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The heart with the pericardium has been removed order 20 mg zocor with mastercard cholesterol in eggs yolk or white, and the lungs and aortic arch have been slightly reflected to show the vagus nerves and their branches. Heart and distal part of esophagus have been removed to display the vessels and nerves of the posterior mediastinum. Three regions in which the esophagus is narrowed are shown: A = termed upper sphincter (at the level of the cricoid cartilage); Diaphragm and organs of mediastinum (anterior aspect). Heart and lungs have been B = termed middle sphincter (at the removed; the costal margin remains in place. During inspiration the diaphragm moves downwards and the lower part of the thoracic cage expands forward and laterally, causing the costodiaphragmatic recess (R) to enlarge (cf. Diaphragm 283 1 Azygos venous arch 2 Right pulmonary artery 3 Superior vena cava 4 Right pulmonary vein 5 Fossa ovalis 6 Hepatic veins 7 Inferior vena cava 8 Right crus of lumbar part of diaphragm 9 Medial arcuate ligament 10 Psoas major muscle 11 Left brachiocephalic vein 12 Terminal crista 13 Right atrium 14 Right auricle 15 Central tendon of diaphragm 16 Esophagus 17 Celiac trunk and superior mesenteric artery 18 Aorta 19 Costal part of diaphragm 20 Costal margin 21 Transversus abdominis muscle Diaphragm. Paramedian section to the right of the median plane through thoracic and upper abdominal cavities. The plane passes through the superior and inferior vena cava just to the right of the vertebral bodies. Most of the heart remains in situ to the left of this plane (viewed from the right side). Ductus venosus between umbilical vein bypass of liver 4 Superior vena cava (of Arantius) and inferior vena cava circulation 5 Ascending aorta 6 Right auricle 2. Foramen ovale between right and left bypass of pulmonary 7 Pulmonary trunk atrium circulation 8 Left primary bronchus 9 Left auricle 3. Ductus arteriosus between pulmonary trunk 10 Right ventricle (Botalli) and aorta 11 Left ventricle 12 Left common carotid artery 13 Trachea 14 Superior lobe of right lung 15 Left subclavian artery 16 Aortic arch 12 17 Ductus arteriosus (Botalli) 18 Inferior lobe of right lung 2 14 19 Left pulmonary artery with branches to the 15 left lung 3 20 Descending aorta 21 Left pulmonary veins 5 18 22 Inferior vena cava 23 Foramen ovale 7 17 24 Right atrium 25 Opening of inferior vena cava 8 19 26 Valve of inferior vena cava (Eustachian valve) 23 27 Opening of coronary sinus 21 28 Anterior papillary muscle of right ventricle 9 20 11 Heart of the fetus (schematic drawing). Fetal Circulatory System 289 1 Internal jugular vein and right common carotid artery 2 Right and left brachiocephalic vein 3 Aortic arch 4 Superior vena cava 5 Foramen ovale 6 Inferior vena cava 7 Ductus venosus 8 Liver 9 Umbilical vein 10 Small intestine 11 Umbilical artery 12 Urachus 13 Trachea and left internal jugular vein 14 Left pulmonary artery 15 Ductus arteriosus (Botalli) 16 Right ventricle 17 Hepatic arteries (red) and portal vein (blue) 18 Stomach 19 Urinary bladder 20 Portal vein 21 Pulmonary veins 22 Descending aorta 23 Placenta Thoracic and abdominal organs in the newborn (anterior aspect). The greater omentum partly fixed to the transverse colon covers the small intestine. The liver, stomach, and superior part of 1 the duodenum are connected to the lesser omentum covering the omental bursa, the entrance of which is the epiploic foramen. The hepatoduodenal ligament contains 2 the portal vein, the common bile duct, and the hepatic arteries. The heart is in contact with the diaphragm (from Lütjen-Drecoll, Rohen, Innenansichten des menschlichen Körpers, 2010). Transverse section through the abdominal cavity at the level of the second lumbar vertebra (from below). Anterior Abdominal Wall 293 1 Left ventricle with pericardium 2 Diaphragm 3 Remnant of liver 4 Ligamentum teres (free margin of falciform ligament) 5 Site of umbilicus 6 Medial umbilical fold (containing the obliterated umbilical artery) 7 Lateral umbilical fold (containing inferior epigastric artery and vein) 8 Median umbilical fold (containing remnant of urachus) 9 Head of femur and pelvic bone 10 Urinary bladder 11 Root of penis 12 Falciform ligament of liver 13 Rib (divided) 14 Iliac crest (divided) 15 Site of deep inguinal ring and lateral inguinal fossa 16 Iliopsoas muscle (divided) 17 Medial inguinal fossa 18 Supravesical fossa 19 Posterior layer of rectus sheath 20 Transversus abdominis muscle 21 Umbilicus and arcuate line 22 Inferior epigastric artery 23 Femoral nerve 24 Iliopsoas muscle 25 Remnant of umbilical artery 26 Femoral artery and vein 27 Tendinous intersection of rectus abdominis Anterior abdominal wall with pelvic cavity and thigh (frontal section, male) muscle (internal aspect). The peritoneum and parts of the posterior layer of rectus sheath have been removed. Parasagittal section through upper 30 Intervertebral disc part of left abdominal cavity 3. Stomach 295 1 2 9 10 4 9 11 1 2 3 5 12 10 4 6 6 11 8 7 13 8 14 Muscular coat of stomach, outer layer (ventral aspect). Stomach and transverse colon have been removed, liver elevated; superior mesenteric vein is slightly enlarged. Parasagittal section through the left side of the abdomen 2 cm lateral to median plane. Liver 299 1 Fundus of gallbladder 2 Peritoneum (cut edges) 3 Cystic artery 4 Cystic duct 5 Right lobe of liver 6 Inferior vena cava 7 Bare area of liver 8 Notch for ligamentum teres and falciform ligament 9 Ligamentum teres 10 Falciform ligament of liver 11 Quadrate lobe of liver 12 Common hepatic duct 13 Left lobe of liver 14 Hepatic artery proper 15 Common bile duct Portal triad 16 Portal vein 17 Caudate lobe of liver 18 Ligamentum venosum 19 Ligament of inferior vena cava 20 Appendix fibrosa (left triangular ligament) 21 Coronary ligament of liver 22 Hepatic veins Liver (inferior aspect). It should be noted that the anatom- ical left and right lobes of the liver do not reflect the internal distribution of the hepatic artery, portal vein, and biliary ducts. With these structures, used as criteria, the left lobe includes both the caudate and quadrate lobes, and thus the line dividing the liver into left and right functional lobes passes through the gallbladder and inferior vena cava. The three main hepatic veins drain segments of the liver that have no visible external Liver (ventral aspect) (transparent drawing illustrating margins of peritoneal folds). In this case the accessory pancreatic duct represents the main excretory duct of the pancreas.

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Some theories deal only with abstract schools of nursing within the United States and phenomena cheap 20mg zocor amex cholesterol lowering foods in sri lanka, but this theory has both abstract and other countries (Leininger & McFarland, 2002). The theory has grown in recognition and value for Sixth, the theory of culture care is a synthesized several reasons. First, the theory is the only nursing concept; integrated with the ethnonursing method, theory that focuses explicitly and in depth on it has already provided a wealth of many new in- discovering the meaning, uses, and patterns of sights, knowledge areas, and valuable ways to work culture care within and between specific cultures. Thus, it has greatly expanded nurses’ are the new knowledge holdings that support the knowledge about care so essential for nurses to new discipline of transcultural nursing. Third, the theory has the “gold nuggets” to change or transform health a “built-in” and tailor-made ethnonursing nursing care to realize therapeutic outcomes for different research method that helps to realize the theory cultures. It is different from ethnography and other been reported in the Journal of Transcultural research methods. The ethnonursing method is a Nursing and other transcultural nursing books and qualitative method and is valuable in discover- journals since 1980. They substantiate the theory ing largely covert, complex, and generally hidden (Leininger, 1991, 1995, 1997a, 1997b). It was Seventh, the theory and its research findings are the first specific research method designed so that stimulating nursing faculty and clinicians to use the theory and method fit together. This has culture specific care appropriate and safe for cul- brought forth a wealth of new data. Thus, transcultural nursing knowledge is to data methods were not helpful to find hidden be used in clinical and community settings. Nursing administrators in service and academia Fourth, the theory of culture care is the only the- need to be active change leaders to use transcultural ory that searches for comprehensive and holistic nursing findings. Nursing faculty members need to care data relying on social structure, worldview, promote and teach ways to be effective with cul- and multiple factors in a culture in order to get a tures (Leininger, 1998). The theory is being used a lot to trism and racial biases and prejudices are being re- do culturalogical–health care assessments. Many nurses transcultural nursing concepts, findings, policies, also like to discover the differences and similarities and standards of care are being developed and used among cultures as it expands their worldviews and from findings (Leininger, 1991). Interdisciplinary deepens their appreciation of human beings of di- health personnel are finding the theory and trans- verse cultures. Learning to become immersed in a cultural nursing concepts and are finding help in culture has been a major benefit. This has been the most rewarding benefit of be used in any culture and at any time and with the theory. The consumer also likes the ethno- the theory slightly to fit their major and unique in- nursing method as they can “tell their story” and terest and goals of their discipline. Several disci- guide health researchers to discover the truths plines, including dentistry, medicine, social work, about their culture. Informants speak of being and pharmacy, are now using the culturally con- more comfortable with researchers. The goal for United States government and several theory encourages the researcher or clinician to dis- states. The concept is growing in use and will be- cover culture from the people and to let them be in come a global force. In general, the theory of culture care is a theory Tenth, nurse researchers who have been pre- of global interest and significance as we continue to pared in transcultural nursing and have used the understand cultures and their care needs and prac- theory and method commonly say things like, “I tices worldwide. It is the only theory that makes principles, theory, and findings must become fully sense to help cultures. They grow in ideas and enjoy incorporated into professional areas of teaching, discovering new knowledge of the lifeways of peo- practice, consultation, and research. Unques- Eleventh, nurses who have used the theory and tionably, the theory will continue to grow in rele- findings over time often speak of how much they vance and use as our world becomes more intensely have learned about themselves and about new cul- multicultural. Nurses dis- will be expected in the near future to function com- cover their ethnocentric tendencies as well as petently with diverse cultures.

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Many find the re- occur due to cumulative neurological damage or due to ports a reflection of a sexually disturbed society buy zocor 20mg online xzk cholesterol, while inadequate stimulation and uncertainty in the child about others believe that increased reporting is the result of sen- the learning environment and the absence of positive sationalist media accounts, celebrity pronouncements parental interactions that would stimulate language and about their own abuse, and over-zealous therapists who motor processes. These delays, in concert with their par- too readily suggest to patients that episodes of sexual ents’ higher-than-normal expectations for their children’s abuse may lay at the heart of their other problems. A coercive cycle frequently devel- peatedly tortured by friends and family members in ops where parents and children mutually control one an- elaborate Satanic ceremonies often involving human other with threats of negative behavior. Writing in The Journal of School-aged children who are abused typically have Psychohistory in 1994, psychoanalyst David Lotto re- problems academically with poorer grades and perfor- ported that at a recent convention of the American mance on standardized achievement tests. Studies of Psychological Association, 800 therapists reported that abused children’s intellectual performance find lower they were currently treating cases of ritual abuse. Abused children also toward dis- researcher David Finkelhor found that as many as 13% tractibility and overactivity, making school a very diffi- of child abuse allegations occurring at day care centers cult environment for them. Stanley Hall, the “father of child psychology their abuse occurred, and yet no trace has ever been in America,” publishes The Contents of Children’s found of such a construction. Putting aside the current controversy over the preva- 1914 John Broadus Watson publishes his most impor- lence of child sexual abuse in this country, no one dis- tant work, Behavior—An Introduction to Com- putes that sexual abuse does in fact occur and takes a parative Psychology. Sexually abused chil- 1926 Jean Piaget publishes The Child’s Conception of dren may still be preoccupied in adulthood with events, the World, followed ten years later by The Orgin trying to understand and repair the damage. Sexual abuse, like severe physi- 1934 Arnold Gesell publishes An Atlas of Infant Behav- cal and emotional abuse, can lead to other psychological ior, followed by Child in the Culture of Today (1943), The Child from Five to Ten (1946), and disorders as well, such as depression, mood disorders, Child Development (1949). In this work, Darwin advanced Interview with National Committee for the Prevention of Child the hypothesis that each individual’s development from Abuse, April 17, 1996. Child development Berry Brazelton, child development has been studied and written about to better understand of children in order The study of the sequential physical, cognitive, to promote their well-being during the various stages of emotional, and social changes a child undergoes childhood, and to help them mature into healthy adults. Freud developed many theories about the enormous The first detailed scientific study of child development influence of childhood experiences on adult behavior was probably Charles Darwin’s Biographical Sketch of and also proposed a five-stage chronological model of an Infant (1877), based on a log he had kept on the devel- childhood psychosexual development. Next comes the phallic stage (3 to 7 years), during Lawrence Kohlberg’s work on the development of which a child experiences and resolves the Oedipal crisis moral reasoning approaches childhood from a different and assumes his or her sexual identity. After studying the different ways in which cy stage (ages 7 to 12) sexuality is dormant, and the pri- children aged 7 through adolescence respond to moral mary love objects are people outside the home. With the dilemmas, Kohlberg determined that there are universal genital stage, which begins at age 12 and lasts into adult- stages in moral development, which, like the cognitive hood, instinctual sexual drives increase and parental at- stages delineated by Piaget, differ from each other quali- tachments are dissolved. Children from the ages of 7 through about 10 act Arnold Gesell was among the first psychologists to on the preconventional level,which involves deferring to undertake a thorough quantitative study of normal adults and obeying rules based on the immediate human development from birth through adolescence. At around age 10, Based on his work at Yale’s Child Development Clinic they progress to the conventional level, where their be- and his own Institute, Gesell produced reports that had a havior is guided by the opinions of other people and the widespread influence on both parents and educators, and desire to conform. During adolescence, children become created the Gesell Development Schedules, which are capable of postconventional morality, which entails the still used today to assess motor and language develop- ability to formulate abstract moral principles and act on ment, adaptive behavior, and personal-social behavior in motives that transcend self-interest and even social children between four weeks and six years of age. Probably the most famous theory of child develop- In recent years, researchers in child development ment is the cognitive development model pioneered by have focused increasingly on the developmental patterns the Swiss psychologist Jean Piaget. Carol Gilligan, development between birth and late adolescence into four Kohlberg’s colleague at Harvard University, found fault stages of increasingly complex and abstract thought, each with Kohlberg’s exclusive focus on white males in his qualitatively different from the ones preceding it but still initial research, and in her own study, In a Different dependent on them. The first, or sensorimotor, stage Voice, Gilligan differentiates between male and female (birth to approximately 2 years) is a time of nonverbal, moral development. In contrast to the male problem- experimental basic learning when infants experience the solving approach to moral dilemmas based on an “ethic world primarily through their senses and gradually gain of justice,” she describes a female “ethic of care” that is mastery of their own bodies and external objects. The based on empathy and involves the perception of moral preoperational stage (ages 2 to 6 years) involves the asso- dilemmas in terms of conflicting responsibilities rather ciation of objects with words and the ability to solve than competing rights. Child Psychology: Development and Be- operations, stage (ages 12 and higher) is characterized by havior Analysis. A Child’s World: Infancy through Adoles- stages is the one proposed by neo-Freudian Erik Erikson cence. While Erikson’s eight- stage theory encompasses the entire human life span, much of it is centered on childhood and adolescence. Each devel- opmental stage in Erikson’s scheme is concerned with a central conflict: trust versus mistrust in infancy; autonomy Childhood versus doubt and shame in early childhood; initiative ver- The period between birth and adulthood, during sus guilt in the preschool period; and industry versus infe- which a person develops physically, intellectually, riority during the early school years. In addition to genetic Childhood has been defined differently across the abnormalities like Down syndrome,environmental ages. These might lieved children were born with certain dispositions that be maternal viruses such as rubella (German measles) or could be changed by their environment.

Further reading Most texts describe widely used methods of monitoring; occasional articles appear on less commonly used modes purchase zocor 20 mg fast delivery lowering cholesterol with diet change, usually in medical journals. Jones (1995), is a useful source for information on auscultation; there are fewer recent nursing articles, but O’Hanlon-Nichols (1998) describes techniques. The most recent microbiological results of his sputum show presence of Pseudomonas Respiratory monitoring 153 and Escherichia coli. His sputum on spontaneous coughing and aspiration is thick, mucopurulent, yellow-green and copious. On auscultation, vesicular breath sounds are diminished in apices, with crackles in both bases. Consider the range of monitoring approaches and specify which one nurses initiate/use, nurses role in interpreting and acting on results, troubleshooting, training, supervising use of monitoring equipment. Chapter 18 Gas carriage Fundamental knowledge Pulmonary anatomy and physiology (including vasculature) Normal respiration (including chemical+neurological control and mechanics of external respiration) Dead space Erythropoietin and erythropoiesis Introduction Studying physiology and pathology necessitates reductionism, but body systems function as parts of the whole body not in isolation. Cardiovascular and respiratory functions are particularly closely interdependent: delivering oxygen (and nutrients) to tissues while removing carbon dioxide (and other waste products) from the tissues. Respiration should achieve adequate tissue oxygenation, so that gas movement across the lung membranes forms external respiration, while gas movement between tissue cells and capillaries forms internal respiration. This chapter explores internal respiration, identifying various factors that affect tissue perfusion and oxygenation. The structure of haemoglobin, and its effect on oxygen carriage and the oxygen saturation curve are identified. Carbon dioxide carriage and some haemoglobinopathies (methaemoglobin, sickle cell, thalassaemia) are also discussed. The fraction of inspired oxygen (FiO2) should be expressed as a decimal (or a fraction). Thus Oxygen carriage Oxygen is carried by blood in two ways: ■ plasma (3 per cent) ■ haemoglobin (97 per cent) At normal (sea-level) atmospheric pressure 0. As cardiac output would need to be about 100 litres per minute to meet metabolic demands (Prencipe & Brenna, undated), oxygen Gas carriage 155 carriage by plasma is normally insufficient to maintain life. Erythrocyte production takes eight days, cells remaining functional for approximately 120 days, with 1 per cent of erythrocytes being replaced each day. Renal or bone marrow disease reduces erythrocyte production, resulting in hypoplastic anaemia. Each haemoglobin molecule contains two pairs of polypeptides, making haemoglobin a large molecule (weighing about 64,450 Da (Ganong 1995)) and so above capillary permeability. Haemoglobin is therefore not normally lost into interstitial fluid (oedema) or urine. An average 70 kg adult has about 900 grams of circulating haemoglobin, giving ‘normal’ levels of 14–18 g/dl for men and 12–16 g/dl for women (Rowswell 1997). Lower concentrations decrease viscosity, so aid perfusion: 10 g/dl being preferred with critically ill patients. Macrophages metabolise old erythrocytes, releasing iron (for further haemoglobin synthesis) and waste (excreted in bile). Polypeptides of normal adult haemoglobin (HbA) consist of two alpha and two beta chains:. The slight biochemical differences between alpha and beta chains are not significant for clinical nursing, but abnormalities of either chain can cause pathologies. Each erythrocyte contains approximately 640 million haemoglobin molecules (Hoffbrand & Pettit 1993). Adult haemoglobin normally replaces fetal haemoglobin soon after birth, although the latter can (abnormally) persist throughout life, predisposing patients to tissue hypoxia. Haemoglobin levels of 10 g/dl with an average 5-litre circulating volume give a total body haemoglobin of. If all four limbs of the molecule carry oxygen, the haemoglobin is described as fully (100 per cent) saturated.

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