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Without consistency on the part of all staff members working with this client female cialis 20 mg online, a positive outcome will not be achieved purchase generic female cialis on-line. Client is able to verbalize how anger and acting-out behav- iors are associated with maladaptive grieving discount female cialis 10mg. Client is able to discuss the original source of the anger and demonstrates socially acceptable ways of expressing the emotion. Possible Etiologies (“related to”) [Fixation in rapprochement phase of development] [Extreme fears of abandonment and engulfment] [Lack of personal identity] Defining Characteristics (“evidenced by”) [Alternating clinging and distancing behaviors] [Inability to form satisfactory intimate relationship with an- other person] Use of unsuccessful social interaction behaviors [Use of primitive dissociation (splitting) in their relationships (viewing others as all good or all bad)] Goals/Objectives Short-term Goal Client will discuss with nurse or therapist behaviors that impede the development of satisfactory interpersonal relationships. Client will interact with others in the therapy setting in both social and therapeutic activities without difficulty by time of discharge from treatment. Client will display no evidence of splitting or clinging and distancing behaviors in relationships by time of discharge from treatment. Encourage client to examine these behaviors (to recognize that they are occurring). Client may be unaware of splitting or of clinging and distancing pattern of interaction with others. Help client realize that you will be available, without rein- forcing dependent behaviors. Posi- tive reinforcement enhances self-esteem and encourages repetition of desirable behaviors. Rotate staff who work with the client in order to avoid client’s developing dependence on particular staff members. Remember that splitting is a primary defense mechanism of these individuals, and the impressions they have of others as either “good” or “bad” are a manifestation of this defense. Suggest that the client discuss the problem directly with the staff person involved. Explore with client feelings that relate to fears of abandon- ment and engulfment. Help client understand that cling- ing and distancing behaviors are engendered by these fears. Exploration of feelings with a trusted individual may help client come to terms with unresolved issues. Help client understand how these behaviors interfere with satisfactory relationships. Client may be unaware of others’ perception of him or her and why these behaviors are not acceptable to others. This may help client resolve fears of abandonment and develop the ability to establish satisfactory intimate relationships. Client is able to interact with others in both social and thera- peutic activities in a socially acceptable manner. Client does not use splitting or clinging and distancing be- haviors in relationships and is able to relate the use of these behaviors to failure of past relationships. Possible Etiologies (“related to”) [Failure to complete tasks of separation/individuation stage of development] [Underdeveloped ego] [Unmet dependency needs] [Absence of, or rejection by, parental sex-role model] Defining Characteristics (“evidenced by”) [Excessive use of projection] [Vague self-image] Personality Disorders ● 291 [Unable to tolerate being alone] [Feelings of depersonalization and derealization] [Self-mutilation (cutting, burning) to validate existence of self] Gender confusion Feelings of emptiness Uncertainties about goals and values Goals/Objectives Short-term Goal Client will describe characteristics that make him or her a unique individual. Long-term Goal Client will be able to distinguish own thoughts, feelings, behav- iors, and image from those of others, as the initial step in the development of a healthy personal identity. Because of the blurred ego boundaries, client may believe you can read his or her mind. Help client recognize separateness from nurse by clarifying which behaviors and feelings belong to whom. Touch and physical presence provide reality for the client and serve to strengthen weak ego boundaries. Help client recognize ownership of these feelings rather than pro- jecting them onto others in the environment. Verbalization of feelings in a nonthreatening environment may help client come to terms with unresolved issues. The expression of reasonable doubt as a therapeutic technique may be helpful (“I find that hard to believe”). If the problem is with gender identity, ask the client to describe his or her perception of appropriate male and female behaviors. If client experiences feelings of depersonalization or derealization, orientation to the environment and correction of misperceptions may be helpful. These interventions help to preserve client’s feel- ings of dignity and self-worth. Help client understand that there are more adaptive ways of validating his or her existence than self-mutilation. A contract gets the subject out in the open and places some of the responsibility for his or her safety with the client. Disc u s s bel ief s, at t it ude s, and feelings underlying his or her behaviors. Help client to identify those values that have been (or are intended to be) incorporated as his or her own. Care must be taken by the nurse to avoid imposing his or her own value sys- tem on the client. Because of underdeveloped ego and fix- ation in early developmental level, client may not have established own value system. In order to accomplish this, ownership of beliefs and attitudes must be identified and clarified. Photographs may help to increase client’s awareness of self as separate from others. Alleviate anxiety by providing assurance to client that he or she will not be left alone. Early childhood traumas may predispose borderline clients to extreme fears of abandonment. Before this technique is used, however, assess cultural influences and degree of trust. Touch and physical presence provide reality for the client and serve to strengthen weak ego boundaries. Client is able to distinguish between own thoughts and feel- ings and those of others. Client claims ownership of those thoughts and feelings and does not use projection in relationships with others. Personality Disorders ● 293 Possible Etiologies (“related to”) [Lack of positive feedback] [Unmet dependency needs] [Retarded ego development] [Repeated negative feedback, resulting in diminished self- worth] [Dysfunctional family system] [Fixation in earlier level of development] Defining Characteristics (“evidenced by”) [Difficulty accepting positive reinforcement] [Self-destructive behavior] [Frequent use of derogatory and critical remarks against the self] Lack of eye contact [Manipulation of one staff member against another in an attempt to gain special privileges] [Inability to form close, personal relationships] [Inability to tolerate being alone] [Degradation of others in an attempt to increase own feelings of self-worth] Hesitancy to try new things or situations [because of fear of failure] Goals/Objectives Short-term Goals 1. Client will exhibit increased feelings of self-worth as evi- denced by verbal expression of positive aspects about self, past accomplishments, and future prospects. Client will exhibit increased feelings of self-worth by setting realistic goals and trying to reach them, thereby demonstrat- ing a decrease in fear of failure. It is important for client to achieve something, so plan for activities in which success is likely. Promote understanding of your acceptance for him or her as a worth- while human being. Enforce the limits and impose the consequences for violations in a matter-of-fact manner.

The milestone of menopause is reached when a woman goes one year without a menstrual period cheap female cialis online. The average age for menopause is about 51 years discount female cialis 10mg on line, but it can oc- cur naturally between ages 40 and 55 buy female cialis 20 mg line. During this time hormone levels fluctuate and the menstrual cycle becomes erratic, yet you may still be able to conceive. High cortisol levels caused by stress can negatively impact these hormones as well. The severity and duration of symptoms experienced vary due to genetics, ethnicity, cultural factors, and even attitude. High estrogen levels, as is common in perimenopause or among those with estrogen 324 dominance (low progesterone levels), can impair thyroid function, which may lead to weight gain because the thyroid gland is involved in regulating metabolic rate. Weight gain around the waist could be associated with stress, which elevates cortisol levels and causes fat to accumulate around the midsection. One study also found that estrogen caused cognitive decline and dementia in older women. When it is necessary, it should be used at the lowest dose for the shortest periods of time (less than five years). Bioidentical hormones are becoming more widely used as a safer alternative to synthetic hormones, while still providing symptom relief. Bioidentical means that the hormones are exactly the same as the ones your body produces. Compounding pharmacists can make customized hormones in various dosages and forms (creams, suppositories, and capsules) to suit your individual needs. Bioidentical hormones are available in compounding pharmacies, by a doctor’s prescription. Women who experience serious emotional symptoms are sometimes prescribed antidepressants and tranquilizers. However, there are many side effects with these drugs, and it is best to try natural methods first. Bone-building drugs such as bisphosphonates (Didrocal, Fosamax, and Actonel) or selective estrogen receptor modulators (Evista) are often given to women with osteoporosis or those at great risk. It is still important that women taking these drugs get adequate calcium intake and weight-bearing exercise for optimal bone health. Most blood tests measure hor- mones that are bound to protein, not that which is available to the tissues. Saliva tests M measure the amount of hormone that has made it into tissue because hormones pass through the salivary gland tissue before getting into saliva. Dietary Recommendations Foods to include: • Vegetables, fruit, whole grains, and legumes provide essential vitamins, minerals, anti- oxidants, fibre, and compounds that can reduce the risk of cancer and heart disease and improve overall health. In particular, load up on broccoli, Brussels sprouts, cauliflower, and cabbage, as these vegetables contain compounds that help the liver process hormones while reducing the risk of breast cancer. It also contains lignans (another form of phytoestrogen), which may help balance estrogens and reduce menopausal symptoms. Stress can make menopausal symptoms more pronounced and af- fect your adrenal gland function, reducing hormone production. Massage and acupuncture promote relax- ation and studies have shown that acupuncture can reduce hot flashes. Studies have shown that regular exercise reduces the frequency and severity of hot flashes. It also improves mood and sleep, protects against heart disease, and weight-bearing activities strengthen the bones. Smoking can worsen hot flashes and symptoms of anxiety, irritability, and depression. Watch funny movies, go to comedy shows, and spend time M with people who make you happy and laugh. Top Recommended Supplements Black cohosh: An herb that has been found in many studies to reduce hot flashes, night sweats, insomnia, nervousness, and irritability. Calcium and magnesium: Important minerals for bone health; women over 50 years should have 1,200 mg of calcium and 320 mg of magnesium daily, or more if they have osteopo- rosis. It is difficult to get this amount from diet alone, so supplements are often necessary. Chasteberry: An herb that helps balance hormones and is particularly helpful during peri- menopause. Fish oils: Help to protect against heart disease by lowering blood pressure and cholesterol, reducing atherosclerosis, and protecting against heart attack. Complementary Supplements Ginkgo biloba: An herb that helps improve memory and cognitive function by increasing blood flow to the brain. Supplements help improve sleep quality by reducing the time needed to fall asleep and nighttime wakening. While there may be certain symptoms, they are usually short-lived and can often be managed effectively with proper lifestyle measures and supplements. Ensure adequate calcium intake or take a mineral supplement for bone health; consider fish oils for heart health. Having just one of these conditions increases your risk of disease, but having them in combination multiplies the risk significantly. Ac- M cording to research, those who have three features of metabolic syndrome are nearly twice as likely to have a heart attack or stroke and more than three times as likely to develop heart disease as are those with no features. There is a great deal of research focused on this problem as it is affecting a grow- ing number of our population. According to reports, over half of people over age 60 meet the criteria for metabolic syndrome, and overall about 25 percent of the entire population are classified as having metabolic syndrome. Researchers believe that insulin resistance is the key underlying cause of this syn- drome and responsible for the metabolic changes that occur. Insulin is the hormone secreted by the pancreas that takes glucose from your blood and moves it into the cells to be used for energy. In people with insulin resistance, cells don’t respond to insulin and glucose can’t enter the cells. The pancreas reacts by releasing more and more insulin to help glucose get into your cells. High insulin levels also promote fat storage around the belly, lead- ing to abdominal obesity. These combined factors greatly increase one’s risk of heart disease, stroke, diabetes, and other conditions. The key to the management of metabolic syndrome and the prevention of its con- sequences is to address insulin resistance. This can be done effectively with lifestyle strategies (diet, exercise, and supplements). Over half of children who are obese have the features of metabolic syn- drome, putting them at significant risk of heart disease, diabetes, and premature death. Studies have shown, however, that in as little as 12 weeks, regular exercise and healthy eating can facilitate weight loss and improve blood pressure, cholesterol, and blood sugar. Medications can be used to lower blood pressure, cholesterol, triglycerides, and blood sugar and to improve insulin sensitivity.

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Typically purchase 20mg female cialis with amex, it is a polymicrobial infection involving aerobic and anaerobic bacteria of the mouth order discount female cialis on line. The most commonly isolated organisms include streptococci buy female cialis discount, staphylococci, and bacteroides species. A tense edema and brawny induration of the neck above the hyoid may be present and is described as a “bull neck. Trismus and fever are often present, but usually no palpable fluctuance or cervical lymphadenopathy. Signs of impending airway compromise include stridor, tachypnea, dyspnea, drooling, and agitation. The upper airway may be distorted making endotracheal intubation difficult or impossible. Cricothy- rotomy may also be difficult and increases the risk of spreading infection into the mediastinum. Soft-tissue radiographs of the neck may confirm the diagnosis by demonstrating edema of the affected area, airway narrowing, and gas collections. However, radiographs should not delay treatment or place the patient in an area where emergent airway management is difficult. Today, surgery is used only for those patients who fail to respond to antibiotic therapy or those with purulent collections. Appropriate regimens include high-dose penicillin with metronidazole, or cefoxitin used alone. Clin- damycin, ticarcillin-clavulanate, piperacillin-tazobactam, or ampicillin sul- bactam may also be used. It is characterized by a sharply demarcated border surrounding skin that is raised, deeply erythematous, indurated, and painful, and is associated with nephrotic syndrome, postoperative wounds, and small breaks in the skin. Erysipelas is more superficial than cellulitis and is more likely to occur in the young and in the elderly, but the distinction between the two is often subtle and therapeutically irrelevant. Treatment of erysipelas and facial cellulitis requires hospital admission and parenteral antibiotics. Treatment is aimed at the predominant organism, group A Streptococcus, but Staphylococcus and other Streptococcus species are also found. An immediate ophthalmologic consult should be obtained if there is any orbital or periorbital involvement. A Tzanck smear is a test that is done to diagnose infections caused by herpesviruses. When Fever Answers 199 unilateral, they must be distinguished from early herpes zoster infection, especially if vesicles are present. Women of childbearing age comprise 90% of affected individuals, and clinical presentation generally includes multisystem involvement. The Centor criteria, seen below, is used for predicting streptococcal pharyngitis and whether or not to treat the patient with antibiotics. Centor Criteria Points Presence of tonsillar exudates +1 Tender anterior cervical adenopathy +1 Fever by history +1 Absence of cough +1 Age <15 years +1 Age >45 years −1 Centor criteria 4 points 2–3 points 0–1 point Treat with Rapid antigen No further tests antibiotics test + No further Treat with Throat No antibiotics testing antibiotic culture 200 Emergency Medicine Since his rapid antigen test was negative, the patient should receive a throat culture and be treated only if the results are positive. In addition, he should be treated symptomatically with fluids, topical anesthetics, and acetaminophen or ibuprofen. Signs and symptoms include a sore throat, muffled voice, trismus, fluctuant mass, deviation of the uvula, odynophagia, and drooling. Airway patency must be assessed because of the obstructing potential of an abscess. Treatment includes either needle aspi- ration or incision and drainage of the abscess, in addition to antibiotic treatment. Some studies demonstrate the safety and cost-effectiveness of needle aspiration over incision and drainage. It is a progressive cellulitis of the floor of the mouth and neck that begins in the submandibular space. Physical findings include bilateral sub- mandibular swelling, tongue swelling, and protrusion. A tense edema and induration of the neck may occur that is described as a “bull neck. There is debate on whether these patients should be managed surgically with incision and drainage or medically with antibiotics. Conventional radiography on the day of injury is insensitive to the detection of osteomyelitis; even 1 week after the injury x-ray diagno- sis is limited. How- ever, Pseudomonas is responsible for bone and joint infections in three settings. Pseudomonas does not grow on the puncture object, but rather is associated with the shoe itself and may be inoculated into the bone as the sharp object passes through the col- onized shoe into the wound. Treatment is aggressive fluid resuscitation, surgical debridement, broad-spectrum antibiotics, and possibly hyperbaric oxygen therapy. If not promptly treated, the overall mortality rate of these patients is approximately 20%. However, widespread involvement of the fascia and genital structures makes a bedside incision and drainage inadequate. Since most children are immunized against Haemophilus influenzae type B (Hib), most cases of epiglottitis are now seen in adults, with an average age of 46 years. Signs and symptoms include a prodromal period of 1 to 2 days consisting of constitutional symp- toms, then the patient exhibits high fever, dysphagia, odynophagia, drooling, and dyspnea. The “thumbprint sign” seen on lateral cervical radiograph demonstrates a swollen epiglottis obliterating the vallecula. Cervical lymphadenopathy is prominent and inflam- mation may be so severe that patients develop an inflammatory torticollis, causing the patient to rotate the head toward the affected side. Treatment is incision and drainage or needle aspiration, fol- lowed by high-dose penicillin or clindamycin. Patients present with erythematous tonsils, tonsillar exudates, enlarged and tender anterior cervical lymph nodes. This patient has several of these factors and should, therefore, be admitted for further management. Surgical drainage or salpingectomy and oophorec- tomy may be required in resistant cases. Other symptoms include weakness, myalgias, dyspnea, chest pain, cough, headache, and anorexia. Neurologic signs and symptoms (eg, confusion, personality changes, decreased level of consciousness, and focal motor deficits) are seen in 30% to 40% of patients. Vasculitic lesions, including petechiae, splinter hemorrhages, tender fingertip nodules (Osler nodes), and nontender palmar plaques (Janeway lesions) are seen in 35% of patients. Splenomegaly, new heart murmur, and retinal hemorrhages may also be detected on physical examination. Bacteria and enteroviruses, especially Coxsackie B virus and adenovirus, predominate as causative agents. Often myocarditis presents with flu-like complaints, including fever, fatigue, and myalgias.

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Basicity and nucleophilicity Basicity is defined by the equilibrium constant for abstracting a proton safe 10 mg female cialis. On the other hand female cialis 20 mg low cost, a nucleophile forms a new bond with an atom other than a proton 10 mg female cialis otc. Species with a negative charge are stronger nucleophiles than analogous species without a negative charge. The more electronegative elements hold on more tightly to their nonbonding electrons. Fluoride is a nucleophile having hard or low polarizability, with its electrons held close to the nucleus, and it must approach the carbon nucleus closely before orbital overlap can occur. The outer shell of the soft iodide has loosely held electrons, and these can easily shift and overlap with the carbon atom at a relatively long distance. Solvent effects Different solvents have different effects on the nucleophi- licity of a species. Solvents with acidic protons are called protic solvents, usually OÀÀHorNÀÀH groups. F , can be solvated so well in polar protic solvents that their nucleophilicity is reduced by the solvation. Steric effects Base strength is relatively unaffected by steric effect, because a base removes a relatively unhindered proton. Thus, the strength of a base depends only on how well the base shares its electrons with a proton. A 3 bulky nucleophile has difficulty in getting near the backside of the sp carbon. Steric effects of the substrate Large groups on the electrophile hinder the approach of the nucleophile. Generally, one alkyl group slows the reaction, two alkyl groups make it difficult and three alkyl groups make it close to impossible. The reaction is stereospecific since a certain stereoisomer reacts to give one specific stereoisomer as product. Conversion of alkyl halides Williamson ether synthesis: preparation of ether The sodium or potas- À sium alkoxides are strong bases and nucleophiles. Alkyl azides are easily prepared from sodium or potassium azides and alkyl halides. The reaction mechanism for the 2 N formation of 1 amine is similar to the formation of nitrile. The formation of ester follows 2 N a similar mechanism to the formation of alkyne. Preparation of alkanes The coupling reaction is a good synthetic way to join two alkyl groups 0 together. The reaction is limited to primary alkyl halide, but the alkyl groups in the Gilman reagents may be 1 ,2 or 3. The nucleophilic substitution reaction of alcohols only occurs in the presence of an acid. Protonation to convert the leaving group to H2O has limited utility, as not all substrates or nucleophiles can be utilized under acidic conditions without unwanted side reactions. An alternative is to convert the alcohol into alkyl halide or alkyl tosylate (see below), which has a much 5. Acid-catalysed condensation of alcohols: preparation of ethers Bimolecular dehydration is generally used for the synthesis of symmetrical ethers from unhindered 1 alcohols. In this reaction, ethanol 2 4 is protonated in the presence of an acid, which is then attacked by another molecule of ethanol to give diethyl ether. Without the use of ZnCl , the S 2 reaction is 2 N slow, because chloride is a weaker nucleophile than bromide. The ZnCl2 coordinates to the hydroxyl oxygen, and generates a better leaving group. Thionyl chloride converts the hydroxyl group in an alcohol to a chlorosulphite leaving group that can be displaced by the chloride. This type of reaction does not lead to rearranged products, and does not work well with 3 alcohols. The hydroxyl oxygen displaces a halide, a good leaving group, from the phosphorus. The halide attacks the backside of the alkyl group and displaces the positively charged oxygen, which is a good leaving group. Tosylate esters (alkyl tosylates) are formed from alcohols from the reaction with p-toluenesulphonyl chloride (TsCl). Although an epoxide and an ether have the same leaving group, epoxides are more reactive than ethers due to ring strain in the three membered ring. Thus, epoxides are synthetically useful reagents, and they react with a wide variety of nucleophiles. Cleavage of ethers and epoxides by haloacids Preparation of alkyl halides Ethers can be cleaved at the ether linkage only at high temperatures using haloacids, e. Protonation of the oxygen in ether creates a good leaving group, a neutral alcohol molecule. The oxygen is protonated to form a protonated ethylene oxide, which, being attacked by the halide, gives bromoethanol. For example, hydrolysis of ethylene oxide in the presence of acid-catalyst produces 1,2-ethanediol (ethylene glycol). For example, propylene oxide reacts with alcohol in the presence of acid to give 2-methoxy-1-propanol. For example, propylene oxide is an unsymmetrical epoxide, which reacts with methyl magnesium bromide to produce 2-butanol, after the acidic work-up. Nucleophilic acyl substitution can interconvert all carboxylic acid derivatives, and the reaction mechanism varies depending on acidic or basic conditions. Under acidic conditions, the carbonyl group becomes protonated, and thus is activated towards nucleophilic acyl substitution. A simultaneous deproto- nation and loss of the leaving group reforms the carbonyl CÀÀÀÀO double bond. The equilibrium can be driven to completion by using an excess of the alcohol, or by removing the water as it forms. The carbonyl group of a carboxylic acid is not sufficiently electrophilic to be attacked by the alcohol. The acid catalyst protonates the carbonyl oxygen, and activates it towards nucleophilic attack. The alcohol attacks the protonated carbonyl carbon, and forms a tetrahedral intermedi- ate. Intramolecular proton transfer converts the hydroxyl to a good leaving group as H2O. This is where the alcohol part of the ester can be replaced with a new alcohol component.

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