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When discharge order cialis soft 20mg free shipping erectile dysfunction drugs market, irregular bleeding purchase 20mg cialis soft erectile dysfunction diabetes pathophysiology, or pain or bleeding after sexual intercourse occurs cialis soft 20mg with mastercard erectile dysfunction treatment phoenix, the disease may be advanced. Diagnosis Nursing Diagnoses • Anxiety related to the diagnosis of cancer, fear of pain, perceived loss of femininity, or childbearing potential • Disturbed body image related to altered fertility, fears about sexuality, and relationships with partner and family • Pain related to surgery and other adjuvant therapy Cancer of the Cervix 149 • Deflcient knowledge of perioperative aspects of hysterectomy and self-care Collaborative Problems/Potential Complications C • Hemorrhage • Deep vein thrombosis • Bladder dysfunction • Infection Planning and Goals the major goals may include relief of anxiety, acceptance of loss of the uterus, absence of pain or discomfort, increased knowledge of self-care requirements, and absence of complications. Nursing Interventions Relieving Anxiety Determine how this experience affects the patient and allow the patient to verbalize feelings and identify strengths. Explain all preand postoperative and recovery period preparations and procedures. Improving Body Image • Assess how patient feels about undergoing a hysterectomy related to the nature of diagnosis, signiflcant others, religious beliefs, and prognosis. Relieving Pain • Assess the intensity of the patient’s pain and administer analgesics. C Monitoring and Managing Complications • Hemorrhage: Count perineal pads used and assess extent of saturation; monitor vital signs; check abdominal dressings for drainage; give guidelines for restricting activity to promote healing and prevent bleeding. Cancer of the Colon and Rectum (Colorectal Cancer) 151 Evaluation Expected Patient Outcomes • Experiences decreased anxiety C • Has improved body image • Experiences minimal pain and discomfort • Verbalizes knowledge and understanding of self-care • Experiences no complications For more information, see Chapter 47 in Smeltzer, S. Cancer of the Colon and Rectum (Colorectal Cancer) Colorectal cancer is predominantly (95%) adenocarcinoma, with colon cancer affecting more than twice as many people as rectal cancer. It may start as a benign polyp but may become malignant, invade and destroy normal tissues, and extend into surrounding structures. Cancer cells may migrate away from the primary tumor and spread to other parts of the body (most often to the liver, peritoneum, and lungs). If the disease is detected and treated at an early stage before the disease spreads, the 5-year survival rate is 90%; however, only 39% of colorectal cancers are detected at an early stage. Clinical Manifestations • Changes in bowel habits (most common presenting symptom), passage of blood in or on the stools (second most common symptom). Assessment and Diagnostic Methods • Abdominal and rectal examination; fecal occult blood testing; barium enema; proctosigmoidoscopy; and colonoscopy, biopsy, or cytology smears. Gerontologic Considerations the incidence of carcinoma of the colon and rectum increases with age. In men, only the incidence of prostate cancer and lung cancer exceeds that of colorectal cancer. Patients with colorectal cancer usually report fatigue, which is caused primarily by iron deflciency anemia. In early stages, minor changes in bowel patterns and occasional bleeding may occur. The later symptoms most commonly reported by the elderly are abdominal pain, obstruction, tenesmus, and rectal bleeding. Lack of flber is a major causative factor because the passage of feces through the intestinal tract is prolonged, which extends exposure to possible carcinogens. Excess dietary fat, high alcohol consumption, and smoking all Cancer of the Colon and Rectum (Colorectal Cancer) 153 increase the incidence of colorectal tumors. C Medical Management Treatment of cancer depends on the stage of disease and related complications. Supportive therapy and adjuvant therapy (eg, chemotherapy, radiation therapy, immunotherapy) are included. Surgical Management • Surgery is the primary treatment for most colon and rectal cancers; the type of surgery depends on the location and size of tumor, and it may be curative or palliative. Diagnosis Nursing Diagnoses • Imbalanced nutrition: less than body requirements related to nausea and anorexia • Risk for deflcient fluid volume related to vomiting and dehydration • Anxiety related to impending surgery and diagnosis of cancer • Risk for ineffective therapeutic regimen management related to deflcient knowledge concerning the diagnosis, surgical procedure, and self-care after discharge • Impaired skin integrity related to surgical incisions, stoma, and fecal contamination of peristomal skin • Disturbed body image related to colostomy • Ineffective sexuality patterns related to ostomy and selfconcept Collaborative Problems/Potential Complications • Intraperitoneal infection • Complete large bowel obstruction • Gastrointestinal bleeding and hemorrhage • Bowel perforation • Peritonitis, abscess, sepsis Planning and Goals the major goals may include attainment of optimal level of nutrition; maintenance of fluid and electrolyte balance; reduction of anxiety; learning about the diagnosis, surgical procedure, and self-care after discharge; maintenance of optimal tissue healing; protection of peristomal skin; learning how to irrigate the colostomy (sigmoid colostomies) and change the appliance; expressing feelings and concerns about the colostomy and the impact on self; and avoidance of complications. Include information about postoperative wound and ostomy care, dietary restrictions, pain control, and medical management. Providing Emotional Support • Assess patient’s level of anxiety and coping mechanisms and suggest methods for reducing anxiety, such as deep breathing exercises and visualizing a successful recovery from surgery and cancer. Maintaining Optimal Nutrition • Teach about the health beneflts of a healthy diet; diet is individualized as long as it is nutritionally sound and does not cause diarrhea or constipation. Maintaining Fluid and Electrolyte Balance • Administer antiemetics and restrict fluids and food to prevent vomiting; monitor abdomen for distention, loss of bowel sounds, or pain or rigidity (signs of obstruction or perforation).

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During the early stages of illness: uncontrollable flts of anger; profound order cialis soft 20mg free shipping impotence natural remedies, often suicidal depression; apathy; anxiety; psychosis; or euphoria cheap cialis soft 20mg line cost of erectile dysfunction injections. Assessment and Diagnostic Findings • Diagnosis is made based on the clinical presentation of charH acteristic symptoms order cialis soft 20mg without a prescription erectile dysfunction vitamin shoppe, a positive family history, the known presence of a genetic marker, and exclusion of other causes. Medical Management No treatment stops or reverses the process; palliative care is given. Akathisia (motor restlessness) in the overmedicated patient is dangerous and should be reported. Nursing Management • Teach patient and family about medications, including signs indicating need for change in dosage or medication. Hyperglycemic Hyperosmolar Nonketotic Syndrome 373 • Arrange for consultation with a speech therapist, if needed. Pathophysiology Persistent hyperglycemia causes osmotic diuresis, resulting in water and electrolyte losses. Although there is not enough insulin to prevent hyperglycemia, the small amount of insulin present is enough to prevent fat breakdown. This condition occurs most frequently in older people (50 to 70 years of age) who have no known history of diabetes or who have type 2 diabetes. Nursing Management See “Nursing Management” under “Diabetes Mellitus” and “Diabetic Ketoacidosis” for additional information. Fluid status and urine output are closely monitored because of Hypertension (and Hypertensive Crisis) 375 the high risk of renal failure secondary to severe dehydration. H Hypertension (and Hypertensive Crisis) Hypertension is deflned as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, based on two or more measurements. Hypertension carries the risk for premature morbidity or mortality, which increases as systolic and diastolic pressures rise. Prolonged blood pressure elevation damages blood vessels in target organs (heart, kidneys, brain, and eyes). Essential (Primary) Hypertension In the adult population with hypertension, between 90% and 95% have essential (primary) hypertension, which has no identiflable medical cause; it appears to be a multifactorial, polygenic condition. Hypertensive Crisis H-1 Hypertensive crisis, or hypertensive emergency, exists when an elevated blood pressure level must be lowered immediately (not necessarily to less than 140/90 mm Hg) to halt or prevent target organ damage. Hypertensive urgency exists when blood pressure is very elevated but there is no evidence of impending or progressive target organ damage. Close hemodynamic monitoring of the patient’s blood pressure and cardiovascular status is required. Hypertensive emergencies and urgencies may occur in patients whose hypertension has been poorly controlled, whose hypertension has been undiagnosed, or in those who have abruptly discontinued their medications (see Box H-1). Secondary Hypertension Secondary hypertension is characterized by elevations in blood pressure with a speciflc cause, such as narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism (mineralocorticoid hypertension), certain medications, pregnancy, and coarctation of the aorta. Hypertension can also be acute, a sign of an underlying condition that causes a change in peripheral resistance or cardiac output. Clinical Manifestations • Physical examination may reveal no abnormality other than high blood pressure. Hypertension (and Hypertensive Crisis) 377 • Symptoms usually indicate vascular damage related to organ systems served by involved vessels. Medical Management the goal of any treatment program is to prevent death and complications by achieving and maintaining an arterial blood pressure at or below 140/90 mm Hg (130/80 mm Hg for people with diabetes mellitus or chronic kidney disease), whenever possible. Two classes of drugs are available as flrst-line therapy: diuretics and beta-blockers. Nursing Interventions Increasing Knowledge • Emphasize the concept of controlling hypertension (with lifestyle changes and medications) rather than curing it. Hypertension (and Hypertensive Crisis) 379 • Arrange a consultation with a dietitian to help develop a plan for improving nutrient intake or for weight loss. Gerontologic Considerations Compliance with the therapeutic program may be more difflcult for elderly people. The medication regimen can be difflcult to remember, and the expense can be a problem. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive.

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Third year is an excellent transition from the classroom to discount cialis soft 20 mg amex impotence spell learning from your clinical experiences and your patient encounters to generic cialis soft 20mg free shipping impotence following prostate surgery acting as a healthcare provider and decision maker cialis soft 20 mg discount coke causes erectile dysfunction. Over the course of the next year, you will experience stress, exhilaration, emotion, loss, satisfaction, frustration, joy and fatigue. The hope is that this booklet may help with some of the uncertainty, at least logistically, you may encounter as you navigate the next phase of your medical training. The National Alpha Omega Alpha was established in 1902 at the College of Physicians and Surgeons in Chicago, with the Kansas Alpha Chapter receiving its charter in 1931. Its raison d’etre can be expressed in a phrase: to recognize and to perpetuate excellence in the medical profession. Scholastic excellence is a key criterion, but not the only one integrity, capacity for leadership, compassion and fairness in dealing with one’s colleagues are also to be considered. The Alpha Chapter at the University of Kansas has two separate elections in which undergraduates may be voted into Alpha Omega Alpha. The students elected to the society are men and women who have compiled the requisite high academic standing and who, in the judgment of the members of the local chapter, have shown promise of becoming leaders in their profession. They are also dedicated to fostering mentorship and an environment of scholastic excellence within their institutions. This orientation manual represents an attempt to assist in the transition from basic sciences to the wards and to make that transition as painless as possible. Since each person’s medical school experience is unique, it does not pretend to foresee everything that will be encountered on the clinical wards. We ask you, therefore, to critically evaluate the information provided in this manual as you progress through the first several months of clinics, make note of important topics which were omitted as well as information which was unnecessarily included, and use that evaluation to modify this orientation manual so that it will be of even greater benefit to the class of 2019. Since much of the transition from basic science student to clinical student concerns itself with figuring out just exactly what it is that one is supposed to be doing on the wards, this section concerns itself with outlining some of the basic responsibilities and expectations placed on the clinical student. Therefore, clinical students are well advised to define, as clearly as possible, their responsibilities early on in each rotation by consulting with the residents and attending physician. For virtually all clerkships, demonstrating a commitment to your patient, showing interest along with being enthusiastic, helpful and hard-working is the single most important thing one can do to maximize learning and enjoyment on the service. If you are unable to find patient information in O2, you should first check in Chartmaxx and then call medical records. Some resources that might help you save money: clerkship coordinators (for certain rotations), counseling center, other classmates/big sib’s who’ve completed the rotation already. Select books you feel you can read cover-to-cover during the one to two months of a rotation. You may access Uptodate on your personal computer off campus if you log into O2 and follow the link (once you have “wrenched” it in). Many excellent reference books and atlases can be found there or online on AccessMedicine. Not pertinent to get Epocrates, but it is a must to have some sort of drug reference. These skills include clinical reasoning, management of chronic disease, preventative care and health maintenance, specific physical examinations skills, and physician-patient communication skills. General Overview: Each week as a student you may have a variety of responsibilities. Patients are seen with a team of students who then collaborate to formulate a plan for the patient. There are didactic lectures on Friday afternoons and students are given day a week off for shelf preparation. The test has ten sections including: one standardized patient, one joint musculoskeletal exam, two x-ray readings, two dermatology pictures, a mock acute visit on the computer, a mock follow-up visit on the computer, and multiple short answer questions regarding preventative medicine. This makes it much harder to get a good grade on the shelf score as compared to other rotations. Books: Blueprints Family Medicine and Case Files Family Medicine are the two most commonly used reference books. Practical Advice Because of the grading breakdown (shelf not curved, student clinic as a large portion of your grade, etc), it is difficult to obtain high marks in this clerkship.

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Docetaxel is the first drug shown to cialis soft 20mg low cost erectile dysfunction therapy treatment improve the survival rate in men with the advanced stage of the disease cialis soft 20 mg visa otc erectile dysfunction pills walgreens. Nonsurgical treatments Radiation therapy may cure locally invasive lesions in early disease and may relieve bone pain from metastatic skeletal involvement buy cialis soft 20 mg with mastercard erectile dysfunction treatment. It’s also used prophylactically to prevent tumor growth for patients with tumors in regional lymph nodes. This treatment increases radiation to the area while minimizing exposure to surrounding tissues. Chemotherapy with combinations of cyclophosphamide, doxorubicin, fluorouracil, methotrexate, estramustine, vinblastine, and cisplatin reduce pain from metastasis but hasn’t helped patients live longer. How it happens Risk factors for prostate cancer include: • age (nearly two out of three cases of prostate cancer are diagnosed in men over age 65) • diet high in red meat and dairy products. The disease is common in North America and northwestern Europe and is rare in Asia and South America. When primary lesions spread beyond the prostate gland, they invade the prostatic capsule and then spread along the ejaculatory ducts in the space between the seminal vesicles or perivesicular fascia. Again, early detection is key When prostate cancer is treated in its localized form, the 5-year survival rate is 70%; after metastasis, it’s lower than 31%. What to look for Prostate cancer seldom produces signs and symptoms until it’s advanced. Signs of advanced disease include a slow urinary stream, hematuria, urinary hesitancy, incomplete bladder emptying, and dysuria. Pathway for metastasis of prostate cancer When primary prostatic lesions metastasize, they typically invade the prostatic capsule, spreading along the ejaculatory ducts in the space between the seminal vesicles or perivesicular fascia. Testicular cancer Malignant testicular tumors are the most prevalent solid tumors in males ages 20 to 40. Testicular cancer is rare in nonwhite males and accounts for less than 1% of all male cancer deaths. These tumors, which are characterized by uniform, undifferentiated cells, resemble primitive gonadal cells. When treated with surgery, chemotherapy, and radiation therapy, almost all patients with localized disease survive beyond 5 years. Battling illness Treating testicular cancer In testicular cancer, treatment includes surgery, radiation therapy, and chemotherapy. Surgical options include orchiectomy and retroperitoneal node dissection to prevent disease extension and assess its stage. Treatment of seminomas involves postoperative radiation to the retroperitoneal and homolateral iliac nodes. Patients whose disease extends to retroperitoneal structures may be given prophylactic radiation to the mediastinal and supraclavicular nodes. Treatment of nonseminoma includes radiation directed to all cancerous lymph nodes. Chemotherapy is most effective for late-stage seminomas and most nonseminomas when used for recurrent cancer after orchiectomy and removal of the retroperitoneal lymph nodes. Autologous bone marrow transplantation is usually reserved for patients who don’t respond to standard therapy. It involves giving high-dose chemotherapy, removing and treating the patient’s bone marrow to kill remaining cancer cells, and returning the processed bone marrow to the patient. Typically, when testicular cancer extends beyond the testes, it spreads through the lymphatic system to the iliac, para-aortic, and mediastinal nodes. A genetic prediposition may also exist; testicular cancer has a higher incidence among brothers, identical twins, and other close male relatives. The patient may describe a feeling of heaviness or a dragging sensation in the scrotum. He may also report swollen testes or a painless lump found while performing testicular self-examination. Occasionally, acute pain occurs because of rapid growth of the tumor, resulting in hemorrhage and necrosis. In late disease stages, the patient may complain of weight loss, a cough, hemoptysis, shortness of breath, lethargy, and fatigue. Looking at testicular cancer In testicular cancer, palpation may reveal a firm, smooth testicular mass.

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