart surgery) pericarditis also are common. Patients with myocarditis often are particularly Pathophysiology sensitive to the effects of digitalis, so it is used with caution. Inflam medications used in treating myocarditis include antidysrhythmic matory mediators released from the injured tissue cause vasodilation, agents to control dysrhythmias and anticoagulants to prevent emboli. Capillary permeability increases, allowing Bed rest and activity restrictions are ordered during the acute plasma proteins, including fibrinogen, to escape into the pericar inflammatory process to reduce myocardial work and prevent myo dial space. In some cases, the exudate may contain red blood cells or, if infectious, purulent material. Nursing care is directed at decreasing myocardial work and maintain Fibrosis and scarring of the pericardium may restrict cardiac ing cardiac output. Pericardial effusions may develop as serous or purulent cause anxiety increases myocardial oxygen demand. Activity tolerance, urine output, and heart causes the pericardium to become rigid. Consider the following nursing diagnoses for the patient with Manifestations myocarditis: Classic manifestations of acute pericarditis include chest pain, a • Activity Intolerance related to impaired cardiac muscle function pericardial friction rub, and fever. Chapter 31 • Nursing Care of Patients with Cardiac Disorders 947 symptom, has an abrupt onset. It is caused by inflammation of nerve fibers in the lower parietal pericardium and pleura covering the di aphragm. The pain is usually sharp, may be steady or intermittent, Pericardium and may radiate to the back or neck. The pain can mimic myocar dial ischemia; careful assessment is important to rule out myocardial infarction. Sitting upright and leaning forward reduces the dis comfort by moving the heart away from the diaphragmatic side of the lung pleura. Normal Normal Although not always present, a pericardial friction rub is the expiration inspiration characteristic sign of pericarditis. A pericardial friction rub is a leathery, grating sound produced by the inflamed pericardial layers rubbing against the chest wall or pleura. It is heard most clearly at the left lower sternal border with the patient sitting up or leaning forward. The rub is usually heard on expiration and may be constant Tamponade or intermittent. Pericardial effusion Complications Pericardial effusion, cardiac tamponade, and constrictive pericarditis Figure 31–8 • Cardiac tamponade. The manifestations of a pericardial effusion depend on the rate at which inspiration. Although the pericardium normally contains about during inspiration also indicates pulsus paradoxus. Over time, the pericardial sac can accommodate heart sounds, dyspnea and tachypnea, tachycardia, a narrowed pulse up to 2 L of fluid without immediate adverse effects. Slowly developing pericardial effusion is often painless restricting diastolic filling and elevating venous pressure. Neck Cardiac tamponade is a medical emergency that must be aggressively veins are distended, and may be particularly noticeable during in treated to preserve life. This occurs because the right atrium is dial effusion, trauma, cardiac rupture, or hemorrhage. Rapid collec unable to dilate to accommodate increased venous return during in tion of fluid in the pericardial sac interferes with ventricular filling spiration. A paradoxical pulse markedly decreases • Paradoxical pulse in amplitude during inspiration. Intrathoracic pressure normally • Narrowed pulse pressure, hypotension • Tachycardia drops during inspiration, enhancing venous return to the right heart. When ventricular filling is impaired by excess fluid in the • High central venous pressure pericardial sac, this bulging of the interventricular septum decreases • Decreased level of consciousness • Low urine output cardiac output during inspiration (Figure 31–8 •). In severe cases or with recurrent pericarditis, corticosteroids may be given to suppress the inflammatory response. The physician inserts a large (16 to 18 gauge) needle into the peri cardial sac and withdraws excess fluid.