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Model estimates represent the average from 100 simulations; women are only counted if they currently have a sexual partner. Although the previous figures show the model outputs in terms of contraceptive use, it is useful to validate the model by comparing modelled fertility patterns with those observed in surveys. As expected, the ratio is very low in the 15-19 28 age group because many of the women in this age group who are not married are not yet sexually active. The model results are roughly consistent with the survey results, even though the model makes no explicit assumption about the effect of marital status on contraceptive use. Similar to the approach in other mathematical models of fertility [71, 72], we assume that the age at which women become fecund is uniformly distributed between ages 12 and 20, and that the age at which women cease to be fecund is uniformly distributed between ages 35 and 50. This parameter is sampled from a gamma distribution with a mean of 1 and a standard deviation of 0. The standard deviation is based on the coefficient of variation in fertility levels, which was found to be relatively consistent at 0. The persistent component accounted for 58% of the variation on average (across three historical populations) [73], and since it is the persistent component that 29 we are interested in for the purpose of parameterizing our model, we set the standard deviation to 0. Women are assumed not to be at risk of falling pregnant while breastfeeding (lactational amenorrhoea). Although menstruation may resume while a women is breastfeeding (particularly if she is no longer breastfeeding exclusively), we assume for the sake of convenience that there is negligible risk of pregnancy during this time. Assumptions about the duration of breastfeeding are the same as described previously [74, 75], viz. In the case of sex workers who have no regular partners, we assume that the risk of falling pregnant is the same as that in women with one regular partner. The model also assumes that a woman is not at risk of falling pregnant if her current partner is temporarily absent due to migration or incarceration (in modelling circular migration, we assume that the pregnancy risk is concentrated during the periods in which the migrant partner returns home). In the interests of simplicity, we model only the incidence of pregnancies that lead to live births. This means that it is possible to work backwards from observed fertility rates to estimate the incidence of pregnancy. Further suppose that Fr1 (x, t) represents the rate of falling pregnant (where pregnancy leads to live birth) in year t, in women of race r who are aged x at the start of year t. Note that of women aged x at the start of year t, who fall pregnant in year t, approximately one quarter will deliver in year t and the remainder will deliver in year t + 1 (assuming that conceptions occur uniformly over the period from time t to t + 1, and assuming the time to delivery is 9 months on average). Now suppose that for the ith women, who is aged xi at the start of year t, and is of race group ri, the fecundability parameter is i, the number of partners is ni, the level of condom use with her jth partner is cij, the reduction in the risk of conception due to other contraceptive methods is i, and Pi is an indicator of whether the woman is currently pregnant or breastfeeding (1 if currently pregnant or breastfeeding, 0 otherwise). We define Fr2 (x, t) as the rate of falling pregnant (where pregnancy leads to live birth) in year t, in women of race r who are aged x at the start of year t, with average fecundability (relative fecundability parameter equal to 1) who have a single sexual partner and who are using no contraception. We relate Fr1 (x, t) and Fr2 (x, t) by noting that on average we would expect Fr1 (x, t) N r (x, t) i:xi x, ri r Fr2 (x, t) i 1 i 1 Pi 1 cij E, ni j 1 where Nr(x, t) is the number of women of race r who are aged x at the start of year t, and E is the efficacy of condoms in preventing pregnancy. This equation allows us to approximate Fr2 (x, t): F (x, t) 2 r Fr1 (x, t) N r (x, t) i:xi x, ri r i 1 i 1 Pi 1 cij E ni j 1. Because of stochastic variation, and because of the relatively small number of women in some age-race compartments, these rates may be quite volatile. To stabilize these rates, we define a smoothed set of pregnancy incidence rates, Fr3 (x, t). These are calculated as moving averages of the Fr2 (x, t) estimates: Fr3 (x, t) 0. However, the calculations of Fr3 (x, t) and i are only updated at the start of each year. The first variable represents their highest level of completed education; this takes on a value from 0 (no education) to 13 (completed some form of tertiary education), with values of 1 to 12 corresponding to completion of grades 1 to 12. The second variable determines whether the individual is currently either enrolled in school/tertiary study or not enrolled. For the sake of simplicity, we assume that all children who start school do so before age 10, and that children who drop out of school do so only after grade 1 (studies show that the average age of starting schooling in recent cohorts is around 6 years [81], and that rates of dropout prior to grade 5 are negligible [82-84]).

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Identification of individual compounds is based on comparison of mass spectra and retention times with those of reference material or with assistance of mass spectral databases. Unknown contaminants like 3,6-dichlorocarbazole and bis(4octylphenyl)amine as well as anthropogenic molecular marker compounds derived from municipal sources like polycyclic musks, 4-oxoisophorone and methyltriclosan; molecular markers derived from effluents of three different industrial branches. Full-scan mass spectra were used for a spectral library search and additional structural elucidation to achieve (provisional) identification. In full scan mode, this information can be obtained, however, the lack of compound databases and mass spectra libraries often represent an obstacle for efficient structural elucidation of unknown compounds. Such instrument provides mass determinations with an accuracy of 5-10 ppm, which is an impressive improvement over the conventional nominal-mass information of a quadrupole instrument. Such an instrument enables accurate mass measurement with accuracies of <5 ppm, which allows removal of interpretation ambiguities and easy differentiation of charge states even in weak eollisionally-aetivated decomposition tandem mass spectra [262]. However, environmental applications of this technique are still scarce and further development is expected. A large body of literature exists on occurrence of specific groups of organic contaminants in freshwater and estuary sediments. However, the levels found in the polluted areas were higher, ranging between 200 ng/g d. For this reason, greater toxicity contributions of less potent contaminants with higher concentrations could be found. Higher levels in sediments up to 1400 ng/g-dw were found in a downstream area of a manufacturing plant in United Kingdom [266]. Of 40 congeners included in the analytical work, 17 congeners were detected in river sediments. Samples analysed included air, deposition, water, soil, sediments, sludge, biota and foodstuffs. In the textile industry area, concentrations were considerably higher downstream than upstream the industrial effluents, indicating a local impact. Levels of found upstream of point sources of pollution were generally lower than 200 ng/g. The highest concentrations were detected in the first sediment layer, which is easily resuspendable, while underlying sediment contained concentrations of at least 5 times lower, probably due to dilution, not breakdown [270]. Concentrations found in bed sediments span three to four orders of magnitude, mainly depending on the vicinity of local industrial and urban sources. The highest concentrations found were closely related to the input of industrial wastewaters from plastic production and were limited to a few kilometres downstream of the source of contamination. Chemical analysis of contaminants in sediments 111 117 A) H ·H Q]f Adriatic Sea a Baltic Sea b Casco Bay, U. Elsevier Pharmaceuticals (including steroid sex hormones) Most of the studies carried out to assess the environmental occurrence of drugs have focused of the aquatic media, especially in connection to drinking water. Soils, sludge and sediments have been scarcely investigated as compared to water media. Pharmaceuticals, especially those presenting the greatest consumption and persistence, have been found in sediments at considerably higher concentrations than those reported for sex hormones. The parasiticide ivermectin, used in veterinary medicine, has been found in sediments close to fish farms because of its elevated lipophilicity. The mean concentration detected in the six sediment cores taken directly under the cage block was 5. Concentrations were under the limit of quantitation at depths below 9 cm in all cores taken from directly under the cage block [196]. Pharmaceuticals detected in sediments were bezafibrate, erythromycin, ibuprofen, linomycin, ranitidine, sparamycin and tylosin; the latest two used a growth promoters in animals were found in the concentrations of 2. Of the various estrogens most frequently monitored in environment programs, the natural hormone estradiol and the synthetic estrogen ethynyl estradiol, are the most relevant because of their high estrogenic potency. However, these two compounds are often the least frequently detected in environmental waters, and estriol and estrone, the main metabolites of estradiol, the most ubiquitous [273,274].

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The selected bioassays are a screening test, Microtox in solid phase with a bioluminiscence bacteria Vibrio fisheri [132] and an acute toxicity test with marine amphipods representatives of the Basque estuaries, Corophium sp and Corophium multisetosum (protocol in [133,134]. Samples that present high contaminant concentrations and show biological effects must be isolated. The study of the benthos community alteration is done at the area to be dredged and that at the disposal site. France: Characterization of total toxicity in marine sediments the analysis of potential hazards only considers a limited number of contaminants, i. It is therefore essential to incorporate in the method both their real bioavailability and the toxicity of other potential substances not detected via the chemical analysis. Hence, integrated risk characterization requires a determination of the total sediment toxicity. The common practice involves the use of bioassays, as in situ methods are usually too complex and frequently yield results difficult to interpret. Assays available to assess total sediment toxicity are numerous and vary according to the tested species as well as to the nature of the effects observed: disturbances in growth and physiological functions, lethality, etc. Nendza [138] recently established an inventory of bioassays used to analyse dredge spoils and sediments. The author proposes three series of assays: · Series 1: screening and detection of toxic impacts with bacterial bioluminescenee (V. A battery of nine bioassays was used to evaluate the toxicity of dredged sediments. Bioassays were finally classified in four categories based on their response: Sensitive and discriminating: development of bivalve larvae, copepod Tigriopus brevicornis in total sediment (lethality and acetylcholinesterase in vivo in copepodites and oviferous females), 202 J. This approach is based on the methodology applied for environmental risk assessment, with the two following steps. This assessment is specific to each considered sediment management system and each site. For each above step, the three following phases are applied; · Problem description. In the detailed risk assessment step, it is necessary to conduct bioassays on the aqueous phase (water extracts and pore water) and on the whole sediment. The bioassays battery should include acute toxicity assays, chronic assays and, if possible, genotoxicity assays. National policymakers are currently investigating the possibility to use bioassays as an alternative to distinguish the presence of groups of compounds exerting a specific toxicological response. The techniques have been extensively used in research programmes to identify contaminants in different environmental compartments. Food-web accumulation and magnification of dioxin-type chemicals is the main pathway for reaching critical concentrations in target organisms. This pathway can be imitated by using extraction methods that mimic the accumulation of those compounds by the lower trophic levels, like macrozoobenthos. As a first step, sediment pore water extracts and sediment solvent extracts were screened using a battery of bioassay tests. Lethal toxicity was only measured in 10% of the sediment pore water samples tested. Potential mutagens were not detected in any of the pore water samples, while 25% of sediment solvent extracts scored positive. Where available, occurrence, persistence, bioaccumulation and toxicity data indicate that some of these compounds should be considered for further assessment. Peterson, Biomimetic extraction as a cost-effective analytical tool for determining the aquatic toxicity hazard of complex petroleum products. Bakker, Dioxin-type toxicity in harbour dredge of the Harbour Channel at Delfzijl. Report # L-04/02, Institute for Environmental Studies, Free University, Amsterdam, 2004.

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Nevertheless, some data have shown that treatment of trichomoniasis by the vaginal route can be a real alternative to systemic treatment. Generally, little attention is paid to improving the formulation vehicle residence time on the mucosa infected with T. Moreover, when formulations are intended for the vagina, other elements should also be taken into account. In fact, the formulations should (i) be stable at the acidic vaginal pH, (ii) be easily applied to obtain a homogeneous distribution of the drug, (iii) be retained in the vagina as long as possible, (iv) be compatible with other coadministered substances, and (v) be nontoxic to the vaginal mucosa (124). Vaginally applied formulations can also be used as controlled-release devices for vaginally applied drugs. An increase of the absorption of leuprolide (a gonadotropin-releasing hormone analog) was observed after adding organic acids which partially dissolved the cellular cement. Furthermore, the efficacy of a gel containing dinoprostone (prostaglandin E2) was significantly related to the pH of the vagina. Semisolid drug delivery forms, such as gels, are widely used in the development of topical formulations against vaginal microbial infections (128). Pharmaceutical gels consist of natural polymers, in particular some proteins (collagen and gelatin) and polysaccharides (alginate, carrageenan, and guar gum), semisynthetic polymers (carboxymethyl cellulose and hydroxypropyl methylcellulose), and other synthetic (carbomer and Pluronic) or inorganic (aluminum hydroxide, bentonite, and laponite) substances (123). Hydrogels have many advantages: they are generally colorless, odorless, and tasteless and can be used in combination with vaginal devices or condoms (129). In terms of their effectiveness, the most important problems presented by these forms are their low remanence at the epithelial surface and their rapid detachment from the application site (129, 130). In order to overcome these problems, mucoadhesive polymers are often added to formulations to immobilize the gel as long as possible on the vaginal mucosa (131). For all these reasons, the use of thermosensitive and mucoadhesive gels was recently presented as an alternative strategy for treatment of T. These gels are liquid at low temperature, thus facilitating the spreading of the formulation on the whole vaginal area, even in difficult-to-access places, and they become semisolid at body temperature, increasing the residence time of the formulation on the mucosa (134­136). In addition, drug resistance emergence and intolerance to nitroimidazoles contribute to making trichomoniasis treatment a societal challenge to be addressed. Because of this, chemotherapy and vaccines are the best ways to control the expansion of this cosmopolitan disease. Besides in vitro screening of new compounds, all strategies that attempt to improve the biodistribution of anti-Trichomonas compounds provide real added value to the fight against this disease. In particular, approaches consisting of the prevention of side effects linked to parenteral treatments need to be prioritized. In this regard, advances in mucoadhesive polymer formulation should particularly be supported in the future. Trichomonas vaginalis metronidazole resistance is associated with single nucleotide polymorphisms in the nitroreductase genes ntr4Tv and ntr6Tv. Trichomonas vaginalis: pathogenicity and potential role in human reproductive failure. Trichomonas vaginalis infection is uncommon in the British general population: implications for clinical testing and public health screening. Mycoplasma genitalium and Trichomonas vaginalis in France: a point prevalence study in people screened for sexually transmitted diseases. Interrelationships among human immunodeficiency virus type 1 infection, bacterial vaginosis, trichomoniasis, and the presence of yeasts. The effect of treatment of vaginal infections on shedding of human immunodefi- 25. Association between high risk human papillomavirus infection and co-infection with Candida spp. An association between Trichomonas vaginalis and high-risk human papillomavirus in rural Tanzanian women undergoing cervical cancer screening. Endobiont viruses sensed by the human host- beyond conventional antiparasitic therapy.

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W is a 28 year old female who presented to the emergency department with nausea and chest pain radiating to the right arm. Recent medical history was significant for induction of labor due to gestational hypertension two weeks prior to presentation without complication. One week prior to presentation, she experienced fever and bilateral breast warmth and tenderness and was treated with Keflex for early mastitis. Family history was significant for a sister with myopericarditis complicated by ventricular tachycardia unrelated to pregnancy. Echocardiogram showed a left ventricular ejection fraction of 61% with hypokinesis of the mid and distal anteroseptum without pericardial effusion. With evidence of myocardial injury despite normal coronary arteries, evaluation for possible inflammatory cardiomyopathy was pursued. Colchicine was not initiated due to lack of evidence of efficacy in patients with myopericarditis. Because significant ventricular ectopy was observed on telemetry, the patient was discharged with a 30-day heart monitor. Results were significant for an 11 beat run of ventricular tachycardia that occurred shortly after hospital discharge. It is important to note that these will be normal in a subset of patients with myopericarditis, requiring a high index of suspicion for diagnosis. He has past medical history of resistant hypertension and end-stage renal disease, and presented with severe headaches and blurry vision of one day duration. He had blurred margins of optic disc, decreased visual acuity without any visual field deficits, and no neurologic deficits. Hence, any deterioration of mental status should trigger emergent neurologic exam, fundoscopy and head imaging. Clinical cues include reversible time course, and propensity to cause vision loss, headache and focal deficits. A good recovery can be expected in days to week; nevertheless, patient should be closely monitored. Most characteristic presentation is of focal deficits, blindness and altered consciousness which subsequently improves. Theories proposed regarding etiology include dysfunctional autoregulation of vascular tone (vasogenic) and endothelial cell damage (cytotoxic). Our patient presented at a young age, and did not have any defined predisposing condition except resistant hypertension. One oft-cited indication of malignancy is a lymphocytic predominance in ascitic fluid; however, in this case lymphocytes were elevated but not the predominant cell type. Thus a reliance on cell count alone in identifying the etiology of ascites may miss malignancy or multifactorial etiologies. In particular, the high protein level and atypical cell counts including high lymphocyte count in his ascitic fluid should have prompted further workup. In this case, fluid was sent for cytological analysis only after atypical cells were noted on gram stain, representing a near-miss in the diagnostic workup. Malignancy should remain on the differential in patients at risk presenting with atypical cell counts in peritoneal, pleural, or pericardial effusions. She denied fever, chills, flank pain, nausea, vomiting, hematuria, or abdominal pain. The patient denied history of abnormal pap smears, sexually transmitted infections, or family history of malignancy. Her surgical history was noncontributory and her medications were levothyroxine, buspirone, and trazodone. Within a few days, she went to an urgent care for bloating and was diagnosed with constipation. Five days later the patient presented to the emergency room for worsening symptoms, including straining with urination. Urology was consulted for Foley placement, and vaginal masses were palpated during their exam. Often a diagnosis is clear and made without a pelvic exam; however, in cases with unknown etiologies, a broad differential, close follow up, and pelvic exam are essential.

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Analysis of the data shows that nurses felt as though there was better and more open communication of patient plans and communication in general postlocalization (p = 0. Both nurses and physicians agreed that after localization information was better relayed (p = 0. It should be noted that nurses and physicians had differing perceptions as to whether they functioned as a team; with physicians believing that nurses and physicians work well as a team post-localization whereas nurses postlocalization were not in agreement as to the level at which they did function as a team with physicians (p = 0. Requires ongoing socialization and orientation of healthcare teams (usage spikes following national trainings) 2. Important to include all team members in training and orientation not just prescribers 3. Usage data feedback with targeted training of sites or teams weeks 1-16 residents were not notified of the admission order set changes. Pre and postsurveys involving free response, Likert scale, and multiple choice questions were collected. Orthostatic Hypotension is one of the etiology for it but measurement of orthostatic vitals are confusing, time consuming and overwhelming. Create an app which will do orthostatic measurements in standardize way as per American Autonomic Society guideline 2. Pre-intervention Analysis: We have prepared a survey with 18 questions and multiple choice answers. Based on the results, only 6 % answered correctly on how to record orthostatic vitals based on current guidelines. Top 3 challenges reported based on survey are time consuming, confusing time interval and risk of patient passing out. Intervention: We have created an app which will conduct orthostatic vitals based on current guidelines, with detail visual and voice instructions and automatic interpretion. It will not only help to save the time but also will help to standardize way of recording, interpreting correct diagnosis and providing clear and consistent result. We aimed to schedule at least three patients for the group visit to match usual clinic productivity. Providers identified appropriate patients, who then received a description of the session, invitation to bring a guest (caregiver/family), and provided informed consent. Seventeen patients and 4 guests attended 7 English sessions, and 10 patients and 3 guests attended 2 Spanish sessions. A needs assessment was conducted by chart review (n=43) and provider surveys (n=50). Educational interventions alone are insufficient to create change in provider habits. While this project had a complex needs assessment, the cost was low and and could be easily generalized to major academic centers and many community hospitals as well. All patients discharged from the adult hospitalists inpatient services are potentially eligible for the program if they signed up with home care services with one of the two agencies and if they agreed to a telemedicine follow-up visit. Physicians we asked to routinely inquire about issues with discharge medications, clinical changes since discharge, and follow-up plans. Once the process is robust and sustainable, we will assess the impact on patient care as well as patient as well as user experience. To assess the impact on quality of care, we will track the number of video visits leading to changes in medication reconciliation or changes in the plan of care. Nurses attempted to contact the hospitalist via the app 28 times; being able to connect with clinicians 10 times (35% connection rate). Average visit time was 4:59 minutes; average wait time by the nurse was 7:15 minutes; removing two outlier visits with >20 minutes wait time, average wait time was 2:47 minutes. At least three of the ten video visits were deemed to improve patient care and/or patient experience by the conducting hospitalists. Although telemedicine tools are becoming more user friendly, integration of these technologies is still challenging and requires careful adjustment in current processes and the diligent addition of new workflows. Interviews and focus groups were recorded and transcribed and/or detailed field notes were taken. We used the constant comparative method to identify recurring themes within and across sites, and resolve interpretive discrepancies. Preliminary analyses included a paired samples t-test to compare drinks per drinking day four weeks prior to treatment to four weeks of drinking after eight weeks of treatment for study completers.

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Hyperalbumin is associated with dehydration while hypoalbuminemia is associated with many illnesses including, but not limited to, kidney disease, liver disease, tissue damage and inflammation and malnutrition. Elevated levels of ammonia may be either due to inborn errors of metabolism or secondary to other conditions. Elevated levels are observed in acute nephritis, renal failure, urinary tract obstruction, shock, dehydration, congestive heart failure and diabetes. The measurement of bicarbonate, usually in conjunction with tests such as glucose, urea, sodium, potassium and chloride is useful in the assessment of disturbances of acid base balance resulting from metabolic or respiratory causes. B5355-43: Thermo Scientific Total Bilirubin Reagent offers at least 21 days working reagent stability minimizing reagent wastage. B5358-84: Thermo Scientific Cholesterol Reagents are intended for the in vitro quantitative determination of cholesterol in serum. B5345-31: Thermo Scientific Lithium Reagent is a liquid stable assay offering 12 months stability. Increased conjugated or direct bilirubin generally results from acute hepatitis or when any portion of the biliary tree becomes blocked or abnormally permeable. Measurements are useful in the diagnosis and treatment of a variety of diseases involving the liver, kidney, bone marrow and other metabolic and nutritional disorders. Elevated levels can occur with dietary changes, diseases that impair kidney function, liver disease, congestive heart failure, diabetes and infection. Internal 0°C to 50°C (32°F to 122°F) External -40°C to 70°C (-40°F to 158°F) Temperature accuracy. Internal -10°C to +50°C (+14°F to +122°F) External -50°C to +70°C (-58°F to +158°F) Humidity range. Internal 0°C to 50°C (32°F to 122°F) External -50°C to 70°C (-58°F to 158°F) Temperature accuracy. The measurement is made in 1 to 3 seconds and the memory feature allows recalling the minimum, maximum and the last reading. One end of the tachometer provides contact readings with a rotating spindle; the other end makes touchless readings with a light beam utilizing self adhesive tabs. Economical, precise and reliable means of measuring critical temperatures in blood bank refrigerators, ultra-low freezers, freezers, refrigerators, incubators, ambient/room, block heaters and ovens. Therm-Chex thermometers can be strategically placed anywhere within fridge or freezer wall using supplied magnetic pair. Audible and visual alarm feature provides alert when temperature rises above or falls below two set points. Three foot micro-cable permits refrigerator or freezer doors to close without seal on it. Buffered bottle media models contain glycol/water a thermal dampening media housed in a 5 mL bottle, used to minimize temperature spikes caused when a instrument door is opened for a period of time and thereby preventing false alarms. Simultaneously shows the current, minimum, and maximum temperatures and updates continuously. An audible and visual alarm will trigger when the temperatures goes above or below the set temperatures. Temperature probe is housed in a plastic bottle filled with a Bio-Safe nontoxic, non-hazardous liquid medium. Thermometers are supplied with dual magnets and velcro sets to allow attachment to walls or doors. Internal 0°C to 50°C (32°F to 122°F) External -50°C to 70°C (-58°F to 158°F) Resolution. Internal -10°C to 60°C (14°F to 140°F) External -50°C to 70°C (-58°F to 158°F) Resolution. These high accuracy thermometers are used when temperature measurements are critical and/or when online documentation is required. To measure a temperature point unit at object, pull the trigger and read the measuring value from the display. It registers the highest and lowest temperatures reached over a certain time frame and then can be reset with the push-button feature. It features an enclosed bulb to help ensure average temperature readings and an open scale for easy, accurate readings. The flange seal allows easy opening and closure and provides universal fit on 12 and 13 mm test and culture tubes.

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Instruct the patient · To wash hands with soap and water and dry especially if visibly soiled (if hands not visibly soiled, use alcoholbased hand rub or soap and water) · To dry hands properly so they do not remain colonized with microorganisms · About the signs and symptoms of infection · About neutropenic precautions · About self-administration technique for colony-stimulating factors if appropriate · To report temperature of > 100. High risk for infection related to neutropenia · Monitor blood counts (complete blood count with differential) · Monitor for signs and symptoms of infection · Monitor vital signs · Administer colony-stimulating factors (filgrastim, sargramostim, and pegfilgrastim) as ordered. High risk for bleeding related to thrombocytopenia Explain the facts about blood and blood cells. Instruct the patient · About the signs and symptoms of bleeding and to report these signs and symptoms · About bleeding precautions · About creating a safe environment at home to reduce the risk of injury · When to notify the healthcare professional. Instruct the patient regarding · the signs and symptoms of anemia: pallor, fatigue, shortness of breath, tachycardia, headache, dizziness, irritability, and/or palpitations · Possible causes · the signs and symptoms of fatigue · Energy-conservation practices, including setting priorities, planning and pacing activities, delegating, scheduling activity at peak energy time, napping, structuring routine, and distraction · About self-administration technique for erythropoiesisstimulating agents if appropriate · About the importance of adequate intake of iron · When to notify the healthcare professional. If appropriate, refer for a nutritional consult and encourage dietary supplements. Rinse mouth every four to six hours or more often for comfort Any of the following solutions may be used. For signs of thrush or infection, consult with physician or nurse practitioner regarding initiation of antibiotics. For mouth dryness, instruct patient to take frequent sips of water or other liquids throughout the day. Instruct the patient regarding · the signs and symptoms of mucositis · How to perform an oral assessment · Oral hygiene and care · Removal and cleaning of dental appliances each time mouth is cleaned. Keep dental appliances out at night and if the mucous membranes become irritated, wear them during the day only when eating or out in public. Nursing Care for the Patient Receiving Chemotherapy (Continued) Nursing Diagnosis/ Problem · · · · · · · Intervention and Rationale Encourage oral intake. Patient Education and Instruction Alopecia · Inform the patient about expected time frame of hair loss and duration. Instruct patient regarding · Strategies to minimize alopecia · Considering cutting hair short to prepare for any hair loss · Rinsing hair thoroughly and gently patting it dry · Using a hair net, turban, or scarf to contain falling hair · Using a satin pillowcase · Using a wide-tooth comb or bristle brush on hair; can also "finger-comb" hair by using moistened fingers · Using a shampoo and conditioner with a sunscreen to prevent damage from sun exposure · Informing hairstylist that the patient is receiving chemotherapy · Keeping head covered in the summer to prevent sunburn or using sunscreen on scalp · Avoiding the following products ­ Hair sprays, coloring, dye, bleach, or permanent waves or straightening agents ­ Clips, barrettes, and bobby pins ­ Braids or corn rows ­ Hair dryers, curlers, or curling irons ­ Rubber bathing or swimming caps · Resources to obtain a wig. Instruct patient regarding · Eating small, frequent meals · Rest periods especially before and after eating · Maintaining a high-calorie, high-protein diet · Experimenting with foods · Using gravies · Taking antiemetics or pain medications as prescribed · Oral care · Exercise · Monitoring weight weekly · Not drinking fluids with meals · When to notify the healthcare professional. Potential for electrolyte alterations · Monitor electrolytes (magnesium, potassium, calcium). Patient Education and Instruction Instruct patient regarding · the importance of taking premedication · When to notify the healthcare professional. Potential alterations in cardiac toxicity Instruct patient · Regarding potential toxicity · Regarding monitoring tests · When to notify the healthcare professional. Potential fluid retention related to docetaxel Instruct patient regarding · Prophylactic steroid therapy as ordered · When to notify the healthcare professional. Based on information from Eilers, 2004; Epstein & Schubert, 2003; Friese, 2004; Joanna Briggs Institute for Evidence Based Nursing and Midwifery, 1998; Kostler et al. In these patients, a higher-level antiemetic regimen, possibly started earlier, may be needed. Although the agents used are familiar to gynecologic oncology nurses, the management of intraperitoneal therapy presents challenges related to the route of delivery. External beam and low- or high-dose brachytherapy usually are administered in the outpatient setting. Patient education focuses on the type of radiation and the management of side effects at home. In addition, Table 13-8 gives specific patient-education information related to a knowledge deficit of brachytherapy. Patients can be directed to Internet sites that will provide additional helpful information related to their cancers, the treatment, and possible clinical trials for which they may be eligible. Unique Nursing Management for Intraperitoneal Chemotherapy Nursing Diagnosis/ Problem Abdominal distention/pain Intervention and Rationale Assess abdomen prior to therapy. Patient Education and Instruction Instruct patient to · Eat a light meal · Wear comfortable clothes · Post-therapy, to turn side to side every 15 minutes for 1 hour. Instruct patient to · Void prior to treatment · Call if normal urination pattern does not return within 48 hours.


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