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The prostate is a small gland purchase inderal 40 mg free shipping arrhythmia burlington ma, which lies at the neck of the bladder in men and surrounds the urethra – the tube that carries urine from the bladder to the penis …’ (World Cancer Research Fund 2000) Once you have explained a label discount 40mg inderal hypertension new guidelines, continue to use it rather than introducing any alternatives. Be aware of ambiguous word meanings In English some of the words we use alter in meaning depending on the context in which they are used. Look at the examples below: ° Registrar = ° In the registry office – a keeper of names for births, deaths and marriages. Make sure that your reader will understand the intended meaning of your vocabulary. Check the emotional loading of words Certain words will have a higher emotional loading for clients. For exam­ ple, the words ‘cancer’ and ‘treatment’ in a recall letter after breast screen­ INFORMATION LEAFLETS FOR CLIENTS 99 ing were found to make women worry (Austoker and Ong 1994). Rewording the message may reduce stress and anxiety – so using ‘most re­ called women are found to have normal breasts’ was more reassuring than ‘most recalled women are found not to have cancer’ (Ong, Austoker and Brouwer 1996). Write words in full Avoid using abbreviations or acronyms even if these are explained in your text. They tend to confuse readers who are less familiar with these types of expressions. Phrasing the message The type and length of sentences will affect the amount of information the reader understands and remembers. Use short words and sentences There are a number of published tests designed to calculate the readability of set pieces of text (Flesch 1948; Gunning 1952). These make their calcu­ lations using various formulae that involve looking at the length of sen­ tences and the number of syllables. These tests predict the reading age required to cope with decoding the text. They are of use in checking the readability of your text but are not fail-safe ways of establishing how easy your text is to read. Use short words and sentences as this helps under­ standing and recall of information in written information (Ley 1982). Write sentences in the active rather than the passive voice Active sentences are more direct and give impact to a message. Compare the following sentences: ‘Tooth decay is prevented by regularly brushing the teeth’ (passive). Compare the following: Empowerment give choices, take control, make decisions Episodes of care your stay in hospital, the period of your therapy Partnership working together. The use of vocabulary that requires the reader to make some sort of judgement is best avoided. For example, in the sentence, ‘Make sure you have an adequate fluid intake’, the reader is ex­ pected to estimate the value of ‘adequate’. The sentence might be better phrased as ‘drink six glasses of water a day’. Other examples are ‘excessive bleeding’, ‘severe pain’, ‘small discharge’ or ‘enlarged gland’. Rephrase the statements so they give the reader informa­ tion about how to measure these things. Be succinct Remove any words that are superfluous to the meaning of the sentence. For instance ‘one pill every day of the week’ might be rephrased as ‘a pill daily’. For example, ‘nine out of ten people make a complete recovery’ is better than ‘one in ten people die’. Increasing comprehension of the message The way in which you phrase your message will affect how easy it is for the reader to understand the information. Use simple sentence constructions Simple sentences have more content words like nouns, verbs and adjectives that give the reader specific information. Avoid using complex sentences containing lots of small grammatical words that are not strictly necessary INFORMATION LEAFLETS FOR CLIENTS 101 to the meaning.

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The necessity for long-term had sustained complete tetraplegia below C4 because of C3–4 ventilation should be no bar to the patient returning home order inderal 80mg on line blood pressure chart man, dislocation discount 80mg inderal amex blood pressure range. However, it must be realised that in traumatic tetraplegia the thoracolumbar (T1–L2) sympathetic outflow is interrupted. Vagal tone is therefore unopposed and the patient can become Beware of overinfusion in patients with neurogenic shock hypotensive and bradycardic. Even in paraplegia, sympathetic paralysis below the lesion can produce hypotension, referred to as neurogenic shock. If shock is purely neurogenic in origin, patients can mistakenly be given large volumes of intravenous fluid and then develop pulmonary oedema. Pharyngeal suction and tracheal intubation stimulate the vagus, and in high cord injuries can produce bradycardia, which Treat may result in cardiac arrest. To prevent this it is wise to give Bradycardia <50 beats/min atropine or glycopyrronium in addition to oxygen before suction Hypotension <80mm Hg systolic or adequate urinary excretion not and intubation are undertaken and also whenever the heart rate maintained falls below 50beats/minute. Clinicians, however, must be aware of the possible toxic effects when the standard dose of 0. If the systolic blood pressure cannot maintain adequate perfusion pressure to produce an acceptable flow of urine after any hypovolaemia has been corrected, then inotropic medication with dopamine should be started. Cardiac arrest due to sudden hyperkalaemia after the use of Risk of hyperkalaemic cardiac arrest a depolarising agent such as suxamethonium for tracheal Beware—do not give suxamethonium from three days to nine months intubation is a risk in patients with spinal cord trauma between following spinal cord injury as grave risk of hyperkalaemic cardiac three days and nine months after injury. If muscle relaxation is arrest required for intubation during this period a non-depolarising muscle relaxant such as rocuronium is indicated to avoid the risk of hyperkalaemic cardiac arrest. Prophylaxis against thromboembolism Newly injured tetraplegic or paraplegic patients have a very high risk of developing thromboembolic complications. The incidence of pulmonary embolism reaches a maximum in the third week after injury and it is the commonest cause of death in patients who survive the period immediately after Box 4. The volume of urine in the bladder should never be allowed to exceed 500ml because overstretching the detrusor Beware of paralytic ileus: patients should receive intravenous fluids muscle can delay the return of bladder function. If the patient for at least the first 48 hours after injury is transferred to a spinal injuries unit within a few hours after injury it may be possible to defer catheterisation until then, but if the patient drank a large volume of fluid before injury this is unwise. In these circumstances, and in patients with multiple injuries, the safest course is to pass a small bore (12–14Ch) 10ml balloon silicone Foley catheter. The gastrointestinal tract The patient should receive intravenous fluids for at least the first 48 hours, as paralytic ileus usually accompanies a severe spinal injury. A nasogastric tube is passed and oral fluids are forbidden until normal bowel sounds return. If paralytic ileus becomes prolonged the abdominal distension splints the diaphragm and, particularly in tetraplegic patients, this may precipitate a respiratory crisis if not relieved by nasogastric aspiration. If a tetraplegic patient vomits, gastric contents are easily aspirated because the patient cannot cough effectively. Ileus may also be precipitated by an excessive lumbar lordosis if too bulky a lumbar pillow is used for thoracolumbar injuries. When perforation occurs it often presents a week after injury with referred pain to the shoulder, but during the stage of spinal shock guarding and rigidity will be absent and tachycardia may not develop. A supine decubitus abdominal film usually shows free gas in the peritoneal cavity. Use of steroids and antibiotics (b) An American study (NASCIS 2) suggested that a short course Figure 4. A later study (NASCIS 3) suggested that patients decubitus view showing massive collection of free gas under the anterior abdominal wall. Recently the use of or perforation steroids has been challenged, and their use has not been universally accepted. Policy concerning steroid treatment • Treat with proton pump inhibitor or H2-receptor antagonist should be agreed with the local spinal injuries unit. If treatment is When the patient is transferred from trolley to bed the whole started 3–8 hours after injury, the infusion is continued for of the back must be inspected for bruising, abrasions, or signs 47 hours. The patient should be turned every two 19 ABC of Spinal Cord Injury hours between supine and right and left lateral positions to prevent pressure sores, and the skin should be inspected at each turn. Manual turning can be achieved on a standard hospital bed, by lifting patients to one side (using the method described in chapter 8 on nursing) and then log rolling them into the lateral position. Alternatively, an electrically driven turning and tilting bed can be used. Another convenient solution is the Stryker frame, in which a patient is “sandwiched” between anterior and posterior sections, which can then be turned between the supine and prone positions by the inbuilt circular turning mechanism, but tetraplegic patients may not tolerate the prone position.

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While I waited for the ambulance I found inderal 80mg on line blood pressure chart age 50, unopened on the doormat trusted 40 mg inderal arteria zygomatica, a copy of the government’s ‘Don’t Die of Ignorance’ leaflet which had been distributed to twenty-three million households as part of the campaign to alert the nation to the danger of Aids. Around half of these households contained either an old couple or an old person living alone. What was striking about the ‘worried well’ was not only the intensity of their anxiety about a rare disease that they had little chance of contracting, but the effect of the Aids publicity in making them question the way they conducted their personal life. Whether or not they were at risk of HIV, the Aids campaign put people under real pressure to conform to official guidelines regarding their most intimate relationships. The more I examined the Aids campaign the less it seemed to be a rational response to a new disease, and the more it seemed to be about the promotion of a new code of sexual behaviour. Not only were fears being needlessly inflamed, but this was being done to establish new norms of acceptable and appropriate behaviour. It was also supplemented by a systematic government drive to change personal behaviour in areas such as smoking, alcohol, diet and exercise through the 1992 Health of the Nation initiative, and by the promotion of mass cancer screening programmes targeted at women (cervical smears and mammograms). To an unprecedented degree, health became politicised at a time when the world of politics was itself undergoing a dramatic transformation. The end of the Cold War marked an end to the polarisations between East and West, labour and capital, left and right, that had dominated society for 150 years. The unchallenged ascendancy of the market meant that the scope for politics was increasingly restricted. Collective solutions to social problems had been discredited and there was a general disillusionment with ‘grand narratives’. One indication of the resulting ideological and political flux was the fact that the remnants of the left broadly endorsed the Conservative government’s Aids campaign (some criticising it for not going far enough), while some right-wingers challenged its scaremongering character (though a few hardliners demanded a more traditional anti- gay, anti-sex line). As someone who had always identified with the political left, the ending of the old order in the late 1980s led to some contradictory and disconcerting developments. In response to a series of setbacks at home and abroad, the left lowered its horizons and became increasingly moderate and defensive. The weakness of the British left had always been its tendency to confuse state intervention for socialism. In the past, however, the state had intervened in industry and services; now (as it tried to retreat from some of its earlier commitments) it stepped up its interference in personal and family life. The left’s endorsement of the government’s Aids campaign, following earlier feminist approval of the mass removal of children from parents suspected of sexual abuse in Cleveland, signalled the radical movement’s abandonment of its traditional principles of liberty and opposition to state coercion. While most conservative commentators loyally defended government policy, only a small group of free-market radicals was prepared to advance a, rather limited, defence of individual freedom against the authoritarian dynamic revealed in the government’s health policies (see Chapter 5). Until the early 1990s, politics and medical practice were distinct and separate spheres. Some doctors were politically active, but they viii PREFACE conducted these activities in parties, campaigns and organisations independent of their clinical work. No doubt, their political outlook influenced their style of practice, but most patients would have scarcely been aware of where to place their doctor on the political spectrum. Systematic government interference in health care has since eroded the boundary between politics and medicine, substantially changing the content of medical practice and creating new divisions among doctors. Thus, for example, the split between fundholding and non-fundholding GPs in the early 1990s loosely reflected party-political allegiances as well as the divide between, on the one hand, suburban and rural practices, and on the other, those in inner cities. Despondent at the wider demise of the left, radical doctors turned towards their workplaces and played an influential role in implementing the agenda of health promotion and disease prevention, and in popularising this approach among younger practitioners. Allowing themselves the occasional flicker of concern at the victimising character of official attempts at lifestyle modification, former radicals reassured themselves with the wishful thinking that it was still possible to turn the sow’s ear of coercive health promotion into the silk purse of community empowerment. Reflecting the wider exhaustion of the old order throughout Western society, an older generation of more conservative and traditional practitioners either capitulated to the new style or grumpily took early retirement. In 1987 I co-authored The Truth About The Aids Panic, challenging the way in which the ‘tombstones and icebergs’ campaign had grossly exaggerated the dangers of HIV infection in Britain, causing public alarm out of all proportion to the real risk (Fitzpatrick, Milligan 1987). Though the central argument of this book was rapidly vindicated by the limited character of the epidemic, it received an overwhelmingly hostile response, particularly from the left. Radical bookshops either refused to stock it or insisted on selling it with an inclusion warning potential readers that it might prove dangerous to their health. In public debates I was accused of encouraging genocide and there were demands that I should be struck off the medical register.

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Up to five attempts may be made to achieve two effective breaths when the chest is seen to rise and fall order inderal 80mg without prescription arteria pulmonar. Circulation Recent evidence has questioned the reliability of using a pulse check to determine whether effective circulation is present trusted 80 mg inderal prehypertension warsaw 2014. Therefore, the rescuer should observe the child for 10 seconds for “signs of a circulation. In addition, healthcare providers are expected to check for the presence, rate, and volume of the pulse. The brachial pulse is easiest to feel in infants, whereas for children use the carotid pulse. If none of the signs of a circulation have been detected, then start chest compressions without further delay and combine with ventilation. Immediate chest compressions, combined with ventilation, will also be indicated when a healthcare provider detects a pulse rate lower than 60beats/min. In infants and children the heart lies under the lower third of the sternum. In infants, compress the lower third of the sternum with two fingers of one hand; the upper finger should be one finger’s breadth below an imaginary line joining the nipples. When more than one healthcare provider is present, the two-thumbed (chest encirclement) method of chest compression can be used for infants. The thumbs are aligned one finger’s breadth below an imaginary line joining the nipples, the fingers encircle the chest, and the hands and fingers support the infant’s rib cage and back. In children, the heel of one hand is positioned over a compression point two fingers’ breadth above the xiphoid process. In both infants and children the sternum is compressed to about one third of the resting chest diameter; the rate is 100 compressions/min. The ratio of compressions to ventilations should be 5:1, irrespective of the number of rescuers. The compression phase should occupy half of the cycle and should be smooth, not jerky. In larger, older children (over the age of eight years) the adult two-handed method of chest compression is normally used (see Chapter 1). The compression rate is 100/min and Chest compression in infants and children the compression to ventilation ratio is 15:2, but the compression depth changes to 4-5cm. Activation of the emergency medical services When basic life support is being provided by a lone rescuer the emergency medical services must be activated after one minute 44 Resuscitation of infants and children because the provision of advanced life support procedures is vital to the child’s survival. The single rescuer may be able to carry an infant or small child to the telephone, but older children will have to be left. Basic life support must be restarted as soon as possible after telephoning and continued without further interruption until advanced life support arrives. In circumstances in which additional help is available or the child has known heart disease, then the emergency medical services should be activated without delay. Choking If airway obstruction caused by aspiration of a foreign body is witnessed or strongly suspected, special measures to clear the airway must be undertaken. Encourage the child, who is conscious and is breathing spontaneously, to cough and clear the obstruction themselves. Intervention is only necessary if these attempts are clearly ineffective and respiration is inadequate. Never perform blind finger sweeps of the pharynx because these can impact a foreign body in the larynx. Use measures intended to create a sharp increase in pressure within the chest cavity, such as an artificial cough. Back blows Hold the infant or child in a prone position and deliver up to five blows to the middle of the back between the shoulder blades. This can be achieved by holding a small infant along the forearm or, for older children, across the thighs.

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