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By: E. Mazin, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Co-Director, Syracuse University

With advanced technology symptoms joint pain and tiredness cheap 300 mg neurontin with amex, it may be difficult to accept the fact that nothing more can be done symptoms schizophrenia cheap neurontin 600 mg overnight delivery, or that technology may prolong life but at the expense of comfort and quality of life symptoms 9 days after ovulation neurontin 300mg without a prescription. Focusing on the caring as well as the curing role may assist nurses in dealing with these difficult moral situations. Fear of respiratory depression or unwarranted fear of addiction should not prevent nurses from attempting to alleviate pain for the dying patient or for a patient experiencing an acute pain episode. In the case of the terminally ill patient, for example, the actions may be justified by the principle of double effect (see Chart 3-2). The intent or goal of nursing interventions is to alleviate pain and suffering while promoting comfort. The risk of respiratory depression is not the intent of the actions and should not be used as an excuse for withholding analgesia. Ethically, all patients deserve and should receive appropriate nursing interventions, regardless of their resuscitation status. With a better understanding of the situation, families may change their perspective. Finally, although providing the information may be the morally appropriate behavior, the manner in which the patient is told is important. Nurses must be compassionate and caring while informing patients; disclosure of information merely for the sake of patient autonomy does not convey respect for others. Refusing to Provide Care Any nurse who feels compelled to refuse to provide care for a particular type of patient faces an ethical dilemma. The reasons given for refusal range from a conflict of personal values to fear of personal risk of injury. The ethical obligation to care for all patients is clearly identified in the first statement of the Code of Ethics for Nurses. For example, when applying for a job, one should ask questions regarding the patient population. If one is uncomfortable with a particular situation, then not accepting the position would be an option. Denial of care, or providing substandard nursing care to some members of our society, is not acceptable nursing practice. The nurse may be told to perform a "slow code" (ie, not to rush to resuscitate the patient) or may be given a verbal order not to resuscitate the patient; both are unacceptable medical orders. The best recourse for nurses in these situations is to be aware of hospital policy related to the Patient Self-Determination Act (discussed later) and execution of advance directives. Discussing the matter with the physician may lead to further communication with the family and to a reconsideration of their decision, especially if they are afraid to let a loved one die with no further efforts to resuscitate (Trammelleo, 2000). Finally, when working with colleagues who are confronting such difficult situations, it helps to talk and listen to their concerns as a way of providing support. Many individuals think that food and hydration are basic human needs, not "invasive measures," and therefore should always be maintained. In evaluating this issue, nurses must take into consideration the potential harm as well as the benefit to the patient of either administering or withdrawing sustenance. Research has not supported the belief that withholding fluids results in a painful death due to thirst (Smith, 1997; Zerwekh, 1997). Evaluation of harm requires a careful review of the reasons the person has requested the withdrawal of food and hydration. Although the principle of autonomy has considerable merit and is supported by the Code of Ethics for Nurses, there may be situations when the request for withdrawal of food and hydration cannot be upheld. For patients with decreased decision-making capacity, the issues are more complex. Some of these cases have reached courts of law, and different states have different case law precedents forbidding withdrawal of sustenance. Although an advance directive may provide some answers, at present there are no firm guidelines to assist nurses in this area. This ruling and the public response to it served as an impetus for legislation on advance directives, entitled the Patient SelfDetermination Act, which became effective in December 1991. The intent of this legislation is to encourage people to prepare advance directives in which they indicate their wishes concerning the degree of supportive care to be provided if they become incapacitated.

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There is a lack of agreement concerning the correlation between transcutaneous bilirubin measurements and total bilirubin concentrations measured in serum medications causing dry mouth purchase neurontin with amex. Some studies have reported that agreement between transcutaneous bilirubin measurements and bilirubin measured in serum are worse when serum bilirubin concentrations were 205 mol/L (12 mg/dL) (11 medications before surgery cheap 300 mg neurontin otc, 62) medicine plies generic 100mg neurontin with visa, whereas others reported poorer agreement when serum bilirubin concentrations were 205 mol/L (12 mg/dL) (25). Finally, others suggested that agreement between transcutaneous and serum bilirubin is independent of bilirubin concentrations (24). A number of studies have been performed comparing transcutaneous bilirubin measurements by the Air-Shields meter to serum bilirubin measured in the clinical laboratory. Differences in study design, the particular model of Air-Shields meter that was used, study population tested, site where transcutaneous measurements were performed, and method used to measure serum bilirubin concentrations probably account for the variability in the reported results. Many studies report that the AirShields meter performs better in infants with lighter skin compared with darker skin (37, 15, 47, 60, 62, 67), although 1 study reported skin color to have no effect (23). A single study reported that the correlation between transcutaneous bilirubin measured with the Air-Shields device and serum bilirubin concentrations was adversely affected by the presence of hemolytic disease (68). The use of multiple wavelength readings enables the instrument to correct for differences in skin pigmentation, thereby eliminating the need for performing a baseline reading. Two studies performed a direct comparison between the BiliChek and Air-Shields meters. One study of 64 newborns found no difference in accuracy between the BiliChek and Air-Shields meters (69). Another study of 101 infants found the 95th percentile confidence interval of the Air-Shields meter to be 68 mol/L (4. Two studies found that, although the BiliChek meter showed good correlation with serum bilirubin measurements, the meter underestimated serum bilirubin concentrations by 4 mol/L (2. In addition to assessment of bilirubin with use of transcutaneous meters, the Ingram Icterometer is also considered by some to be a type of transcutaneous bilirubin monitor. The accuracy of this semiquantitative method depends on the ability of the user to visualize the degree of yellow color of the skin. Comparison of bilirubin estimated with the icterometer with bilirubin concentrations measured in serum shows correlation coefficients ranging from r 0. Ar ch iv ed Is measurement of bilirubin with a transcutaneous device more cost-effective compared with bilirubin measurements performed in the clinical laboratory? There is insufficient evidence to evaluate the cost-effectiveness of transcutaneous bilirubin measurements. No studies have been performed to evaluate the actual costs associated with implementation of transcutaneous bilirubin measurements. Some studies suggest that the increased cost of transcutaneous bilirubin measurements is 10 offset by a decrease in the need for serum bilirubin measurements (5, 11, 38). They found that there were decreased charges as a result of fewer readmissions of newborns because of hyperbilirubinemia. However, the decrease in readmissions was offset by increased charges associated with transcutaneous bilirubin measurements and an increased number of newborns treated with phototherapy before discharge after the introduction of transcutaneous measurements. The net result was a small but statistically insignificant increase in charges after the introduction of transcutaneous bilirubin measurements. Because these authors report charges associated with implementation of transcutaneous bilirubin measurements, it is still not clear what the implementation of transcutaneous measurements does to actual costs. Measurement of total bilirubin in serum remains the standard of care for the assessment of newborn jaundice. Replacement of serum bilirubin measurements by a transcutaneous method will require substantial investigation to understand its limitations and benefits. Clinical practice guidelines recently published by the American Academy of Pediatrics recommend that transcutaneous bilirubin measurement or a total serum bilirubin measurement be performed on every infant who is jaundiced, with repeated measurements performed according to the degree of the initial hyperbilirubinemia, the age of the infant, and the evolution of the hyperbilirubinemia (7). An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Association of transcutaneous bilirubin testing in hospital with decreased readmission rate for hyperbilirubinemia. Transcutaneous bilirubinometry: evaluation of accuracy and reliability in a large population. Transcutaneous measurement of hyperbilirubinemia: comparison of the Minolta jaundice and the Ingram icterometer. The clinical application of transcutaneous bilirubinometry in full-term Chinese infants. Transcutaneous bilirubinometer: its use in Chinese term infants and the effect of haematocrit and phototherapy on the TcB index.

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Many women with gonorrhea discharge think they have a yeast infection and self-treat with medications purchased over the counter medicine used to stop contractions best order for neurontin. Because vaginal discharge can be a sign of a number of different problems symptoms 7 days after ovulation purchase 100mg neurontin with visa, it is best to always seek the advice of a doctor to ensure correct diagnosis and treatment inoar hair treatment buy discount neurontin 400 mg on line. Once the gonorrhea bacteria come into contact with the eyes of the newborn, the process may end with acute conjunctivitis. About 536 million people aged 15-49 were estimated to be living with herpes simplex virus type 2 worldwide in 200. The social stigma attached to these diseases, prevents proper dissemination of basic knowledge about the disease. This assumption is based on the political and security instability in Sudan and its neighbouring ones. An estimate of the global prevalence and incidence of herpes simplex virus type 2 infections. Lindsay Edouard Reproductive Health Branch Technical Support Division United Nations Population Fund edouard@unfpa. However, these infections continue to be a serious health problem, particularly among women. Where access to timely treatment is not available, sexually transmitted infections may result in pelvic inflammatory disease, infertility, cancer, neonatal complications or even death. Moreover, programming should strive to avoid duplication of efforts and take advantage of possible synergies in providing services for those with any reproductive health concerns. The discussion of these challenges and their implications for reproductive health policy form the core of this programming note. The most serious complications and long-term consequences of untreated sexually transmitted infections tend to be in women and newborn babies. Gonorrhoea and chlamydial infections can cause pelvic inflammatory disease, which can lead, in turn, to ectopic pregnancy and infertility. Children can be born with congenital syphilis or herpes or with serious eye infections due to gonorrhoea or chlamydia. Family planning settings present excellent opportunities to promote condoms for dual protection (from both unwanted pregnancy and infection). Early treatment of infected individuals is critical to breaking the chain of transmission. Simple tests using microscopy can detect certain vaginal infections, but laboratory tests to detect cervical infections caused by gonorrhoea and chlamydia are more expensive and complicated. Moreover, results are generally not available while the patient is still at the clinic, which often means a missed opportunity for treatment if infection is found. And in resource-poor settings, laboratory methods of diagnosis are often neither affordable nor available. This approach uses standard flowcharts, adapted to the local epidemiological profile, to decide on a treatment that will be effective against all the organisms most commonly known to cause the particular syndrome in the particular setting. The method is simple and does not require extensive training for health personnel. An important advantage is that this approach helps to ensure that the patients get effectively treated at their first ­ and probably only ­ contact with the health system. However, this also means treating for several possible infections even if the patient has only one. Abnormal vaginal discharge is highly indicative of vaginal infections, but is a poor predictor of cervical infections, which are often asymptomatic. Strategies have been developed to improve syndromic management of vaginal discharge and to detect more cases of cervical infection (the cervix is the most common site of infection for gonorrhoea and chlamydia). Syndromic management may be improved in populations with high prevalence of gonorrhoea and chlamydia by introducing speculum examinations to detect cervical mucopus (although where this is not possible, it is better to treat presumptively when cervical infection is suspected). Given the low rate of return by clients for follow-up, diagnosis and treatment in one visit is generally preferable. Specific guidelines for diagnosis and treatment should be adapted to local conditions. However, several programme examples show that with sufficient resources it is possible to surmount social barriers within clinics. All reproductive health programmes should undertake prevention and counselling (with a special emphasis on the dual protection that male and female condoms provide), and symptomatic clients should be treated as appropriate. In areas where overall prevalence rates are low, targeting services to especially vulnerable groups ­ such as sex workers, long-distance truck drivers, prisoners, street children, refugees and the internally displaced ­ can be a cost-effective way to break the cycle of transmission and reduce rates of infection.

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