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Some patients develop shoulder pain treatment shingles buy genuine nitroglycerin on-line, which needs to be managed with both physiotherapy and analgesia treatment meaning buy nitroglycerin. Minor skin infections should be treated and toe nails cut short and straight across treatment with chemicals or drugs purchase nitroglycerin 6.5 mg online, as ingrowing toe nails are particularly common. From an early stage, patients must be taught about the hazards of sensory loss and the need to inspect their skin and Box 8. They must be conscious of the effects of pressure and appreciate that the risk of pressure sores increases • Avoid damage during times of emotional distress, tiredness, depression, and • Educate regarding risks intercurrent illness. The risk factors • Nutritional risk assessment associated with trauma, the initial period of paralytic ileus, a • Parenteral/enteral feeding reduced oral intake, anorexia and the inability to use the hands • Education: in high lesions, can all lead to malnutrition, skin complications, diet and severe weight loss. The nursing goal in the acute phase is to feeding aids maintain nutritional support by: performing a nutritional risk assessment with the dietitian; implementing parenteral or enteral feeding when necessary; and encouraging and helping to feed the patient with their diet and nutritional supplements. Bladder management During the acute phase of spinal cord injury, bladder Box 8. It is important to prevent overdistention of the bladder during this stage, which could otherwise lead to overstretching of nerve endings and muscle fibres, inhibiting their potential to recover, which in turn could reduce the long-term management options for the patient. The prevention of urinary tract infection through the implementation of good hygiene, adequate fluid intake and strict asepsis is vital. The long-term aim is the prevention of complications such as urinary tract infections and calculi, as they may hinder a successful rehabilitation programme. Support and education by skilled staff enables the patient to make an informed choice as to the method of bladder management best suited to him/her, which in turn should improve the quality of life. Catheterisation, either by the patient or carer, requires careful preparation and teaching, to provide the physical and psychological support necessary. Coming to terms with loss of this bodily function is often one of the hardest outcomes of SCI that the patient has to accept. Female patients provide an even greater challenge in the achievement of continence, because of Figure 8. Long-term suprapubic catheterisation is now a popular method of management. It is sexually and aesthetically more acceptable, as well as reducing the risk of urethral damage associated with long-term urethral catheterisation. The presence of an • Prevention of infection, calculi and urethral trauma indwelling catheter does not prevent upper urinary tract • Appropriate fluid intake complications. If possible and practicable, intermittent self-catheterisation is considered one of the best methods of management. Careful control of fluids and a daily routine will be needed to maintain a dry state between catheters. Emptying the bladder by tapping and expression, using condom sheath drainage, is also an excellent method in Box 8. Part of the education is assisting the patient to adapt their Upper motor neurone lesion: chosen method into their individual lifestyle, as well as teaching • Reflex emptying—after suppositories or digital stimulation • May not need aperients if diet appropriate the patient what to do if complications such as autonomic dysreflexia arise. Lower motor neurone lesion: • Flaccid • Manual evacuation and aperients usually required but may be Bowel care able to empty, using abdominal muscles • Suppositories ineffective During the period of spinal shock, the bowel is flaccid, so it Education must not be allowed to overdistend, causing constipation with • Programme established to meet patient’s lifestyle overflow incontinence. An initial rectal check is made to 47 ABC of Spinal Cord Injury ascertain whether faeces are present; if they are, they should be Box 8. Very little bowel activity will be Consider expected for the first two or three days. Evacuation should be • Level of injury performed using plenty of lubricant, and with only one gloved • Pre-injury bowel pattern finger inserted into the anus. Trauma, including anal stretching • Diet/fluid intake • What previously helped defaecation and a split natal cleft, is possible if insufficient care is taken. The patient is taught to have an adequate fibre diet, and a high fluid intake to help prevent constipation. The use of aperients is kept to a minimum, especially in a patient with reflex bowel activity. Bowel management may be performed daily, or • Achieve regular bowel emptying by production of a formed stool on alternate days, depending upon the individual’s bowel at a chosen time and place pattern. The patient is encouraged to sit on a specially padded • Avoid leaks or unplanned emptying shower chair, so that bowel care can be performed over the • Avoid constipation and other complications • Try to complete bowel care in 30–60 minutes toilet, followed by a shower.

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Right: incorrect traction—too great a weight and recommended in some patients with unstable fracture- head in extension—leading to distraction with neurological dislocations to prevent further cord or nerve root damage medicine escitalopram buy cheap nitroglycerin 2.5 mg line, deterioration symptoms stroke purchase nitroglycerin with a visa. As yet there is no convincing evidence that internal fixation aids neurological recovery 897 treatment plant rd generic nitroglycerin 6.5mg without prescription. Transfer to a spinal injuries unit In the United Kingdom, there are only 11 spinal injuries units and most patients will be admitted to a district general hospital for their initial treatment. Immediate transfer is ideal, as management in an acute specialised unit is associated with reduced mortality, increased neurological recovery, shorter length of stay and reduced cost of care, compared to treatment in a non- Box 5. The objects of management are to prevent • To prevent further spinal cord damage by reduction and further spinal cord damage by appropriate reduction and stabilisation of spine stabilisation of the spine, to prevent secondary neuronal injury, • To prevent secondary neuronal injury and to prevent medical complications. Unfortunately, some patients will not be fit enough for immediate transfer because of Box 5. In such cases it is advisable to consult, and perhaps arrange a visit by, a Patient unfit to transfer—multiple injuries —need for emergency surgery spinal injuries consultant. Transfer to a spinal injuries centre is —severe respiratory impairment most easily accomplished by means of a Stryker frame, which —cardiorespiratory instability can be fitted with a constant tension device for skull traction. Consider visit by spinal injuries consultant The RAF pattern turning frame is similarly equipped and was specifically developed for use by the Royal Air Force. In civilian practice, studies have shown that patients can be safely transferred from emergency departments using the standard 23 ABC of Spinal Cord Injury techniques for cervical immobilisation described earlier. Tetraplegic patients should be accompanied by a suitably experienced doctor with anaesthetic skills, who can quickly intubate the patient if respiratory difficulty ensues. Transfer by helicopter is often the ideal and is advisable if the patient has to travel a long distance. Spine 1993; 18:955–70 • Tator CH, Duncan EG, Edmonds VE, Lapczak LI, Andrews DF. Neurological recovery, mortality and length of stay after acute spinal cord injury associated with changes in management. Amsterdam: Elsevier Science Publishers, 1992 24 6 Medical management in the spinal injuries unit David Grundy, Anthony Tromans, John Carvell, Firas Jamil Management of spinal cord injury in an acute specialised unit is associated with reduced mortality, increased neurological recovery, shorter length of stay and reduced cost of care, compared to treatment in a non-specialised centre. The cervical spine In injuries of the cervical spine skull traction is normally Box 6. The spine may be positioned in • Skull traction for at least six weeks neutral or extension depending on the nature of the injury. Thus • Halo traction—allows early mobilisation by conversion into halo flexion injuries with suspected or obvious damage to the posterior brace in selected patients ligamentous complex are treated by placing the neck in a degree • Spinal fusion —acute central disc prolapse (urgent decompression of extension. The standard site of insertion of skull calipers need required) not be changed to achieve this; extension is achieved by correctly —severe ligamentous damage positioning a pillow or support under the shoulders. Most injuries —correction of major spinal deformity are managed with the neck in the neutral position. An appropriately sized neck roll can also be inserted to maintain normal cervical lordosis and for the comfort of the patient. The application of a halo brace is a useful alternative to skull traction in many patients, once the neck is reduced. Its use is often necessary for up to 12 weeks, when it can be replaced by a • Widening of gap between adjacent spinous processes cervical collar if the neck is stable. Radiographs are taken vertebral body regularly for position and at six weeks for evidence of bony • Increased angulation between adjacent vertebrae union, immobilisation being continued for a further two to Figure 6. Note forward slip of C4 on C5 and widened interspinous gap, indicating posterior ligament damage. Flexion-extension views show no appreciable movement but a persisting slight flexion deformity at the site of the previous instability. Once stability is achieved the patient is sat up in bed gradually during the course of a few days, wearing a firm cervical support such as a Philadelphia or Miami collar, before being mobilised into a wheelchair. This process is most conveniently achieved with a profiling bed, but the skin over the natal cleft and other pressure areas must be inspected frequently for signs of pressure or shearing. Some patients, particularly those with high level lesions, have postural hypotension when first mobilised because of their sympathetic paralysis, so profiling must not be hurried. Antiembolism stockings and an abdominal binder help reduce the peripheral pooling of blood due to the sympathetic paralysis. Ephedrine 15–30mg given 20 minutes before profiling starts is also effective.

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He found that both of her middle ears were full of fluid—the remnants of the cold that Lourdes caught after beginning nursery school medications requiring aims testing buy nitroglycerin 2.5mg on-line. Once they placed drain tubes in Lourdes’s eardrums (tympanic mem- branes) treatment hypercalcemia buy nitroglycerin 2.5 mg low price, her hearing improved dramatically medications derived from plants best purchase nitroglycerin. Her vocabulary caught up to her age level, and Lourdes returned to being the bright, inquisitive, and well- behaved child she once was. Without solid research on the Internet and a step-by-step analysis, Lourdes’s mother would not have been able to get the help her daughter needed as quickly as she did. Case Study: Justin Justin was a nine-year-old who had just earned his first badge as a Cub Scout. After he attended scout camp that summer and achieved his second badge, he informed his parents he intended to work toward becoming an Eagle Scout. His parents were pleased and hoped his five-year-old brother would follow in his footsteps. One morning, Justin’s brother told his parents that Justin was not sleeping and was walking around the house during the night. Justin’s folks began to worry that there was something going on at school that their son was not talking about. When they confronted him, he denied anything unusual was happening there. One day Justin began to complain that he had tingling in his hands and feet. Sometimes he wet his pants, and other times he went for long periods without urinating at all. Again, his parents took him to the pediatrician, but the doctor could find nothing wrong. He referred Justin to both a urologist and a neurolo- gist at the local children’s hospital. Neither of these specialists could deter- mine the cause of Justin’s problems, although after numerous tests, the neurologist did find that he was indeed suffering from impaired short- and long-term memory, which accounted for his forgetfulness. She also docu- mented evidence of numbness and decreased sensory perception. Now Justin’s parents were worried sick and begged the neurologist to do something. She put Justin on a regimen of multivitamins and screened him for diabetes and thyroid problems. Not only did the boy’s symptoms not improve, but he was also in a foul mood all the time and becoming less and less motivated to do anything. He wouldn’t even attend Boy Scout meet- ings, the one thing he’d always loved. Fortunately for Justin, his mother and David’s mother, Hilary, shared a carpool. Noting Justin’s frequent absences, Hilary inquired about his health and his mother confided in her. Hilary told Justin’s mother about how she’d solved David’s mystery malady using the Eight Steps. She bought a notebook, listed Justin’s symptoms in detail, and com- pleted all the steps until she reached Step Five (past and present mental or physical problems). At that point, she decided to sit her son down and dis- cuss it with him directly. When his mother asked him if anything unusual had happened to him in the past—a symptom perhaps—that he’d forgotten to tell her about, Justin cheeks reddened. She assured him that he would not be in trouble and reminded him of what she had said consistently in the past: he would never be in trouble if he told the truth. Reluctantly, Justin confided that while he was away at scout camp, he’d gotten a “rash. Justin’s mother did not know if this was relevant, but following the instructions of the Eight Step method, she made a note of it and asked him to describe it to her. He said it was weird because it looked like a bull’s-eye, or an archery target. Together they also recalled that three months prior to that Justin had had a case of the “flu,” with fever, chills, achiness, fatigue, and a sore throat.

Therefore medications online order nitroglycerin 6.5mg with mastercard, while using alternative therapies can allow the individual to change their self-perceptions and transform their identities for the better symptoms 7dpiui buy nitroglycerin with a visa, these benefits to self can come at the price of acquiring a deviant identity medicines360 order nitroglycerin 2.5mg with amex. My intent here is not an in-depth examination of the components of the alternative healer identity. Rather, I am concerned with what motivates these informants to begin, continue, or complete the process of adopting a healer identity. Interested readers should see Boon (1998); Cant and Calnan (1991); and Lowenberg (1992) for analyses of alter- native practitioner identity. Glik’s (1990) characterization of the changes to self experienced by her informants as imagined is problematic. As Thomas and Thomas (1970:154) made plain, “If [people] define situations as real they are real in their consequences. While Lindsey (1996:466) does not identify the source of the beliefs that allowed her informants to find “health within illness” as alternative healing ideology, much of the data she presents in illustrating how her informants describe health are analogous to many of the components which make up the alternative model of health espoused by the people who spoke with me. For example, one woman who took part in her research defined health as “being in control of myself and making my own decisions” (Lindsey 1996:468). CHAPTER SEVEN Using Alternative Therapies: A Deviant Identity The use of alternative therapies as deviant behaviour is neglected as an area of research, despite the fact that people who use so-called unortho- dox therapies have consistently been ridiculed (Johnson 1999; Leech 1999; Miller et al. For example, Hare (1993:40) equates a patient’s disclosure of her use of acupuncture to her doctor with the Catholic confessional, and the use of alternative therapies with a sin that must be absolved: “She is confessing to her physician who absolves her, even confessing his own foray into the domain of the ‘other. My focus here is on the means used by informants to reduce the stigma associated with their participation in alternative approaches to health and healing. In addition to describing the use of perennial methods of coping with stigma, such as managing disclosure and using humour (Davis 1961; Goffman 1963), I analyse informants’ use of accounts as a technique of stigma management (Scott and Lyman 1981). In particular, I reflect on their use of retrospective reinterpretation of biography employed in their accounts of their participation in alternative therapies. One’s self-defined biography is neither static nor fixed; rather, as Goffman (1963:62) points out, a salient feature of biographies is that they “are very subject to retrospective construction. As we remember the past, we reconstruct it in accordance with our present ideas of what is important and what is not. In Scott and Lyman’s (1981:357) words: “Every account is a manifestation of the under- lying negotiation of identities,” and is no less so in negotiating deviant identities (emphasis theirs). According to Scott and Lyman (1981:343–344), “An account is a linguistic device employed whenever an action is sub- jected to valuative inquiry.... A statement made by a social actor to explain unanticipated or untoward behavior. These categories differ in that justifications are accounts in which the actor “accepts responsibility for the act... For Scott and Lyman (1981:348) the crucial distinction between excuses and justifications is that in the former case the individual accepts that the behaviour in question is wrong, while in the latter case he or she “asserts its positive value in the face of a claim to the contrary. Self-fulfillment accounts justify behaviour through the rationale that the act is not wrong if it corresponds with the actor’s notion of what is necessary to his or her self-fulfillment, whereas “The sad tale is a selected (often distorted) arrangement of facts that highlight an extremely dismal past, and thus explain the individual’s present state” (Scott and Lyman 1981:349). Below, Using Alternative Therapies: A Deviant Identity | 97 I critically apply Scott and Lyman’s (1981) notions of justifications and excuses, as well as Sykes and Matza’s (1957) techniques of neutralization, in analysing informants’ accounts of their experiences with alternative therapies. Further, I argue that the concept of retrospective reinterpretation of biographies can also be used to shed new light on how people who use alternative therapies reduce the stigma associated with their participation in alternative forms of health care. ALTERNATIVE THERAPY USE AS DEVIANT BEHAVIOUR The language used in the literature to describe alternative therapies has been and remains largely derogatory and pejorative. For example, consistently and over time, alternative therapies have been styled unconventional, nonconventional, unorthodox (Dunfield 1996); unscientific and unproven (Feigen and Tiver 1986); “fuzzy stuff” (Monson 1995:170); or “deviant forms of health service” (Cassee 1970:391). One extreme example concerns Leech’s (1999:1) pronouncement that alternative therapies are “snake oil [which] belongs in the last century, not this or the next. For example, while she uses the term alternative medicine, Monson (1995:168) refers to allopathic health care as “proper orthodox medicine,” implying that alternative therapies are unorthodox and improper. That allopathic medicine is assumed by many to be normative health care and that alternative therapies are not, is something the people who took part in this research are well aware of.