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It is used for sterilizing heat sensitive culture media containing materials such as carbohydrates 17.5 mg lisinopril sale, egg or serum discount lisinopril 17.5 mg fast delivery. Pasteurization: It is the process of application of heat at temperature of 100 0 0 62 c for 30 minutes(Holder method) or 72 c for 15 seconds (Flash method) followed by rapid cooling to discourage bacterial growth. Autoclaving : Steam under pressure It is based on the principle that when water is boiled at increased pressure, hot saturated steam will be formed which penetrates and gives up its latent heat when it condenses on cooler objects. Hot saturated steam in autoclaving acts as an excellent agent for sterilization because of: 1. Uses: Sterilize solid and fluid culture media, gowns, medical and surgical equipment. Time –Temperature-Pressure level relationship in moist heat sterilization (autoclaving) Temperature Time Pressurelevel 0 2 121 c 15 minutes 15 lb/inch 0 2 126 c 10 minutes 20 lb/inch 0 2 134 c 3 minutes 30 lb/inch Methods of controlling sterilization 1. Color change of autoclave tape from blue to brown-black indicates completesterilization. Biological indicator : Use of paper strips impregnated with spores of Bacillus stereothermophilus. Put the paper strip in the culture medium after autoclaving and observe for germinating bacteria to check for growth. It prevents active multiplication of bacteria by decreasing the metabolic activity of bacteria. Radiation : Ioning and ultra violet radiation Ioning radiation includes χ ray, γ ray and β ray. Ultra violet radiation has less quantum energy with low penetrating power than ionic radiation. Spore forming bacteria are more resistant to ionic and ultra violet radiation than vegetative bacteria because of: 1. Anti-Microbial agents and Sensitivity Testing Anti- Microbial drugs Anti-microbial drugs include. Chemical anti-microbials Antibiotics: Definition: Antimicrobial substances produced by living micro- organisms. Chemical anti-microbials Definition: synthetically produced anti-micorbial compounds. Anti-microbial drugs show specific toxicity to microbial cells due to differences in cell envelope, protein and enzymes to host cells. Those damaging cell membrane leading to loss of cell contents and then cell death. Those inhibiting protein synthesis and then arresting bacterial growth - aminoglycosides - tetracycline - erythromycin - chloramphenicol - clindamycin 4. Those inhibiting nucleotide synthesis - sulfonamide - trimethoprim 105 Resistance of bacteria to anti-microbial drugs Production of enzymes that destroy or inactivate anti-microbials Eg. Developing an altered metabolic pathway that bypasses the reaction inhibited by the drugs Eg. Developing an altered enzyme that can still perform its metabolic function but is much less affected by the drug Eg. Wide spread sensitization resulting in hypersensitivity and anaphylactic reaction, and drug rashes. Changing normal microbial flora leading to “super infection” due to over growth of drug-resistant micro-organism. A filter paper disk containing measured quantities of drug is placed on a solid medium that has been seeded with the test organisms. Following over right incubation, the diameter of the clear zone of inhibition surrounding the deposit of drug is taken as a measure of the inhibitory power of the drug against the particular test organism. Bacterial strains sensitive to the drug are inhibited at a distance from the disk whereas resistant strains grow up to the edge of the disk. Dilution Sensitivity Tests - Agar dilution tests - Broth dilution tests Graded amounts of antimcorbial agents are incorporated into liquid or solid bacteriology media. Nowadays the above tests are either time consuming or cumbersome, so the advent of microdilution both solution tests has simplified the method and permit a quantitative result to be reported, indicating the amount of a given drug necessary to inhibit or kill the test micro-organism. Components of medium - media composition components enhance or inhibit bacterial growth. Size of inoculum: the larger the bacterial inoculum, the lower the apparent sensitivity of the organisms. Length of incubation: short exposure of moisture to the drug inhibits their growth but does not kill them; longer exposure of moisture to a drug gives a chance for resistant motants to emerge. Metabolic activity of moistures - actively and rapidly growing micro-organisms are more susceptible to drug action than those in the resting phase. Techniques of routinely used antimicrobial sensitivity testing (disc diffusion tests) Required: - sensitivity testing media - Anti-microbial discs - Control strains - Turbidity standard 109 Sensitivity testing media: The commonly used media is Mueller- Hinton agar. For pathogens requiring enriched media like Neisseria gonorrhea, Heamophilus influenzae and Streptococcus pneumoniae, it is necessary to add blood to (heat it if needed) sensitivity testing agar. Turbidity (Opacity) standard: This is a barium chloride standard against which the turbidity of the test inocula can be compared. The turbidity of the standard is equivalent to the turbidity of subcultured broth test micro-organism.

A Pharmacogenetics (sometimes called are important in identifying which condition? Risk for primary biliary cirrhosis Individual differences in drug metabolism can be C generic lisinopril 17.5 mg on line. Progression of hepatitis C to hepatic cirrhosis attributed in part to polymorphisms in the genes D generic 17.5 mg lisinopril with visa. Approximately how may mutations have been polymorphic genes that account for metabolism of identified in the gene coding for the cystic fibrosis approximately 40% of drugs. Phenotypical expression trans membrane conductor regulator protein varies with the locus involved. The most common mutation is a deletion of three base pairs that code for phenylalanine at position 508 of the protein, ΔF508. Some with no other symptoms infants may be too young for accurate sweat testing, D. Which of the following alleles has the highest always associated with pancreatic disease). Other than infertility, they are asymptomatic thrombophilia) and may or may not have a sweat chloride level D. This results in a codon that substitutes valine for alanine and results in an enzyme that is more heat sensitive. The enzyme converts 5,10 methylenetetrahydrofolate to 5-methyltetrahydrofolate (folate). The methyl group from the latter is transferred to homocysteine, forming methionine. Such persons have an approximately threefold increased risk of coronary artery disease. All of the alleles listed are of sufficiently high frequency to warrant screening of at-risk populations. The prothrombin G20210A allele has a frequency of approximately 2%, factor V-Leiden 5%, and ΔF508 approximately 3% (in Whites). Both factor V-Leiden and the prothrombin G20210A mutation result in proteins that increase the risk of thrombosis. The point mutation in factor V-Leiden results in a protein that is resistant to inactivation by protein C. The base substitution in G20210A (guanine to adenine at position 20210) results in increased transcription of the gene and overproduction of prothrombin. Restriction fragment length polymorphism transferred to each well of a 96-well plate. Which statement best describes the relationship with a near ultraviolet light source. Cytogenetic analysis of chromosome 11 This causes production of a fragment that is 200 base D. Labeled probe painting of chromosome 11 pairs longer than seen for the normal β-gene. Heterozygotes produce one normal and one longer band, whereas homozygotes produce a single band that is 200 base pairs longer than the normal amplicon. Which of the following genetic diseases is caused Answers to Questions 23–24 by an expanded trinucleotide repeat? Fragile X syndrome, Huntington’s disease, and myotonic dystrophy are Molecular/Correlate clinical and laboratory data/ examples of diseases caused by an expansion of Length polymorphism/2 trinucleotide repeats. Which is the most common method used for when cells from an affected individual are cultured parentage testing in the United States? In fragile X syndrome, the repeat Molecular/Apply knowledge of special procedures/ is extended and its length determines whether Paternity testing/2 the affected persons will show mental retardation. The gene is needed for normal brain function and its underexpression results in mental retardation. Females in whom the premutation expands in size to a full mutation transmit the syndrome to all of their male and half of their female offspring. The size of the fragments and their fluorescence determine which alleles are present. A single exclusion can result from laboratory possibility of a mutation having occurred in one of error the loci being tested. A single exclusion can result from germ line sufficiently polymorphic that the mother’s sample is mutation within one locus being tested not necessary to determine paternity. Te biological father may be a blood relative to based on the premise that the biological father must the alleged father have at least one allele in common with the child at D. D Hereditary hemochromatosis is an autosomal Molecular/Apply knowledge of special procedures/ recessive disease with a frequency as high as 0. Hereditary hemochromatosis is the result of which base that results in tyrosine substituting for cysteine type of mutation? The remaining cases Molecular/Correlate clinical and laboratory data/Point are caused by a single-point mutation at position mutations/2 63 on the protein (H63D), which produces a milder 27.

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Patients remain at high risk for thrombophlebitis for several months after the initial injury generic 17.5 mg lisinopril with visa. Patients with paraplegia or tetraplegia are at increased risk for the rest of their lives buy lisinopril 17.5 mg low price. Anticoagulation is initiated once head injury and other systemic injuries have been ruled out. Low-dose fractionated or unfractionated heparin may be followed by long- term oral anticoagulation (ie, warfarin) or subcutaneous fractionated heparin injections. Additional measures such as range-of-motion exercises, thigh-high elastic compression stockings, and adequate hydration are important preventive measures. Pneumatic compression devices may also be used to reduce venous pooling and promote venous 421 return. It is also important to avoid exter-nal pressure on the lower extremities that may result from flexion of the knees while the patient is in bed. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Interruption in the reflex arcs that normally produce vasoconstriction in the upright position, coupled with vasodilation and pooling in abdominal and lower extremity vessels, can result in blood pressure readings of 40 mm Hg systolic and 0 mm Hg diastolic. Orthostatic hypotension is a particularly common problem for patients with lesions above T7. In some patients with tetraplegia, even slight elevations of the head can result in dramatic changes in blood pressure. A number of techniques can be used to reduce the frequency of hypotensive episodes. Thigh-high elastic compression stockings should be applied to improve venous return from the lower extremities. Abdominal binders may also be used to encourage venous return and provide diaphragmatic support when the patient is upright. Activity should be planned in advance, and adequate time should be allowed for a slow progression of position changes from recumbent to sitting and upright. Autonomic Dysreflexia Autonomic dysreflexia (autonomic hyperreflexia) is an acute emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). Because this is an emergency situation, the objectives are to remove the triggering stimulus and to avoid the possibly serious complications. The following measures are carried out: The patient is placed immediately in a sitting position to lower blood pressure. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. If one is present, a topical anesthetic is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia. The process begins during hospitalization, as acute symptoms begin to subside or come under better control and the overall deficits and long-term effects of the injury become clear. Patient teaching may initially focus on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the injury and the resulting disability, the focus of teaching broadens to address issues necessary for carrying out the tasks of daily living and taking charge of their lives (Kinder, 2005). They will require dedicated nursing support to gradually assume full care of the patient. Although maintaining function and preventing complications will remain important, goals regarding self-care and preparation for discharge will assist in a smooth transition to rehabilitation and eventually to the community. The nurse becomes a support to both the patient and the family, assisting them to assume responsibility for increasing aspects of patient care and management. The nurse often serves as coordinator of the management team and as a liaison with rehabilitation centers and home care agencies. The patient and family often require assistance in dealing with the psychological impact of the injury and its consequences; referral to a psychiatric clinical nurse specialist or other mental health care professional often is helpful. Preconception assessment and counseling are strongly recommended to ensure that the woman is in optimal health and to increase the likelihood of an uneventful pregnancy and healthy outcomes. Therefore, teaching in the home and community focuses on health promotion and addresses the need to minimize risk factors (eg, smoking, alcohol and drug abuse, obesity) (Mastrogiovanni, Phillips & Fine, 2003). Assisting patients to identify accessible health care providers, clinical facilities, and imaging centers may increase the likelihood that they will participate in health screening. Visual disturbances due to lesions in the optic nerves or their connections may include blurring of vision, diplopia (double vision), patchy blindness (scotoma), and total blindness. Management • Medical –Corticosteroid therapy may be used to reduce inflammation and diminish severity of the disorder.

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After several days of drainage order 17.5 mg lisinopril fast delivery, the tube may be clamped for 1 hour before and after each 94 meal to deliver bile to the duodenum to aid in digestion cheap lisinopril 17.5 mg line. The patient who goes home with a drainage tube in place requires instruction and reassurance about the function and care of the tube. In all patients with biliary drainage, the nurse (or the patient, if at home) observes the stools daily and notes their color. Specimens of both urine and stool may be sent to the laboratory for examination for bile pigments. In this way, it is possible to determine whether the bile pigment is disappearing from the blood and is draining again into the duodenum. Improving Nutritional Status The nurse encourages the patient to eat a diet that is low in fats and high in carbohydrates and proteins immediately after surgery. At the time of hospital discharge, there are usually no special dietary instructions other than to maintain a nutritious diet and avoid excessive fats. Fat restriction usually is lifted in 4 to 6 weeks, when the biliary ducts dilate to accommodate the volume of bile once held by the gallbladder and when the ampulla of Vater again functions effectively. After this time, when the patient eats fat, adequate bile will be released into the digestive tract to emulsify the fats and allow their digestion. This is in contrast to the condition before surgery, when fats may not be digested completely or adequately, and flatulence may occur. Monitoring and Managing Potential Complications Bleeding may occur as a result of inadvertent puncture or nicking of a major blood vessel. Postoperatively, the nurse closely monitors vital signs and inspects the surgical incisions and drains, if any are in place, for evidence of bleeding. The nurse also periodically assesses the patient for increased tenderness and rigidity of the abdomen. The nurse instructs the patient and family to report to the surgeon any change in the color of stools, because this may indicate complications. Gastrointestinal symptoms, although not common, may occur with manipulation of the intestines during surgery. After laparoscopic cholecystectomy, the nurse assesses the patient for loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. These may indicate infection or disruption of the gastrointestinal tract and should be reported to the surgeon promptly. Because the patient is discharged soon after laparoscopic surgery, the patient and family are instructed verbally and in writing about the importance of reporting these symptoms promptly. Promoting Home and Community-Based Care Teaching Patients Self-Care The nurse instructs the patient about the medications that are prescribed (vitamins, anticholinergics, and antispasmodics) and their actions. It also is important to inform the patient and family about symptoms that should be reported to the physician, including jaundice, dark urine, pale-colored stools, pruritus, and signs of inflammation and infection, such as pain or fever. This is the result of a continual trickle of bile through the choledochoduodenal junction after cholecystectomy. Usually, such frequency diminishes over a period of a few weeks to several months. If a patient is discharged from the hospital with a drainage tube still in place, the patient and family need instructions about its management. The nurse instructs them in proper care of the drainage tube and the importance of reporting to the surgeon 95 promptly any changes in the amount or characteristics of drainage. Managing Pain You may experience pain or discomfort in your right shoulder from the gas used to inflate your abdominal area during surgery. Sitting upright in bed or a chair, walking, or use of a heating pad may ease the discomfort. Managing Follow-Up Care Make an appointment with your surgeon for 7 to 10 days after discharge. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. In addition, fat breakdown occurs, resulting in an increased production of ketone bodies, which are the byproducts of fat breakdown. Type 2 Diabetes Mellitus • Accounts for 90% of patients with diabetes • Usually occurs in people over 40 years of age • 80-90% of patients are overweight Etiology and Pathophysiology • Pancreas continues to produce some endogenous insulin • Insulin produced is either insufficient or poorly utilized by the tissues • Insulin resistance –Body tissues do not respond to insulin –Results in hyperglycemia • Inappropriate glucose production by the liver –Not considered a primary factor in the development of type 2 diabetes Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises, and type 2 diabetes develops. One consequence of undetected diabetes is that long-term diabetes complications (eg, eye disease, peripheral neuropathy, peripheral vascular disease) may have developed before the actual diagnosis of diabetes is made Etiology (not well know) –Genetic factors –Increased weight. Secondary Diabetes • Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels –Cushing syndrome –Hyperthyroidism –Parenteral nutrition Clinical Manifestations Diabetes Mellitus • Polyuria • Polydipsia (excessive thirst) • Polyphagia • In Type I –Weight loss –Ketoacidosis Polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. Plasma glucose values are 10% to 15% higher than whole blood glucose 103 values, and it is crucial for patients with diabetes to know whether their monitor and strips provide whole blood or plasma results Assessing the Patient with Diabetes • History: Symptoms related to the diagnosis of diabetes: Symptoms of hyperglycemia Symptoms of hypoglycemia Frequency, timing, severity, and resolution Results of blood glucose monitoring Status, symptoms, and management of chronic complications of diabetes: Eye; kidney; nerve; genitourinary and sexual, bladder, and gastrointestinal Cardiac; peripheral vascular; foot complications associated with diabetes Adherence to/ability to follow prescribed dietary management plan Adherence to prescribed exercise regimen Adherence to/ability to follow prescribed pharmacologic treatment (insulin or oral antidiabetic agents) Use of tobacco, alcohol, and prescribed and over-the-counter medications/drugs Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment Effects of diabetes or its complications on functional status (eg, mobility, vision) Physical examination Blood pressure (sitting and standing to detect orthostatic changes) Body mass index (height and weight) Fundoscopic examination and visual acuity Foot examination (lesions, signs of infection, pulses) Skin examination (lesions and insulin-injection sites) Neurologic examination Vibratory and sensory examination using monofilament Deep tendon reflexes Oral examination • Laboratory Examination • Need for Referrals 104 105 Diabetes Mellitus Collaborative Care • Goals of diabetes management: –Reduce symptoms –Promote well-being –Prevent acute complications –Delay onset and progression of long-term complications Nutritional Therapy –Overall objectives • Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control • Control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease. Nutrition, meal planning, and weight control are the foundation of diabetes management.

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