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Medical Management Topical corticosteroids (ie zinc antibiotic resistance doxycycline 100 mg on-line, hydrocortisone suppositories) are the usual treatment for lichen planus antibiotic resistance global threat purchase 100mg doxycycline otc. Treatment is often complete in 2 to 3 weeks; this condition is not likely to recur after treatment is complete antibiotic jeopardy doxycycline 200mg visa. If malignant cells are detected on biopsy infection vs virus buy discount doxycycline 200 mg online, local excision, laser therapy, local chemotherapy, and immunologic treatment are used. Vulvectomy is avoided, if possible, to spare the patient from the stress of disfigurement and possible sexual dysfunction. Nursing Management Key nursing responsibilities for patients with vulvar dystrophies focus on teaching. Important topics include hygiene and selfmonitoring for signs and symptoms of complications. Instructions for patients with benign vulvar dystrophies include the importance of maintaining good personal hygiene and keeping the vulva dry. A simple cyst may be asymptomatic, but an infected cyst or abscess may cause discomfort. This catheter, a short latex stem with an inflatable bulb at the distal end, creates a tract that preserves the gland and allows for drainage. A local anesthetic agent is injected, and the cyst is incised or lanced and irrigated with normal saline; the catheter is inserted and inflated with 2 to 3 mL of water. The patient is informed that discharge should be expected, as the catheter allows drainage of the cyst. She is instructed to contact her primary health care provider if pain occurs because the bulb may be too large for the cavity and fluid may need to be removed. Symptoms usually consist of varying degrees of itching, but some patients have no symptoms. A few pa- Chapter 47 Management of Patients With Female Reproductive Disorders 1427 may result or increase. The patient is instructed to notify her primary health care provider about any change or ulceration because biopsy may be necessary to rule out squamous cell carcinoma. By encouraging all patients to perform genital self-examinations regularly and have any itching, lesions, or unusual symptoms assessed by a health care provider, nurses can help prevent complications and progression of vulvar lesions. They are a common reason for hysterectomy as they often result in menorrhagia that can be difficult to control. They arise from the muscle tissue of the uterus and can be found in the lining (intracavitary), muscle wall (intramural), and outside surface (serosal) of the uterus. Other symptoms are due to pressure on the surrounding organs and include pain, backache, constipation, and urinary problems. Menorrhagia (excessive bleeding) and metrorrhagia (irregular bleeding) may occur because fibroids may distort the uterine lining. Dermoid cysts are tumors that are thought to arise from parts of the ovum that normally disappear with ripening (maturation). They grow slowly and are found during surgery to contain a thick, yellow, sebaceous material arising from the skin lining. Hair, teeth, bone, and many other tissues are found in a rudimentary state within these cysts. Symptoms of a ruptured cyst mimic various acute abdominal emergencies, such as appendicitis or ectopic pregnancy. Larger cysts may produce abdominal swelling and exert pressure on adjacent abdominal organs. Polycystic ovary syndrome, a complex endocrine condition involving a disorder in the hypothalamic-pituitary and ovarian network or axis resulting in anovulation, occurs in women of childbearing age. Irregular periods resulting from lack of regular ovulation, obesity, and hirsutism may be presenting complaints. Cysts form in the ovaries because the hormonal milieu cannot cause ovulation on a regular basis.

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Anatomic and Physiologic Overview In males and females treatment for fungal uti 200 mg doxycycline mastercard, the breasts are the same until puberty antibiotic resistance horizontal gene transfer doxycycline 100 mg otc, when estrogen and other hormones initiate breast development in females antibiotic resistance explained purchase doxycycline 200 mg with mastercard. This development usually occurs at about age 10 years and continues until about age 16 years virus 01 april generic 100mg doxycycline visa, although the range can vary from 9 to 18 years. Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring around the nipple), and stage 4 occurs when the nipple and areola form a secondary mound on top of the breast tissue. The breast contains glandular (parenchyma) and ductal tissue, along with fibrous tissue that binds the lobes together and fatty tissue in and between the lobes. These paired mammary glands are located between the second and sixth ribs over the pectoralis major muscle from the sternum to the midaxillary line. Each breast consists of 12 to 20 cone-shaped lobes that are made up of lobules containing clusters of acini, small structures ending in a duct. Specific responses may include fears of disfigurement, loss of sexual attractiveness, abandonment by her partner, and death. These fears may cause some women to delay seeking health care for evaluation of a possible breast problem. Alternatively, in some women anxiety or fear regarding breast cancer may cause them to seek the services of a health care provider for the slightest change or problem. Nurses can help women through the potentially frightening visit to the primary health care provider or surgeon. Other questions include: Is pain associated with the symptom, and can you feel any areas in your breast that are of concern The woman is asked about her reproductive history because of its relationship to risk for breast disorders. Other necessary information includes her history of pregnancies, live births, abortions, or miscarriages, and breastfeeding. If the patient is postmenopausal, her age at menopause and any symptoms she experienced and current or previous use of hormone replacement therapy are also addressed. Her medical and surgical history is important to obtain, along with any family history of diseases, particularly cancer. Social information, such as marital status, occupation, and the availability of resources and support persons, should also be elicited. Purpose Women undergoing diagnostic workup for symptoms of breast disease have identified the process as very stressful for them and their partners. This qualitative portion of a larger study investigated the experience of undergoing fine-needle biopsy and waiting for the results of the biopsy. The transactional theory of stress, appraisal, and coping of Lazarus and Folkman served as the framework for the study. Study Sample and Design Focus interviews were conducted with a subset of the 235 women who participated in the larger study and had fine-needle aspirations at two outpatient breast clinics. The subset consisted of 40 women; 20 of the women were diagnosed with breast cancer and 20 with benign breast disease. The women were interviewed in their homes 2 to 3 weeks post-diagnosis about their experiences from discovery of their breast abnormality to the time of diagnosis. Findings Analysis of the transcripts revealed four different types of threatrelated cues during the diagnostic period: temporal, interpersonal, procedural, and spatial. For example, the amount of time from referral by the primary care practitioner to the specialist breast unit was perceived by women as an indicator of the urgency of their problem; the quicker the referral, the greater urgency they perceived their problem to have. Interpersonal cues identified by the women were words, actions, gestures, or pauses in conversation by health care personnel. Active identification and interpretation of interpersonal cues by women were linked to uncertainty and lack of control during the diagnostic process. Procedural cues were those associated with the aspects of how the biopsy and other diagnostic procedures were performed. For example, the need to repeat an x-ray or the refusal of the radiologist to let the patient see the mammogram were taken as cues of a likely diagnosis of cancer. Spatial cues were those in which women interpreted usually uneventful aspects in the environment as indicative of their diagnosis. For example, one women interpreted the actions of health care personnel in arranging the chairs in the room in a certain way as she entered as indicative of the fact that they were about to inform her of a diagnosis of cancer. Nursing Implications these findings, described by the researchers as monitoring activities on the part of women undergoing diagnostic assessment for breast cancer, suggest the need women have to know their diagnosis and to reduce their uncertainty about the diagnosis.

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The elderly are prone to this type of head injury secondary to brain atrophy antibiotic hives discount 100mg doxycycline with visa, which is an expected consequence of the aging process antibiotics for sinus infection allergic to penicillin purchase doxycycline 200mg on-line. Seemingly minor head trauma may produce enough impact to shift the brain contents abnormally antibiotic 10 days cheap 100mg doxycycline visa. The time between injury and onset of symptoms may be lengthy (eg antibiotic gonorrhea discount 100mg doxycycline, 3 weeks to months), so the actual insult may be forgotten. A chronic subdural hematoma resembles other conditions and may be mistaken for a stroke. The bleeding is less profuse and there is compression of the intracranial contents. The blood within the brain changes in character in 2 to 4 days, becoming thicker and darker. In a few weeks, the clot breaks down and has the color and consistency of motor oil. The brain adapts to this foreign body invasion, and the clinical signs and symptoms fluctuate. There may be severe headache, which tends to come and go; alternating focal neurologic signs; personality changes; mental deterioration; and focal seizures. Unfortunately, the patient may be labeled neurotic or psychotic if the cause of the symptoms is overlooked. The treatment of a chronic subdural hematoma consists of surgical evacuation of the clot. The procedure may be carried out through multiple burr holes, or a craniotomy may be performed for a sizable subdural mass that cannot be suctioned or drained through burr holes. It is commonly seen in head injuries when force is exerted to the head over a small area (missile injuries or bullet wounds; stab injury). These hemorrhages within the brain may also result from systemic hypertension, which causes degeneration and rupture of a vessel; rupture of a saccular aneurysm; vascular anomalies; intracranial tumors; systemic causes, including bleeding disorders such as leukemia, hemophilia, aplastic anemia, and thrombocytopenia; and complications of anticoagulant therapy. The onset may be insidious, beginning with the development of neurologic deficits followed by headache. Surgical intervention by craniotomy or craniectomy permits removal of the blood clot and control of hemorrhage but may not be possible because of the inaccessible location of the bleeding or the lack of a clearly circumscribed area of blood that can be removed. Management of Brain Injuries Assessment and diagnosis of the extent of injury are accomplished by the initial physical and neurologic examinations. A flowchart developed by the Brain Trauma Foundation for the initial management of brain-injured patients is presented in Figure 63-4 (Brain Trauma Foundation, 2000). Any individual with a head injury is presumed to have a cervical spine injury until proven otherwise. From the scene of the injury, the patient is transported on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical spinal cord injury documented. All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury. Common causes of secondary injury are cerebral edema, hypotension, and respiratory depression that may lead to hypoxemia and electrolyte imbalance. Treatments to prevent this include stabilization of cardiovascular and respiratory function to maintain adequate cerebral perfusion, control of hemorrhage and hypovolemia, and maintenance of optimal blood gas values (Wong, 2000). Initial management is based on the principle of preventing secondary injury and maintaining adequate cerebral oxygenation. The patient is cared for in the intensive care unit, where expert nursing care and medical treatment are readily available. Comatose patients are intubated and mechanically ventilated to ensure adequate oxygenation and protect the airway. Because seizures are common after head injury and can cause secondary brain damage from hypoxia, antiseizure agents may be administered. A nasogastric tube may be inserted because reduced gastric motility and reverse peristalsis are associated with head injury, making regurgitation and aspiration common in the first few hours. Since 1981, all 50 states have recognized the Uniform Determination of Brain Death Act (Lovasik, 2000). This act states that death will be determined with accepted medical standards and that death will indicate irreversible loss of all brain function.

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Avoids burning sensation from prolonged contact of oscillating blade with padding infection 2 app purchase doxycycline with amex. Performs hygiene and grooming activities independently or with minimal assistance virus 01 april buy doxycycline 100mg mastercard. To prevent pressure on the cervical spinal nerves infection kongregate doxycycline 200mg generic, the sling should distribute the supported weight over a large area and not on the back of the neck antibiotic quiz questions cheap doxycycline 200 mg on line. The nurse encourages the patient to remove the arm from the sling and elevate it frequently. Circulatory disturbances in the hand may become apparent with signs of cyanosis, swelling, and an inability to move the fingers. Contracture of the fingers and wrist occurs as the result of obstructed arterial blood flow to the forearm and hand. The patient is unable to extend the fingers, describes abnormal sensation (eg, unrelenting pain, pain on passive stretch), and exhibits signs of diminished circulation to the hand. This serious complication can be prevented with nursing surveillance and proper care. Compartment syndrome is managed in part by bivalving (cutting) the cast to release constricting cast and dressings. The nurse, in consultation with an occupational therapist, suggests devices designed to aid onehanded activities. The patient may experience fatigue due to modified activities and the weight of the cast. The cast may be a short leg cast, extending to the knee, or a long leg cast, extending to the groin. The fresh cast must be handled in a manner that will not cause denting or disruption of the cast. The patient should also assume a recumbent position several times a day with the casted leg elevated to promote venous return and control swelling. The nurse assesses circulation by observing the color, temperature, and capillary refill of the exposed toes. Nerve function is Nursing Interventions To control swelling, the nurse elevates the immobilized arm. When the patient is lying down, the arm is elevated so that each joint is positioned higher than the preceding proximal joint (eg, elbow higher than the shoulder, hand higher than the elbow). Numbness, tingling, and burning may be caused by peroneal nerve injury from pressure at the head of the fibula. When the cast is hard and dry, the nurse teaches the patient how to transfer and ambulate safely with assistive devices (eg, crutches, walker). If weight bearing is allowed, the cast is reinforced to withstand the body weight. A cast boot, worn over the casted foot, provides a broad, nonskid walking surface. Hip spicas are used for some femoral fractures and after some hip joint surgeries, and shoulder spica casts are used for some humeral neck fractures. Nursing Interventions Nursing responsibilities include preparing and positioning the patient, assisting with skin care and hygiene, and monitoring for cast syndrome. The nurse reassures the patient that several people will provide care during the application, that support for the injured area will be adequate, and that care providers will be as gentle as possible. Medications for pain relief and relaxation administered before the procedure enable the patient to cooperate during application of the cast. Cracking or denting of the cast is prevented by supporting the patient on a firm mattress and with flexible, waterproof pillows until the cast dries. The nurse positions the pillows next to each other, because spaces between pillows allow the damp cast to sag, become weak, and possibly break. A pillow is not placed under the head and shoulders of a patient in a body cast while the cast is drying, because doing so causes pressure on the chest. The nurse turns the patient as a unit toward the uninjured side every 2 hours to relieve pressure and to allow the cast to dry. Sufficient personnel (at least three people) are needed when the patient is turned so that the fresh cast can be adequately supported with the palms of the hands at vulnerable points (ie, body joints) to prevent cracking. The nurse encourages the patient to assist in the repositioning, if not contraindicated, by use of the trapeze or bed rail. A stabilizing abduction bar incorporated into a spica cast should not be used as a turning device.

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