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Pitocin is a synthetic DRUGS USED DURING LABOR form used to induce labor at or near full-term gestation and AND DELIVERY AT TERM to augment labor when uterine contractions are weak and in- effective 160mg super p-force visa impotence viriesiem. It also can be used to prevent or control uterine At the end of gestation buy super p-force 160mg amex impotence 16 year old, labor usually begins spontaneously and bleeding after delivery or to complete an incomplete abor- proceeds through delivery of the neonate. It is contraindicated for antepartum use in the presence prostaglandin preparations (eg, Prepidil or Cervidil formula- of fetal distress, cephalopelvic disproportion, preterm labor, tions of dinoprostone) are administered intravaginally to pro- placenta previa, previous uterine surgery, and severe mote cervical ripening and induce labor. Methergine is used for management of post- during labor, delivery, and the immediate postpartum period partum hemorrhage related to uterine atony. Analgesics Oxytocics Parenteral opioid analgesics are used to control discomfort Oxytocic drugs include oxytocin (Pitocin) and methyler- and pain during labor and delivery. Oxytocin is a hor- and cause sedation and respiratory depression in the mother CHAPTER 67 DRUG USE DURING PREGNANCY AND LACTATION 975 and neonate. Meperidine may cause less neonatal depression than other opioid analgesics. If Nursing Process neonatal respiratory depression occurs, it can be reversed by naloxone (Narcan). Assessment Duramorph is a long-acting form of morphine that pro- Assess each female client of reproductive age for possible vides analgesia up to 24 hours after injection into the epidural pregnancy. If the client is known to be pregnant, assess sta- catheter at the completion of a cesarean section. Possible • Use of prescription, over-the-counter, herbal, nonthera- side effects include maternal urinary retention, but no signifi- peutic, and illegal drugs cant effects on the fetus. They are injected by physicians for regional anesthe- Also determine whether any tissue has been expelled from sia in the pelvic area. When stopping labor is possible or desired, a to- into the epidural space of the spinal cord. With regional anesthesia, the mother • When spontaneous labor occurs in normal, full-term preg- is usually conscious and comfortable, and the neonate is nancy, assess frequency and quality of uterine contrac- rarely depressed. Fentanyl may be combined with a small tions, amount of cervical dilatation, fetal heart rate and amount of an anesthetic drug for both analgesia and anes- quality, and maternal blood pressure. No significant effects on the fetus occurred in clin- • Assess antepartum women for intention to breastfeed. Nursing Diagnoses • Risk for Injury: Damage to fetus or neonate from mater- NEONATAL THERAPEUTICS nal ingestion of drugs • Noncompliance related to ingestion of nonessential drugs In the neonate, any drug must be used cautiously. Drugs are during pregnancy usually given less often because they are metabolized and ex- • Risk for Injury related to possible damage to mother or creted slowly. Immature liver and kidney function prolongs infant during the birth process drug action and increases risks of toxicity. Also, drug therapy • Deficient Knowledge: Drug effects during pregnancy and should be initiated with low doses, especially with drugs that lactation are highly bound to plasma proteins. Neonates have few binding proteins, which leads to increased amounts of free, Planning/Goals active drug and increased risk of toxicity. When the health The client will: care provider is assessing the neonate, drugs received by the • Avoid unnecessary drug ingestion when pregnant or mother during pregnancy, labor and delivery, and lactation likely to become pregnant must be considered. Hemorrhagic disease of the newborn occurs • Obtain optimal care during pregnancy, labor and delivery, because the intestinal tract lacks the bacteria that normally and the postpartum period synthesize vitamin K. Vitamin K is required for liver pro- • Avoid behaviors that may lead to complications of preg- duction of several clotting factors, including prothrom- nancy and labor and delivery bin. Thus, the neonate is at increased risk of bleeding • Breast-feed safely and successfully if desired during the first week of life. It a healthy pregnancy (eg, regular monitoring of blood pres- may be caused by several bacteria, most commonly Chlamy- sure, weight, blood sugar, urine protein, and counseling dia trachomatis, a sexually transmitted organism. Give medications only when clearly indicated, weigh- • Observe and interview regarding actions taken to pro- ing anticipated benefits to the mother against the risk mote reproductive and general health. When drug therapy is required, the choice of drug should • Observe and interview regarding compliance with instruc- be based on the stage of pregnancy and available drug tions for promoting and maintaining a healthy pregnancy. During the first • Interview regarding ingestion of therapeutic and non- trimester, for example, an older drug that has not been therapeutic drugs during prepregnant, pregnant, and lac- associated with teratogenic effects is usually preferred tating states.

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The knee must be straight when the hip rolls over except when you are in a lunge and it points straight down order super p-force 160 mg impotence means. Generously add these rolls into the basic drill but do not count them toward your rep target super p-force 160mg amex impotence depression. If you aspire to do splits, this drill will make an excellent adjunct to your Relax into Stretch split training. Consider starting your contract-relax split sessions with three sets of split switches. If you aspire to do splits, this drill will make an excellent adjunct to your Relax into Stretch split training. You can easily damage your knees with split switches if you relax your quads and let your knees buckle in. Most Comrades who are not near a full split should rest their hands on a piece of furniture rather than the floor. It is normal, but make a point of sinking deeper as you progress through your set. Repetitive gentle rocking of the hips forward at different positions throughout the drill will really loosen up your hips; ask any Russian gymnast. Gently rock your hips forward at different positions throughout the drill. Another cool hip joint mobility drill for very flexible comrades is rolling back and forth between the side split and the roadkill split. Unlike the cobra type drills that pull on the spine with stretched hip flexors, this exercise keeps the psoas slack and can be practiced by nearly anyone. Fokhtin, the author of an original system of strength and flexibility training, mentions that pressing forward with your hands against your lower back or sacrum amplifies the effect of splits, lunges, and various back bends. Try this maneuver with the appropriate Super Joints and Relax into Stretch drills. Starting with your straight legs spread as wide as possible carefully shift your weight forward while arching your back. Do not just round your spine; the action is more like trying to touch your belly button—not your chest! It helps to exhale passively as you roll forward and inhale on the way up. You may choose to practice this exercise during your Relax into Stretch splits session rather than with your mobility drills. The authoritative Soviet Physical Culture and Sports Encyclopedic Dictionary stated that spine mobility is very dependent on the thickness of the intervertebral discs: the thicker the discs, the greater the mobility. When a disc absorbs liquid it can get almost twice as thick—which explains height fluctuations of a few centimeters throughout the day. After fifty years of age discs dry up and a person shrinks and loses his flexibility. Kneel or sit in a chair with your feet and hips solidly planted and start slowly turning your trunk clockwise and counterclockwise building up the amplitude to the max. You may hold a stick behind you to lock the shoulders and localize the movement to the spine cut off at hips. Strength and physique Holding a stick legend Eugene Sandow behind you in placed heavy emphasis the crooks of on various back and your elbows neck bends and twists. Give equal attention to flexion, extension, and rotation, and you will feel like your body has gone back in time. The latter is your ability to assume a stretched position using your own strength. Holding a split in the air while hanging on a pullup bar, as one USSR karate champion used to show off, is active flexibility. Soviet research by Iashvili—inquisitive minds unburdened by the command of Russian can learn the details of this study in Supertraining by Drs. Injury and an active flexibility deficit go together like borsch and vodka.

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Send co- authors regular updates of progress; this will enable everyone to identify those who are slowing the process down discount super p-force 160 mg visa natural erectile dysfunction treatment remedies. Far more important is the support and advice received as you are preparing the various drafts purchase super p-force 160 mg fast delivery impotence blood circulation, and this is really the time you need sensible input from your colleagues. Keep them in touch with what you are doing, and encourage them to play the role of coach rather than critic. The sensible way through this is to judge these comments on whether they are more 22 CO-AUTHORS – or less – likely to increase the chances of publication (see evidence-based writing). Discuss those that are clearly counter productive (see negotiating changes). Keep reminding yourself that you are making progress and that this is one of the last major obstacles. This can be easier said than done, and if you are unlucky enough to be involved in such a situ- ation, seek a wise head for immediate confidential advice. If you survive your relationship with your co-authors, and you become published authors, celebrate. It will make all the aggravation and humiliation seem worthwhile – until the next time. This is not the case in UK English, though your word processing package may not know this (see semicolon; UK-US English). One of the big problems occurs when commas are used to make a separate and self-contained point, in which case they should always travel in pairs. There is a fashion, particularly among medical journals, to be parsimonious with the comma. Commissioning The success of most publications leans heavily on the quality of its contributors, so the ability to persuade good writers to contribute is an important skill (see books, editing of). Having an idea for an article is relatively easy; the hard thing is to find someone who will do it well (better than you, otherwise why bother? If you are commissioning, have a clear idea of what you want: it is not helpful to give a long list of points that you wish the writer to include; instead describe what you want the article to achieve. Also discuss deadline, technical points (such as whether you want the article to be sent by e-mail) and payment or other reward. Once you have agreement, write a follow-up letter, which should cover the following questions. The writer should be clear about the goals of the publication – and about its audience. If you think the writer is unfamiliar with the publication, send one or two back copies. Knowing exactly where it will go will help the writer to do such basic things as write to length and ensure the right tone. The writer needs a clear confir- mation of the subject matter and broad intent, so that he or she can start to work out an appropriate message (see brief setting). You should have agreed this verbally, and it should be realistic for both of you. This is a controversial issue nowadays and some editors may feel safer leaving this out and hoping for the best (see copyright). If you have done your job, by the time the deadline comes you will have exactly what you want – or better. Writers spend long and lonely hours, and usually crave reassurance it has been worthwhile. Many articles disappear into black holes, with authors getting feedback only when someone tells them they have seen the article in print. Commissioning editors, therefore, should always say thank you, by phone, e-mail, letter or in person. If you decide that the article is not what you want, you can ask the writer to try again (in which case you have to be specific about the exact things he or she needs to do). Alternatively you can reject it, in which case you have a duty to return it as quickly as possible to the author, who may wish to submit it elsewhere (see rejection). In such cases you may wish to offer a slightly lower amount as a kill fee. Anything written in committee usually ends up being written for the committee (or rather the powerful figures within it), not for the target audience (see false feedback loop).

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The major problem with using readily available buy generic super p-force 160mg on line erectile dysfunction drugs lloyds, convenient data is that the data usually do a very poor job of answering the questions being asked buy super p-force 160 mg free shipping erectile dysfunction kidney disease. For example, it is not uncommon for quality improvement teams to use average length of stay and average cost (or charges) per discharge as proxy measures for quality. Both average length of stay and average cost are gross outcome (the O part of the Donabedian model) measures. Today, however, with the myriad grow- The Search for A Few Good Indicators 101 ing pressures to demonstrate effectiveness of care and efficiency of health- care processes, this mind-set is not acceptable. Quality and excellence of performance do not occur because organizations do what they have always done or what is convenient. This behavior leads to the perpetuation of the status quo, what most healthcare observers feel the industry definitely does not need. The data collection phase of the journey consists of two parts: (1) planning for data collection and (2) the actual gathering of the data. A well- thought-out data collection plan should address issues such as the following: • What processes will be monitored? What is the rationale for collect- ing these data rather than some other type of data? Once these issues have been resolved, the actual collection of the data usually goes smoothly. Unfortunately, many quality improvement teams do not spend sufficient time discussing their data collection plans; they want to move immediately to the data collection step. This is usually a sure 102 The Healthcare Quality Book guarantee that they will (1) collect too much (or too little) data; (2) col- lect the wrong data; or (3) become frustrated with the entire measurement journey. When individuals or groups become frustrated with the measure- ment process, they begin to lose faith in the data and results. As a result, if the team or management is presented with data they do not believe reflects their preconceived views of reality, they tend to (1) distort the data (which is unethical and illegal); (2) distort the process that produced the data; or (3) kill the messenger! Two key data collection skills—stratification and sampling—will enhance any data collection effort. These skills are based more on logic and clear thinking than on statistics. Yet, most healthcare professionals have received limited training in both concepts. Stratification Stratification is the separation and classification of data into homogeneous categories. The objective of stratification is to create strata, or categories, within the data that are mutually exclusive and allow discovery of patterns that would not be observed if the data were all aggregated together. Stratification allows understanding of differences in the data caused by • Day of the week (are Mondays different than Wednesdays? If you do not think about how these factors might influence your data before you collect it, you run the risk of (1) making incorrect conclu- sions about your data and (2) having to manually try to tease out the strat- ification effect after the data have been collected. Consider the following example of how stratification could be applied to the pharmacy process. A quality improvement team is interested in the following question: What percentage of medication orders are delivered to the nursing stations within one hour of receipt in the pharmacy? Before collecting data on this ques- The Search for A Few Good Indicators 103 tion, someone on the team ought to ask the following stratification ques- tion: Do we believe that this percentage might differ by floor, time of day, day of week, type of medication ordered, pharmacist on duty, or volume of orders received? If you do not spend some time discussing the implications of stratification, you will end up thinking that your data are worse (or better) than they should be. Sampling Sampling is the second key skill that healthcare professionals need to develop. If a process does not generate a lot of data, you will probably analyze all the occurrences. For example, computa- tion of the percent of no-shows for magnetic resonance imaging (MRI) typically does not use a sampling plan; all the scheduled MRIs that do not show up for the procedure (the numerator) are divided by the total num- ber of scheduled MRIs (the denominator). Sampling is probably the single most important thing you can do to reduce the amount of time and resources spent on data collection. Like stratification, however, many healthcare professionals receive little training in sampling procedures.

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