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By B. Hector. Defiance College. 2018.

Type1 reaction is caused by increased activity of the body is immune system in fighting the leprosy bacilli safe 10 mg atorlip-10 cholesterol test results vldl. It occur in people who have strong all mediated immunity Both paucibacillary and multibacillary get type 1 reaction and commonly seen within six months of starting treatment, but some of patients may show this reaction before starting treatment even before leprosy has been diagnosed. The most common clinical feature is inflammation in the skin patches with swelling, redness and warmth. The patches are not usually painful, but there may be some discomfort associated with swelling of the limbs or face may occur. Since these proteins/antigens are present in the blood stream, the reaction will involve the whole body causing generalized symptoms. The reactions occur most commonly during leprosy treatment and since it takes long time to clear the dead bacilli and remains for years after stopping the treatment. It can be few or many in number and occur on the face, trunk, and extremities The lesion appear in groups and subside spontaneously while new crops reappears. The onset may occur at any age but is most common between the ages of 10 and 40 years, but may occur at any age. A combination of specific genetic make-up and environmental stimuli may trigger the onset of the disease. Aggravating factors/ triggering factor ♦ Emotional stress ♦ Anxiety 75 ♦ Trauma ♦ Infections ♦ Seasonal and hormonal changes ♦ Cigarette smoking ♦ Alcohol consumption and drugs ♦ Non steroidal anti-inflammatory drugs. Clinical manifestation: ¾ Lesions appear as dark red, raised plaque lesion covered with silvery scales ¾ Lesions produce multiple bleeding points when the scales are scraped away ¾ These patches are not moist and mostly is not itchy ¾ When psoriasis occurs on the palms and soles, it can cause pustular lesions ¾ Lesions can be symmetrical Particular sites of the body tend to be affected ¾ Scalp ¾ The area over the elbows and knees, lower part of the back & genitalia ¾ The extensor surfaces of the arms and legs, ¾ Over the sacrum and the inter gluteal fold If nails are involved, it may be presented by - Pitting - Discoloration - Crumbling beneath the free edge and - Separation of the nail plates Complications ¾ Arthritis (the relation is not understood) ¾ Erytherodermic psoriasis (involving the whole body surface) Treatment Goal: To reduce the rapid turnover of the epidermis and to promote resolution of the psoriatic lesions 76 - Advise that the disease may persist for life with remission and exacerbation. Systemic therapy • Systemic cytotoxic preparations such as methotrexate, have been used in treating extensive psoriasis that fails to respond to other forms of therapy in specialized center Nursing management ¾ Teach patient to avoid picking or scratching the psoriatic area ¾ Teach patient to avoid any topical irritant or allergy- producing Substance ¾ Teach patient to report to physician for any infection that appears to aggravate the psoriasis ¾ Caution patient about medication because some drugs may worsen psoriasis. Acne is the most commonly encountered skin condition, affecting an estimated 85% of the population between 12 & 35 years of age. Girls develop acne 2years earlier than boys Characteristics Characterized by the presence of – closed comedones (white heads,) Open comedones (black heads) are primary lesions while Papules, Pustules, and Nodules & cysts are secondary lesions ¾ Becomes more marked at puberty ¾ Occurs when the pilosebaceous duct is plugged Clinical manifestations Closed comedones (white head) – - are formed from impacted lipids or oils and keratin that plug the dilated follicle - are small, whitish papules - may evolve in to open comedones - have minute follicular openings that can’t be seen -Open comedones (Black head) – Contents are in open communication with the external environment the blackhead is due to accumulation of lipid, bacterial & epithelial debris that obstruct the flow of sebum. Inflammation as a result of pcapionobacterum acne and leakage of content of pilosebeaceoues content 78 N. B Intradermal rupture of sebaceous gland induces an inflammatory reaction due to the leakage of follicle contents (Sebum, keratin, bacteria) in to the dermis. This inflammatory response may result from the action of certain skin bacteria, such as propoonibacterium acnes, that live in the hair follicles and break down the triglycerides of the sebum into free fatly acids and glycerin. Nursing management ¾ Inform patient that acne arises because of combination of factors ¾ Instruct patient to wash the face with mild soap and water twice a day to remove surface oils and prevent obstruction of the oil glands ¾ Caution the patient to avoid scrubbing the face constantly ¾ Hair should be kept off the face and shampooed daily if necessary ¾ Inform patient that all forms of friction and trauma should be avoided ¾ Teach patient that squeezing merely worsens the problem, this may be cause of post inflammatory hyperpigmantation ¾ Teach patient to be consistent with treatment because the problem is chronic ¾ Advise patient that cosmetics, shaving creams, and lotions can agitate acne ¾ Reassurance and emotional support, reduction of stress 79 4. The skin overlying the sacrum and hips is most commonly involved, but bed sores may also be seen over the occiput areas, elbow, heels, ankles, scapula, medial condyle of tibia and head of fibula. Factors contributing for bed sores Immobility, decreased sensory perception, decreased tissue perfusion and nutritional status, friction, increased moisture of the skin Poor nourishment, and obesity (patient have large amount of poorly vasculirized adipose tissue) Clinical manifestation If a pressure area is noted, the nurse notes its size and location and use grading system to describe its severity. Stage I Pressure ulcer is an area of Erythema, tissue swelling and congestion and with patient complaining discomfort, the skin temperature is elevated because increase vasodilatation. The redness progresses to a dusky, cyanotic blue gray appearance, which is the result of skin capillary occlusion weakening of subcutaneous tissue. The skin lesion may represent only the tip of ice berg” between small surface ulcer may overlie a large under lining area. The appearance of pus or foul odor is suggestive sign of infection Nursing diagnosis Impaired skin integrity related to any of the contributing factors. Nursing goal The major goals of nursing may include relief of pressure; improve mobility, improved nutritional status and tissue perfusion. Relieving pressure – frequent change of position by using variety of pads & supportive device to prominent area or if it is possible use flotation or water bed. Improve mobility – patient is encouraged to remain active, passive and active exercise help to increase muscular skin and vascular tone. Improve nutritional status- high protein and iron will be given to increase the level of hemoglobin 6. Minimizing moisture- soiled skin should be washed with mild soap and water and then dry with soft towels and if the patient is in continent urine catheterization will be done 8. In acute stage erythema (redness), papules, vesicles, scales, crusts, or scabs appear alone or together.

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On the other hand buy generic atorlip-10 10 mg on-line cholesterol diet plan, especially when the underlying obstruction develops slowly other anatomic factors – more or less variable from individual to individual – modify the consequences of the basic design outlined. Variations in the configuration of the circle of Willis and in the relative caliber of the arteries affect the amount of cross flow between the anterior and posterior circulation and between the two sides. Ten percent of individuals with total atherosclerotic occlusion of one internal carotid artery in the neck are asymptomatic. Anastomoses in the subarachnoid space between terminal branches of the major cerebral arteries provide blood flow in one territory to an adjacent arterial field. A few communications between intracranial and extracranial vessels are of little or no consequence, with the exception of connections between the ophthalmic artery and branches of the external carotid artery in the orbit. However, penetrating small arteries and a few muscular arteries that run deep into the parenchyma supply much of the central gray masses of the cerebrum as well as the brain stem. The elastic fibers of intracranial arterial walls are limited to a single layer between the endothelium and the media, the internal elastica lamina. The distal branches of the arterial tree in the brain receive no autonomic innervation. Ultrastructurally, tight junctions between the endothelial cell membranes seal the lining of brain capillaries – a major facet of the relatively impermeable blood-brain barrier. Circulatory disorders of the venous system account for a small fraction of cerebrovascular disease and time does not permit a review of the superficial and deep draining pathways of intracranial blood. Physiologic Considerations Hemodynamic as well as anatomic factors play an important role in the vulnerability of brain to disorders of the circulation. The brain comprises only two percent body weight, but it receives fifteen percent of the cardiac output. Blood flow is a function of perfusion pressure (the gradient between mean arterial pressure and venous pressure) and the resistance of the vascular bed (determined mainly at the arteriolar level). Increased intracranial pressure (see the section on Intracranial Hypertension in this syllabus) raises venous pressure and, unless compensated for, lowers the perfusion gradient and the flow of blood. Overall cerebral blood flow is relatively constant over a broad range of arterial pressure. Arteriolar tone is not mediated by the autonomic nervous system or endocrine influences. Cerebral blood flow is clearly affected by oxygen tension, pH, and carbon dioxide tension. But many observations suggest that additional factors, possible oligopeptide neurotransmitters among them, are important determinants of blood flow in the brain. Lack of information in this area is one of the impediments to major advances in cerebrovascular disease. The nerve cell is dependent on oxidative metabolism and a continuous supply of glucose and oxygen for survival. Neuronal function ceases seconds after circulatory arrest; irreversible structural damage follows a few minutes later. Recent work proposes that an excess of excitatory amino acid transmitters and an abnormal influx of calcium into the cell play a decisive role in the death of the nerve cell. Glial cells, especially astroglial and microglia, are more resistant to impaired circulation than nerve cells. The amount of damage and the survival of tissue at risk depends on a number of modifying factors, which include the duration of ischemia, availability of collateral circulation, and the magnitude and rapidity of the reduction of blood flow. Global cerebral ischemia occurs when there is a generalized reduction of cerebral perfusion, such as in cardiac arrest and severe hypotension. Focal cerebral ischemia occurs when there is a reduction or stoppage of blood flow to a localized area of the brain. The resultant localized lesion is referred to as an “infarct” and the pathological process as “infarction. These macrophages slowly leave the field – over a period of weeks and months – and vacated spaces (microcysts) gradually grow larger.

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For detailed explanation on personal hygiene the reader is advised to refer the lecture notes on personal hygiene prepared by the carter centre for Ethiopian Health centre team generic atorlip-10 10mg with amex cholesterol foods pdf. However, the portal of entry, method of spread, genesis of lesions, and manner of dissemination are still unclear. Prevention of disability and rehabilitation Activities aimed at preventing impairment and disability in leprosy patients are important and depend on a good relationship between health worker and patient. Therefore, patients should be regularly examined, so that reactions and new nerve function impairment can be detected and treated appropriately. However, some microbes have developed the ability to destroy the upper layer of the skin to enable their colonization. Warmth, humidity, sweating, over crowding and poor air circulation all help bring about these fungal infections. Because of all these factors, prevention is a matter of both personal hygiene and minimizing contact with potential carriers or contaminated objects see the chart below for guidelines on prevention. Enforcing the practice of good personal hygiene, such as regular bathing, laundering clothes, not sharing towels, soaps and wearing sandals in communal showers. Arthropods and skin disease Arthropods have been associated with human beings since the age of antiquity. Although arthropods are important in maintaining the ecosystem we live in, they can adversely affect our health in several ways: 170 ª By causing direct, non-allergic, local tissue damage through stings, bites, exposure of toxic body fluid (blister beetles), and tissue invasion (sand flea and brown recluse spider). It is therefore a family disease spreading amongst those living in close association, especially when they sleep together in the same bed. Methods aimed at killing the mites will do little to immediately alleviate the nuisance and irritation caused by the rash, although this will eventually disappear. Separate medical treatment however, may be necessary especially if secondary infections have become established. In the past, a common procedure was to give the patient a hot bath and a vigorous scrubbing with a brush until the patient bled, but this is not very effective at either removing or killing the mites. However, as many but certainly not all, patients with scabies are dirty, an ordinary bath before treatment may be advisable for general hygienic reasons. However, if large numbers of patients suffering from scabies are to be treated, such as in epidemic situations, bathing may not be practical. Decreasing the humidity in rooms, improving ventilation and removing dust can control mites and associated fungi. Bedrooms and living rooms should be aired regularly, or other measures should be taken to reduce dampness. The shaking of bedclothes and frequent washing of sheets and blankets reduces the availability of food and therefore 171 the number of mites. General insecticides used for pest control are not effective but a special product containing benzyl benzoate is available, which destroys mites when applied to mattresses, and upholstery. Cutaneous Leishmaniasis Known under a variety of common names, such as oriental sore in old world, uta or chiclero ulcer in new world. It is caused by leishmania major, leishmania tropica and leishmania aethiopica in old world and by leishmania braziliensis, leishmania mexicana and leishmania peruana in new world. It is characterized by typical ulcer that starts as a nodule at the site of bite, and then a crust develops in the middle which exposes the ulcer. It is recommended that personal protection measures be taken, such as repellents, fine mesh screens, insecticide treated clothing and/ or insecticide treated bed nets are used. Application of basic sanitation This is aimed at abolishing the breeding sites around human habitation, such as proper disposal of refuse; filling of cracks and holes in the soils and walls. Control of Animal Reservoir In Ethiopia, control measures were carried out against the rock hyrax, a wild animal reservoir of leishmaniasis, where by reduction of the prevalence of leishmaniasis was occurred. Case treatment: Treatment is more effective when a partnership develops that includes the patient, family members and doctor. Hunter, savin, and dahi clinical dermatology voli1 and 2 oxford, black well scientific publication 1989. National technical guideline for integrated disease surveillance and response disease prevention and control department A.

Virtually all other muscle rehab Rehab Outcome can be mediated by some form of Assessment Baseline feedback 10 mg atorlip-10 with mastercard xenical cholesterol, usually visual. Differing work and sports specifc training patient populations, protocols will achieve a certain level of and outcome measures make clear 146 guidelines diffcult. This improves range of work over a period of nerve conduction, activates the time, allowing assessment of: neuromuscular junction and • Maximum/minimum contraction stimulates a muscle contraction. It • Maximum/minimum relaxation also promotes synapse formation, • Stability contraction/relaxation protein production and muscle • Speed of initiation/release hypertrophy. A classic ‘slow twitch’ treatment would be passive and would improve sensory conduction, resting tone and normalize bladder refexes. Conclusion A neuromuscular stimulation The pelvic foor physiotherapist unit – The Myomed 932 147 has the necessary skills to assess muscle function and dysfunction and rehab according to sound evidence based principles. Highly developed palpation is needed to differentiate between subtle differences in tone and strength. Special insight into the psychological implications and management of behaviour make the Pelvic Floor Physio an excellent conservative one-stop-shop. A clear assessment, with a patient specifc programme and regular monitoring of compliance and motivation can yield excellent results; better than standing in the corner doing 100 squeezes per day, but not contracting with a cough! It fnds its niche somewhere between patient responsibility and doing the best you can with what you’ve got. Unsurprisingly, in view of completely normal anal sphincter the social stigma attached to this function. Also, a patient with problem, it may be underreported, damaged sphincter muscles may and patients often present late. For example, any to determine if the patient is person who has suffciently severe incontinent to fatus (least severe), diarrhoea will experience urgency liquid stool (more severe), or solid (having to ‘run to the toilet’). One should 149 also ascertain whether the problem as well as any other symptoms is urgency or passive incontinence suggesting bowel cancer or (in which the patient is unaware of infammatory bowel disease (such the passage of stool). The patient should be asked about any general medical conditions, Examination as well as their mobility. Diabetes Apart from a general clinical and many neurological and spinal examination, one should examine Common causes for facial incontinence Anatomical site Disorders Anus/ perineum Anal sphincter injury, pudendal neuropathy, rectal prolapse. This includes infammatory bowel disease and faecal impaction or colorectal neoplasms with overfow diarrhoea. Sensorimotor pathways Diabetes, neurological disorders Brain Dementia, psychological disturbances General Impaired mobility diseases can affect pudendal nerve the perineum for signs of rectal and therefore sphincter function. Examination of the important, particularly any perineum and anus may reveal a history of instrumental deliveries, palpable anal sphincter defect. A digital anal examination is important not only subjectively to One should ask about the patient’s assess sphincter tone (both resting bowel habits and stool consistency and ‘squeeze’), but also to exclude with particular attention to any anorectal neoplasms, and to detect recent change in bowel habits, faecal loading. It is unusual, old, or who have experienced however, for this to change the changes in bowel habits should be management of an incontinent referred for a colonoscopy in order patient, and its usefulness is mainly to exclude colorectal neoplasms or in research and in documentation infammatory bowel disease. Endo- anal ultrasound is a non- Sacral nerve latency testing aims invasive procedure which allows to detect sacral neuropathy (which visualisation of the anal sphincters, is common in incontinent women, and is indicated in all patients and usually due to obstetric injury). It will identify the reproducibility in most operators’ group of patients with isolated hands, and seldom gives results sphincter injuries (almost all of that change management. At present it is not widely used in the assessment of anal sphincter Anorectal manometry is commonly injuries, but may become more so performed to document anal in the future. Measuring resting sphincter pressures Management provides information about Treatable specifc conditions the function of the internal Patients with sphincter injuries sphincter, while the quality of the should be referred for possible (consciously controlled) ‘squeeze’ repair. Although the long- term pressure is dependant on external results of anal sphincter repairs 151 are disappointing (about 25% stop any with side effects on of patients will be continent for gastrointestinal motility. They can empty their rectum at a convenient Bowel diseases such as colorectal time, and hopefully not soil neoplasms or infammatory bowel themselves during the intervening disease should be treated as usual. Conservative management Other surgical options Unfortunately, most patients Patients with incontinence due with faecal incontinence do to pudendal nerve dysfunction not have curable diseases. They or surgically non- repairable anal should initially be treated with sphincter injuries may beneft from conservative measures aimed sacral nerve stimulation. Short at reducing the impact of the term data for this intervention incontinence on the patient’s are encouraging, but long- term lifestyle. Bowel habits may be improved by Neosphincter construction, modifying fbre intake (some will whether with a prosthetic improve by increasing the fbre sphincter or gracilis muscle in their diet, others by decreasing transposition, are complex it).

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