John Tidy MD FRCOG

• Consultant Gynaecological Oncologist, The Jessop Wing,
• Sheffield

Use caution in the digitalized patient; too-rapid re moval of potassium may cause digoxin toxicity impotence questionnaire cheap kamagra oral jelly 100 mg amex. Continue daily throughout the full course of therapy and for 30 days after the last dose of pralatrexate impotence jokes purchase kamagra oral jelly visa. Administer once weekly for 6 weeks in 7-week cycles until progressive disease or unacceptable toxicity occurs erectile dysfunction information 100mg kamagra oral jelly for sale. Management of severe or intolerable side effects may require dose omission or reduction or interruption of therapy; see Dose Adjustments erectile dysfunction treatment stents buy 100mg kamagra oral jelly with mastercard. Do not make up omitted doses at the end of the cycle weak erectile dysfunction treatment purchase 100 mg kamagra oral jelly free shipping, and do not re-escalate once a dose reduction occurs for toxicity erectile dysfunction humor buy generic kamagra oral jelly canada. Aseptically withdraw the calculated dose directly into a syringe for immediate use erectile dysfunction injection dosage order 100 mg kamagra oral jelly with amex. It competitively inhibits dihydrofolate reductase and folylpoly glutamyl synthetase erectile dysfunction exercises wiki order kamagra oral jelly 100mg with mastercard. This inhibition results in the depletion of thymidine and other bio logic molecules. May increase in severity with continued treatment, may involve skin and subcu taneous sites of known lymphoma, and may result in death. May be at greater risk for increased exposure and toxicity; administer with caution. Has not been studied in patients with hepatic impairment, and patients with selected liver test elevations were excluded from clinical trials. Repeat serum chemistry tests, including renal and hepatic function, before the start of the frst and fourth dose of a given cycle. If liver functions test abnormalities are greater than or equal to Grade 3, omit or modify dose; see Dose Adjustments. Allopurinol and alkalinization of urine may be indicated for prevention and/or treatment of hyperuricemia. Patient Education: A patient information guide is available from the manufacturer. Mucositis and thrombocytopenia were the most common reasons for discon tinuing treatment. Other reported side effects include abdominal pain, abnormal liver function tests. After the effects of atropine have become apparent, pralidoxime may be administered. Repeat atropine every 10 minutes until atropine toxicity (delirium, dilated pupils, dry mouth, muscle twitching, pulse 140 beats/min). Pralidoxime: 1 to 2 Gm initially after hypoxemia has been corrected, initial dose of atro pine has been given, and effects of atropine are apparent (secretions are inhibited). If muscle weakness continues, additional doses can be given with extreme caution, usually every 10 to 12 hours (has been given more frequently). Evidence suggests that a loading dose followed by a continuous infusion may maintain therapeutic levels longer than the traditional short intermittent infusion therapy; see pre scribing information for studied regimens. Slows the conversion of phosphorylated cholinesterase to a nonreactivatable form and detoxifes certain organophosphates by direct chemical reaction. Because pralidoxime is less ef fective in relieving depression of the respiratory center, atropine is always required concomitantly to block the effect of accumulated acetylcholine at this site. Primarily useful for many phosphate ester insecticide poisons with anticholines terase activity. Relative contraindications include known hypersensitivity to pralidoxime or any component of the product. May be ineffec tive if more than 36 hours has passed since exposure; some response may be obtained in severe poisoning; see Contraindications. Monitor: Before any medication is given, establish and maintain an adequate airway and controlled respiration as indicated. Cardiovascular support, correction of metabolic abnormalities, and seizure control may be necessary. Muscle fasciculations, apnea, and convul sions have been reported; see Rate of Administration. Excitement and manic behavior may occur (atropinization) if pralidoxime is de layed after atropine has been given. Artifcial ventilation and other supportive therapy should be administered as needed. Wait 10 minutes to allow adequate distribution, then resume dosing until arrhythmia is suppressed, maximum initial dose of 1 Gm is reached, or side effects appear. Maintenance dose: After arrhythmia is suppressed or maximum dose is reached, follow initial dose with an infusion of 1 to 4 mg/min (may require up to 6 mg/min). An alternate dose regimen is 2 to 6 mg/kg as a loading dose given over 5 minutes; follow with a maintenance infusion of 20 to 80 mcg/kg/min to control arrhythmias. Pediatric infusion: Loading dose: Add a calculated loading dose (2 to 5 mg/kg) to a mini mum of 10 mL D5W for each 100 mg or fraction thereof. One source suggests the following compatibilities: Additive: Consider individualized rate adjustments necessary to achieve desired effects. Amio darone (Nexterone), atracurium (Tracrium), dobutamine, fumazenil (Romazicon), lido caine, verapamil. Use an infusion pump or a microdrip (60 gtt/mL) for infusion to deliver a constant rate. After stabilized with loading dose, follow with a maintenance infusion at 1 to 6 mg/min. Procainamide Infusion Rate (Adult) Desired Dose 1 Gm in 500 mL D5W 2 mg/mL 1 Gm in 250 mL D5W 4 mg/mL mg/min mg/hr mL/min mL/hr mg/hr mL/min mL/hr 1 mg/min 60 0. Exerts a depressing antiarrhythmic action on the heart, slowing the rate, slowing conduction, reducing myocardial irritability, and prolonging the refractory period. Decreases membrane permeability of the cell and prevents loss of sodium and potassium ions. If an arrhythmia occurs, use lidocaine for ventricular arrhythmias and calcium channel blockers. Elderly: Half-life of parent drug and active metabolite is prolonged; renal excretion re duced about 25% at age 50 and 50% at age 75. Use dopamine or phenylephrine hydrochloride (Neo-Synephrine) to correct hypotension. Hemodialysis may be indicated or urinary acidifers may in crease renal clearance. Control of severe nausea and vomiting in adult surgical patients: 5 to 10 mg 15 to 30 minutes before induction of anesthesia or to control symptoms during or after surgery. Another source suggests 20 mg diluted in 1 L solution (see Dilution) during and/or after surgery. Management of nausea and vomiting in emetic-inducing chemotherapy (unlabeled): One source suggests 10 to 20 mg 30 minutes before and 3 hours after treatment. Another source sug gests 30 to 40 mg 30 minutes before and 3 hours after treatment. Begin 30 minutes before chemotherapy, repeat every 2 hours for 2 doses, then every 3 hours for 3 doses. Control of severe vascular and tension headaches (unlabeled): 10 mg given as an injection over 2 minutes. Sometimes given concurrently with dihydroergotamine 1 mg as an infu sion over 30 minutes. One source suggests the following compatibilities: Additive: Amikacin (Amikin), ascorbic acid, calcium gluconate, dexamethasone (Deca dron), dimenhydrinate, erthyromycin (Erythrocin), ethacrynic acid (Edecrin), lidocaine, nafcillin (Nallpen), penicillin G potassium, sodium bicarbonate. Infusion: May be given at ordered rate, or rate may be increased or decreased as symp toms indicate. Has weak anticholinergic effects, moderate sedative effects, and strong extrapyramidal ef fects. Unlabeled uses: Use of higher doses to control nausea and vomiting associated with emetic-inducing chemotherapy. For patients receiving phenothiazines, taper and discon tinue preoperatively if they will not be continued after surgery. Maternal/Child: Safety for use in pregnancy, breast-feeding, and pediatric patients not es tablished; see Contraindications. Will require intensive symptomatic treatment, medical monitoring, and manage ment of concomitant medical problems. In treating respiratory depression and unconsciousness, avoid analeptics such as doxapram (Do pram); they may cause convulsions. May combine with a reduced dose of narcotic anal gesic and an anticholinergic drug. When labor fully estab lished, may administer 25 to 75 mg with a reduced dose of a narcotic analgesic. Use the minimum effective dose and avoid concomitant administration with other drugs with respiratory depressant effects. One source suggests the following compatibilities: Additive: Amikacin (Amikin), ascorbic acid, hydromorphone (Dilaudid), penicillin G potassium. A maximum rate of 25 mg or fraction thereof over 1 minute is suggested by the manufacturer. As an antihistamine, it competitively blocks the H1 histamine receptor, antagonizing most of the effects of histamine to at least some degree. Adverse event reports include abscesses, burning, erythema, gangrene, pain, palsies, paralysis, sensory loss, severe spasm of the distal vessels, swelling, thrombophlebitis, tissue necrosis, and venous thrombosis. Monitor: A vesicant; determine absolute patency of vein; extravasation will cause necrosis; see Contraindications and Precautions. Maternal/Child: Category C: safety for use in pregnancy and pediatric patients not estab lished. Concomitant administration with other respiratory depressants increases this risk. Antiemetics are not recommended for treatment of uncom plicated vomiting in pediatric patients. Overdose: Anaphylaxis, cardiac arrest, coma, convulsions, deep sedation, respiratory depression. Sympathetic block and heparinization have been used during acute management of pro methazine extravasation (unintentional intra-arterial injection or perivascular extravasa tion). In some cases surgical intervention, including fasciotomy, skin graft, and/or amputation, has been required. In treating respiratory depression and unconsciousness, avoid analeptics such as doxapram (Dopram); they may cause convul sions. Administer before propofol injection or add to propofol immediately before administration. Healthy adults less than 55 years of age: 40 mg every 10 seconds until induction onset (ap proximately 2 to 2. Neurosurgical patients: 20 mg every 10 seconds until induction onset (approximately 1 to 2 mg/kg). Infusion or slow injection (20 mg over 10 seconds) is used to avoid signifcant hypotension and decrease in cerebral perfusion pressure. If increased intracranial pres sure is suspected, hyperventilation and hypocarbia should accompany administration. Allow 3 to 5 minutes between dose adjustments to allow for and assess clinical effects. Adults less than 55 years of age: Immediately follow induction with an infusion of 100 to 200 mcg/kg/min (6 to 12 mg/kg/hr) or an intermittent bolus in increments of 25 to 50 mg as needed. Cardiac anesthesia: Most patients require 100 to 150 mcg/kg/min in combination with an opioid (primary propofol with an opioid secondary). An alternate regimen is an opioid primary with low-dose propofol 50 to 100 mcg/kg/min (3 to 6 mg/kg/hr). Neurosurgical patients: Immediately follow induction with an infusion of 100 to 200 mcg/kg/min (6 to 12 mg/kg/hr). Healthy adults less than 55 years of age: An infusion of 100 to 150 mcg/kg/min (6 to 9 mg/kg/hr) over 3 to 5 minutes or a slow injection of 0. Slow infusion or slow injection techniques are preferable to rapid bolus administration. Must be given over 3 to 5 minutes as a slow infusion (preferred) or as a slow injection over 3 to 5 minutes. Allow at least 5 minutes between adjustments to reach peak drug effect and to avoid hypotension. Individualize to patient condition, response, blood lipid profle, and vital signs. Some clinicians recommend reducing dose by approximately one half for elderly (over 55 years) and debilitated. Check urinalysis and urine sediment before ad ministration of propofol in patients at risk for renal failure; see Precautions and Monitor. Use caution with doses higher than 50 mcg/kg/min; may increase risk of hypotension. Bolus doses of 10 to 20 mg may be used to rapidly increase the depth of sedation in patients in whom hypotension is not likely to occur. Temporarily reduce dose once each day to assess neurologic and respiratory function and to determine minimum dose required for desired level of sedation. Average maintenance dose under 55 years is 38 mcg/kg/min; over 55 years, 20 mcg/kg/min. Induction with propofol is indicated only in pediatric patients 3 years of age or older. In pediatric patients from 2 months to 3 years of age, induction must be achieved by supplementing with another agent (literature suggests nitrous oxide 60% to 70%). Pediatric patients 2 months of age and older: Immediately follow induction dose with an infusion of 125 to 300 mcg/kg/min (7. Initially, a rate of 200 to 300 mcg/kg/min may be indicated and can usually be reduced to 125 to 150 mcg/kg/min after the frst half-hour. Decrease infusion rate if clinical signs of light anesthesia are not present after 30 minutes of maintenance; see Rate of Administration. Younger pediatric patients may require higher maintenance infusion rates than older pediatric patients. Do not dilute to a concentration less than 2 mg/mL (4 mL diluent to 1 mL propofol yields 2 mg/mL). Strict aseptic technique imperative; emulsion supports rapid growth of microorganisms. Failure to use strict aseptic technique has been associated with microbial contamination of the product with resultant fever, infection, sepsis, other life-threatening illnesses, and/or death. Filters with a pore size less than 5 microns may impede the fow of propofol and/ or cause a breakdown of the emulsion. Discard infusion and tubing every 12 hours or every 6 hours if propofol has been transferred from the original container. Manufacturer states, Should not be mixed with other therapeutic agents prior to admin istration. Continuous administration preferable to intermittent to avoid periods of underse dation or oversedation. In all anesthesia, higher rates are generally required for the frst 15 minutes, then appropriate responses can usually be maintained with a decrease of 30% to 50%. Always titrate rates downward until there is a mild response to surgical stimulation. If control not effective within 5 min utes, consider use of an opioid, barbiturate, or inhalation agent. Can provide conscious (verbal contact maintained) or unconscious sedation, depending on dose. Produces hypnosis rapidly and smoothly with minimal excitation, usually within 40 seconds. Due to extensive redistribution from the central nervous system to other tissues and high meta bolic clearance, recovery from anesthesia or sedation is rapid. Other effects include decreased systemic vascular resistance, myocardial blood fow, and oxy gen consumption; a decrease in cerebral blood fow and intracranial pressure; and a de crease in intraocular pressure. Has minimal impact on cardiac output, but changes may occur because of assisted or controlled ventilation. Hy potension, oxyhemoglobin desaturation, apnea, and airway obstruction can occur. Continuous infusions of low doses allows controlled recovery of con sciousness when required and for assessment. Pediatric patients: Induction of anesthesia as a part of a balanced anesthetic technique for inpatient and outpatient surgery in pediatric patients over 3 years of age. Unlabeled uses: Subhypnotic doses used for relief of pruritus associated with use of spinal opiates or cholestasis; treatment of status epilepticus refractory to standard anticonvul sant therapy. Both life-threatening and fatal anaphylactoid and anaphylactic reactions have been reported. May cause undesirable cardiopulmonary de pression, including apnea, airway obstruction, hypotension, and oxygen desaturation. Consider alterna tive means of sedation when there is a prolonged need for sedation, when large doses of propofol are required to maintain a desired level of sedation, or if a patient develops metabolic acidosis.

The primary concentration of phosphorous (85%) is located in the erectile dysfunction injection therapy cost buy generic kamagra oral jelly pills, with about 15% is located in erectile dysfunction treatment medicine discount kamagra oral jelly american express. The upper and lower blood pH levels that are incompatible with life are: and erectile dysfunction recovery time cheap kamagra oral jelly 100 mg without prescription. Indicate which of the following factors contribute to hyponatremia by writing Low in the space provided erectile dysfunction injection medication kamagra oral jelly 100 mg low price, and indicate which contribute to hypernatremia by writing High in the space provided erectile dysfunction doctors in coimbatore buy discount kamagra oral jelly online. Indicate which of the following factors contribute to hypokalemia by writing Low in the space provided erectile dysfunction first time buy kamagra oral jelly 100 mg with mastercard, and indicate which contribute to hyperkalemia by writing High in the space provided erectile dysfunction drugs at gnc discount kamagra oral jelly 100 mg without a prescription. Indicate which of the following factors contribute to hypocalcemia by writing Low in the space provided erectile dysfunction doctor toronto kamagra oral jelly 100mg on-line, and indicate which contribute to hypercalcemia by writing High in the space provided. Indicate which of the following factors contribute to hypomagnesemia by writing Low in the space provided, and indicate which contribute to hypermagnesemia by writing High in the space provided. Indicate which of the following factors contribute to hypophosphatemia by writing Low in the space provided, and indicate which contribute to hyperphosphatemia by writing High in the space provided. Write the mathematical formula that a nurse would use to approximate the value of serum osmolality. Explain why the administration of a 3% to 5% sodium chloride solution requires intense monitoring. List four of six symptoms associated with air embolism, a complication of intravenous therapy:, and. Explain why decreased urine output, despite adequate fluid intake, is an early indicator of a third space fluid shift. Explain the important role of two opposing forces, hydrostatic pressure and osmotic pressure, in maintaining fluid movement through blood vessels. Calculate the usual per hour output for adults with the following weights: 110 lb, 132 lb, and 176 lb. Distinguish between hypervolemia and hypovolemia (pathophysiology, clinical manifestations, assessment, diagnostic findings, medical, and nursing management). Compare and contrast the clinical manifestations, assessment, diagnostic findings, medical and nursing management, and prevention and correction of hypokalemia and hyperkalemia. Discuss why serum albumin levels and arterial pH must be considered when evaluating serum calcium levels. Compare and contrast the clinical manifestations, assessment, diagnostic findings, medical and nursing management, and prevention and correction of hypochloremia and hyperchloremia. Compare and contrast the clinical manifestations, assessment, diagnostic findings, medical and nursing management for acute and chronic metabolic acidosis and metabolic alkalosis. Compare and contrast the clinical manifestations, assessment, diagnostic findings, medical and nursing management for acute and chronic respiratory acidosis and respiratory alkalosis. Distinguish between the purposes of using isotonic, hypotonic, or hypertonic intravenous solutions. Discuss the nursesrole in managing the common complications of intravenous therapy: infiltration, phlebitis, thrombophlebitis, hematoma, clotting, and obstruction. Define the term osmosis, and explain how a fluid concentration gradient influences the movement between fluid compartments. Give some examples of osmosis, diffusion, and filtration. Explain the interdependence of renin, angiotensin, and the aldosterone system on the fluid regulation cycle. Sodium, the most abundant electrolyte in extracellular fluid, is primarily responsible for maintaining fluid, which. Sodium is regulated by, and the system. Sodium establishes the electrochemical state necessary for and the. Signs of lethargy, increasing intracranial pressure, and seizures may occur when the serum sodium level reaches: a. In a patient with excess fluid volume, hyponatremia is treated by restricting fluids to how many milliliters in 24 hours To return a patient with hyponatremia to normal sodium levels, it is safer to restrict fluid intake than to administer sodium: a. A nursing plan of care for Harriet should include assessing blood pressure with the patient in the supine and upright positions. He was admitted to the hospital with a diagnosis of extracellular fluid volume excess. During the assessment process, the nurse expects to identify all of the following except: a. On his admission, the nurse observed rapid respirations, confusion, and signs of dehydration. In terms of cellular buffering response, the nurse should expect the major electrolyte disturbance to be: a. The nurse knows that one of these four arm veins would be a recommended site:, and. The nurse also knows that if a central vein is needed it would most likely include either the or vein. Since the flow of the intravenous infusion is inversely proportional to the fluids viscosity, an infusion of blood would require than that used for saline or water. The formula to calculate flow rate at milliliter per hour (mL/h) is:. A positive-pressure infusion pump maintains a steady infusion by overcoming vascular resistance caused by two things: the and the. Four systemic intravenous complications are:, and. Five local complications of intravenous therapy are:, and. Physiologic responses to all types of shock include all of the following except: a. Baroreceptors are a primary mechanism of blood pressure regulation which results from the initial stimu lation of what type of receptors The nurse knows to report an early indicator of compensatory shock that would be a pulse pressure of: a. The nurse assesses a patient in compensatory shock whose lungs have decompensated. In progressive stage shock, clinical hypotension is present if the systematic blood pressure is: a. Oliguria occurs in the progressive stage of shock because the kidneys decompensate. To verify this condi tion, the nurse should expect all of the following signs or symptoms except: a. Hematologic system changes in progressive shock would be characterized by all of the following except: a. Vasoactive agents are effective in treating shock if fluid administration fails because of their ability to: a. In cardiogenic shock, decreased cardiac contractility leads to all of the following compensatory responses except: a. Sympathomimetic drugs increase cardiac output by all of the following measures except: a. The nurse assesses for the negative effect of intravenous nitroglycerin (Tridil) for shock management, which is: a. The vasoactive effects of dopamine are diminished when high doses are given, because vasoconstriction increases cardiac workload. The basic, underlying characteristic of shock is, which results in, and. Energy metabolism occurs in the cells, where is primarily responsible for cellular energy in the form of. To maintain an adequate blood pressure, three components of the circulatory system must respond effectively: the, and. The formula for calculating cardiac output is: cardiac output is the product of times. Baroreceptors are located in the and, whereas chemoreceptors are located in the and. With the progression of shock, damage at the and level occurs when the blood pressure drops. Two crystalloids commonly used for fluid replacement in hypovolemic shock are: and. Three medical management goals for cardiogenic shock are:, and. A new cardiac marker for ventricular dysfunction, increases when the ventricle is overdistended. Circulatory shock can be caused by: and. Neurogenic shock can be caused by:, or. Discuss the cellular changes that occur with shock, especially the movement of water and electrolytes through the membrane. Compare and contrast the clinical findings in the three states of shock: compensatory, progressive, and irreversible. Distinguish between the advantages and disadvantages of administering crystalloid and/or colloid solutions as fluid replacement for shock. Discuss nursing assessment activities to monitor possible complications of fluid administration. Discuss the action and disadvantages of common vasoactive agents used to treat shock: sympathomimetics, vasodilators, and vasoconstrictors. Flow Chart: Blood Pressure Regulation Shock A drop in blood pressure (baroreceptor response) release of and from # and =. A drop in blood pressure (response by kidneys) release of the enzyme converts to from the adrenal cortex promotes retention of and. Mazda is a 57-year-old, 154-lb (70-kg) patient who was received on the nursing unit from the recovery room after having a hemicolectomy for colon cancer. Mazda was alert, yet anxious; his skin was cool, pale, and moist; and his abdominal dressings were saturated with bright red blood. Vital signs were blood pressure, 80/60 mm Hg; heart rate, 126 bpm; and respirations 40 breaths/min (baseline vital signs were 130/70, 84, and 22, respectively). The nurse understands that hypovolemic shock will occur with an intravascular volume reduction of 15% to 30%. The nurse knows that the progressive pattern of changes in vital signs is more important than the exact readings. A in pulse rate, followed by a in blood pressure, is indicative of shock. The nurse understands that a systolic reading of 80 mm Hg is serious, because a systolic reading lower than mm Hg in a normotensive person indicates well-advanced shock. An output less than mL/h is indicative of decreased glomerular filtration. Nursing interventions include notifying the physician, reinforcing the abdominal dressings, and treating the patient for shock by administering fluids ordered, such as:, and. Dressler had a normal postoperative recovery period until his first afternoon on the unit. He was shaking with chills, his skin was warm and dry, yet his extremities were cool to the touch. Dressler was probably experiencing septicemia, immediately notified the physician. Septic shock has traditionally been caused by gram-negative organisms such as:. The nurse knows that the mortality rate associated with septic shock is between % and %. The nurse expects that the physician will request body fluid specimens for culture and sensitivity tests. The nurse prepares to collect specimens of:, and. The two most common and serious side effects of fluid replacement are: and. The etiology of cancer can be associated with specific agents or factors such as: a. He is white, has been employed as a landscaper for 40 years, and has a 36-year history of smoking one pack of cigarettes a day. To reduce nitrate intake because of possible carcinogenic action, the nurse suggests that a patient decrease his or her intake of: a. An endoscopic procedure can be used to remove an entire piece of suspicious tissue growth. A patient is scheduled for an outpatient procedure whereby liquid nitrogen is used to freeze a cervical cancer. Surgery done to remove lesions that are likely to develop into cancer is known as: a. The incorrect rationale for the effectiveness of radiation therapy is its ability to: a. Radiation therapy for the treatment of cancer is administered over several weeks to: a. When a patient takes vincristine, a plant alkaloid, the nurse should assess for symptoms of toxicity affect ing the: a. Initial nursing action for extravasation of a chemotherapeutic agent includes all of the following except: a. The most frequently occurring gram-positive cause of infection in cancer patients is: a. List, in order of frequency, the three leading causes of cancer deaths in the United States: men (, and ); women (, and ). The two key ways by which cancer is spread are: the and the. The single most lethal chemical carcinogen that accounts for 30% of all cancer deaths is:. Two examples of an inherited cancer susceptibility syndrome are: and. List four of seven cancers that are associated with an increased intake of alcohol:, and. Three dietary substances (cruciferous vegetables) appear to reduce cancer risk:, and, whereas, and tend to increase the risk of cancer. Identify five substances produced by the immune system in response to cancer cells:, and. Oral mucosal membrana:, and. Stomach or colon:, and. Bone marrow-producing sites:, and. List five of nine signs that indicate that an extravasation of an infusion of a cancer chemotherapeutic agent has occurred:, and. The two most common side effects of chemotherapy are: and. Myelosuppression, caused by chemotherapeutic agents, results in, and an increased risk of and. Three chemotherapeutic agents that are particularly toxic to the renal system are:, and. Distinguish between the terms invasion and metastasis as they relate to the spread of cancerous cells. Distinguish between primary and secondary prevention of cancer, and provide an example of how nurses can participate in both types of prevention. Explain the modes of action for the following two classifications of chemotherapeutic agents: cell cycle specific and cell cycle-nonspecific. Discuss the nursing role in responding to a hypersensitivity reaction to a chemotherapeutic agent. Discuss the nursesmanagement of patientspre and post-bone marrow transplantation. Select at least three nursing diagnoses and collaborative problems for patients with cancer and discuss nursing interventions for treatment. Describe the factors and underlying mechanisms that predispose a cancer patient to infection.

Those who and abnormal clinical and laboratory findings as R52 treat cancer pain find that three months is sometimes Pain Not Elsewhere Classified impotence while trying to conceive cheap kamagra oral jelly 100mg on line. Pain that persists for a given length of time provision for conditions that are not well described would be a simpler concept impotence forums cheap kamagra oral jelly online american express. Other repair may never be complete; presence or absence of irrationality (psychosis erectile dysfunction heart buy kamagra oral jelly 100 mg online, neuro for example erectile dysfunction and smoking buy 100 mg kamagra oral jelly with mastercard, neuromata in an amputation stump con xi stitute a permanent failure to heal that may be a site of associated with it is not a focus of attention once the persistent pain erectile dysfunction medication natural order kamagra oral jelly 100mg fast delivery. Scar tissue around a nerve may be patient has consulted a physician or surgeon and the fully healed but can still act as a persistent painful condition has been properly diagnosed erectile dysfunction caused by jelqing generic kamagra oral jelly 100mg free shipping. Such changes can make it even including some of the foregoing erectile dysfunction keeping it up purchase kamagra oral jelly in india, have a fairly difficult to say that normal healing has taken place erectile dysfunction topical treatment 100 mg kamagra oral jelly with amex. Sometimes, quests to appropriate colleagues, of whom enough as with spinal stenosis, the main problem with the replied to get this work underway. Alternatively, pain in the Emphasis was placed on the description of the face, or anywhere else, for which a diagnosis has not pain. By contrast, this volume cannot provide a guide yet been determined can be given a regional code in to treatment, but where the results of treatment may which the second digit will be 9 and the fifth digit 8, be relevant to description or diagnosis they are noted. This reflects the decisions of the individual frequency and troublesome quality of the disorders. It must be gory such as acceleration-deceleration injury (cervical emphasized, however, that the editors cannot decide sprain) may be used, covering several individual on their own which conditions to incorporate and muscle sprains, some of which are also described which to reject. One such term is Atypical psychiatric diagnoses and to indicate the contribution, Facial Pain. In this does not describe a definite syndrome but is used approach pain is seen as a unitary phenomenon expe variously by different writers to cover a variety of rientially, but still one that may have more than one conditions. As in the rest of the identification and description of different types of the classification, they require recognition of the site, headache. Be this direction, but back pain remained amorphous, and cause of the use of variable axes, particularly the first xiv and fourth axes, where as many as ten different en Bonica, J. Identify yourself and your address and dis cipline at the head of a sheet of paper. For a fresh topic please provide a new page identified in the same fashion as for the first one. Pelvic region 700 Accordingly, it is shown as an X throughout the Anal, perineal, and genital region 800 tabulation of codes in association with descriptions More than three major sites 900 here. Relatively because both phenomena are present, the letter C (for generalized syndromes are presented first, followed by Combined spinal and root pain) is preferred. In these circumstances the R codes have been lesions of the brachial plexus, which used to occupy provided for relative completeness but will rarely, if Group X, have been placed with pain in the shoulder, ever, be required. X5c (vascular) If three or more major sites are involved, code first digit as 9: 903. Cervical pain may be subdivided into upper cervical the coding system and schedules provide categories pain and lower cervical pain by subdividing the above for both spinal pain and radicular pain when they are region into two equal halves by an imaginary transverse associated with each other or when they occur plane. Subsequent to the schedule of classifications for the Thoracic Spinal Pain: Pain perceived as arising cervical and thoracic regions a more detailed description from anywhere within the region bounded superiorly by of radicular pain and radiculopathy is provided. Pain located over the posterior chest wall but lateral to the above region is best described as posterior chest wall pain to distinguish it from thoracic spinal pain. The location of the pain Lumbar Spinal Pain: Pain perceived as arising can be described in terms similar to those used to from anywhere within a region bounded superiorly by an describe the five regions of the vertebral column, i. Lumbosacral Pain: Pain perceived as arising from a region encompassing or centered over the lower third of the lumbar region as described above and the upper third of the sacral region as described above. Combined States: Spinal pain not satisfying either the primary or conjunctional descriptors defined above but otherwise encompassing more than one spinal region should be described in composite forms. Consequently, without detracting from the intent of the above definition, referred pain can be defined more strictly in neurological terms as pain perceived as arising or occurring in a region of the body innervated by nerves or branches of nerves other than those that innervate the actual source of pain. Referred pain in the lower limb may be qualified using standard anatomical terms that describe its Scapular Pain: Pain perceived as arising topographic location, viz. In this section, individual descriptions of the quality Ectopic activation may occur as a result of mechanical of pain have not been presented throughout the deformation of a dorsal root ganglion, mechanical descriptions of syndromes. This is because pain in the stimulation of previously damaged nerve roots, back tends not to discriminate much among the different inflammation of a dorsal root ganglion, and possibly by diagnostic groups. Acute back pain is often cramping or knifelike, but Ectopic activation results in pain being perceived as may be merely dull or aching. It also tends to be the disease processes that cause radicular pain are made worse by movement. Cervical angina, Spine, I (1976) 28 Smyth and Wright 1959; McCulloch and Waddell 1980). The symptom of spinal pain should be described in For conditions that are considered still controversial terms of its location and nature using the definitions or unproven, the Committee has formulated criteria that supplied on pages 11 and 12; these descriptions, should be fully satisfied before the diagnosis is ascribed. In adopting this stance, the Committee seeks to an anatomic axis specifying the structure that is the mediate contemporary controversies by on the one hand source of pain, including its regional or segmental acknowledging novel or controversial entities while on location, and a pathologic axis specifying the the other hand outlining criteria that if satisfied should pathological basis for the cause of pain. However, it posterior thigh and calf due to stenosis of the L4-5 is mentioned in the context of spinal pain for not intervertebral foramen. Foraminal stenosis due to vertical subluxation of the When associated with spinal pain, the spinal pain intervertebral joint, osteophytes stemming from the warrants an independent classification to which the zygapophysial joint or intervertebral disk, buckling of classification of the radicular pain may then be the ligamentum flavum, or a combination of any of appended. Radiculitis caused by inflammatory exudates leaking extent or distribution of referred pain has no bearing on from an intervertebral disk in the absence of frank the underlying cause of the spinal pain. Radiculitis caused by exudates from a zygapophysial (unless one believes the patient is suffering from two joint. Diagnosis: the diagnosis can be ascribed on clinical In compiling a taxonomy based on anatomical and grounds alone if the appropriate clinical features are pathological axes, the Committee has endeavored to present. Chronic inflammation of the nerve root complex and numbness and weakness, confirmed objectively by its meningeal investments. The former relates to objective Radiculopathy may occur in isolation or in association neurological signs due to conduction block. There is no physiological or in axons of a spinal nerve or its roots either directly by clinical evidence that referred pain can be caused by the mechanical compression of the axons or indirectly by same processes that underlie radiculopathy. Thoracic Spinal or Radicular Pain Syndromes X-1 Thoracic Spinal or Radicular Pain Attributable to a Fracture S/C codes R only/in addition X-1. XlnR X-2 Thoracic Spinal or Radicular Pain Attributable to an Infection S/C codes R only/in addition X-2. X2bR X-3 Thoracic Spinal or Radicular Pain Attributable to a Neoplasm S/C codes R only/in addition X-3. X4 X-8 Thoracic Spinal Pain of Unknown or Uncertain Origin S/C codes R only/in addition X-8. Where spinal and radicular pain occur, the suffixes S and R are used, respectively. For example, pain due to a prolapsed disk causing both local spinal and local radicular pain in the neck would be coded 133. Sacral Spinal or Radicular Pain Syndromes * Note: S codes include R codes unless specified as S only. X9fS (See also 1-16) * the asterisk is inserted in spinal and radicular codes where no letter is required in the sixth place. Summary of Essential Features and Diagnostic Criteria Site Chronic distal burning or deep aching pain with signs of Usually distal (especially the feet) with burning pain, but sensory loss with or without muscle weakness, atrophy, often more proximal and deep with aching. X8a Legs: unknown or other of a single affected nerve (b) deep aching, especially X03. Distal burning and deep aching pains are often long Pain is not referred to the absent body part but is per lasting, and the disease processes are relatively unre ceived in the stump itself, usually in region of transected sponsive to therapy. Pain often Page 40 elicited by tapping over neuroma in transected nerve or from person to person. This title is being introduced to cover the painful syn dromes which formerly were described under the head Main Features ings of Reflex Sympathetic Dystrophy and Follows amputation, may commence at time of amputa Causalgia. It is taken to be pain tions in hair growth, and loss of joint mobility may de that is maintained by sympathetic efferent innervation or velop. Guarding of the af servation that in certain cases sympatholytic interven fected part is usually observed. Edema is usually present and may be soft or hard, and either hyperhidrosis or hypohidrosis may be Pathology present. Continuing pain, allodynia, or hyperalgesia with tions in hair growth, and loss of joint mobility may oc which the pain is disproportionate to any inciting cur. The presence of continuing pain, allodynia, or hyper injury but may be delayed for months. The nerves most algesia after a nerve injury, not necessarily limited to commonly involved are the median, the sciatic, the the distribution of the injured nerve. Anticonvulsant drugs help in abnormal sensibility to temperature and to noxious some instances, especially carbamazepine and particu stimulation. In consequence their social life and work be restricted simply to the face or part of one extremity. Allodynia in response to exter nal stimuli and movements may hamper rehabilitation System and prevent activities, thus making the patient physically Central nervous system. Pain Quality: many different qualities syringomyelia, syringobulbia, and spinal vascular mal of pain occur, the most common being burning, aching, formation, and may occur after operations like cor pricking, and lancinating. Some patients have no cated at any level along the neuraxis, from the dorsal pain at rest but suffer from evoked pain, paresthesias, horn of the spinal cord to the cerebral cortex. The pain can be augmented by startle sometimes may involve the medial lemniscal pathways. Intensity: varies Regional pain attributable to a lesion or disease in the from mild but irritating to intolerable. Essential Features Site Pain in the relevant distribution of slowly progressing Pain in shoulder, arm, chest, or leg, rarely in the face, muscle weakness and wasting and impairment of sensa occasionally bilateral. It may be a periodic diffuse dull ache but some Code times, and particularly when the pain is situated in fore 007. Associated Symptoms Polymyalgia Rheumatica (1-8) Muscular weakness in affected region. Definition Signs There is commonly muscle wasting beginning in small Diffuse aching, and usually stiffness, in neck, hip girdle, muscles of the hand and ascending to the forearm and or shoulder girdle, usually associated with a markedly shoulder-girdle with fasciculation and an early loss of raised sedimentation rate, sometimes associated with tendon reflexes. Primary fibromyalgia, without important associated dis Complications ease, is uncommon compared to concomitant fibromyal Blindness from giant cell arteritis. Symmetrical proximal limb myalgia and severe stiff though pain in the trunk and proximal girdle is aching, ness. Low grade symp Skinfold Tenderness: the rolling of the skin and subcu toms may be increased by mental stress or fatigue. In addition, axial skeletal pain (cervical spine Cold, poor sleep, anxiety, humidity, weather change, or anterior chest or thoracic spine or low back) must be fatigue, and mental stress intensify symptoms in 60 present. Pain in 11 of 18 Tender Point Sites on Digital Pal Signs pation Tender points, widely and symmetrically distributed, are the characteristic sign of the syndrome. Pain, on digital palpation, must be present in at least 11 of the following 18 tender point sites: Relief Relief may be provided by reassurance and explanation Occiput: bilateral, at the suboccipital muscle insertions. Blood flow during exercise is reduced, Gluteal: bilateral, in upper outer quadrants of buttocks in and decreased oxygen uptake in muscles has been noted. Two studies have found increased levels of substance P Greater Trochanter: bilateral, posterior to the tro in the cerebrospinal fluid of patients. The syndrome may begin in childhood or ject must state that the palpation was painful. X8a Main Features Diffuse aching, burning pain in joints, usually moder References ately severe; usually intermittent with exacerbations and Wolfe, F. The condition affects about 1% of the popu College of Rheumatology 1990 criteria for the classification of lation and is more common in women. Diagnostic crite fibromyalgia: report of the Multicenter Criteria Committee, ria of the American Rheumatism Association describe Arthritis Rheum. Specific myofascial syndromes may occur in any volun tary muscle with referred pain, local and referred tender Classical rheumatoid arthritis requires seven criteria to ness, and a tense shortened muscle. Inflammation may affect eyes, demonstration of a trigger point (tender point) and re heart, lungs. Chronic destruction and joint de proximal pathology such as nerve root irritation. Others may be coded as required according to individual muscles that are Relief identified as being a site of trouble. Aching, burning joint pain due to systemic inflammatory disease affecting all synovial joints, muscle, ligaments, Essential Features and tendons in accordance with diagnostic criteria be Aching, burning joint pain with characteristic pathology. Simultaneous soft tissue swelling or fluid in at least There is deep, aching pain which may be severe as the three joint areas observed by a physician. At least one area of soft tissue swelling or effusion in rest and later nocturnal pain. Simultaneous involvement of Stiffness occurs after protracted periods of inactivity and the same joint areas as defined in 2 above in both sides in the morning but lasts less than half an hour as a rule. Only about 25% of those with radiographic changes any method for which any result has been positive in report symptoms. Signs Clinically, joint line tenderness may be found and crepi Differential Diagnosis tus on active or passive joint motion; noninflammatory Systemic lupus erythematosus, palindromic rheumatism, effusions are common. Later stage disease is ac mixed connective tissue disease, psoriatic arthropathy, companied by gross deformity, bony-hypertrophy, con calcium pyrophosphate deposition disease, seronegative tracture. X-ray evidence of joint space narrowing, spondyloarthropathies, hemochromatosis (rarely). Joint rest in the Deep, aching pain due to a degenerative process in a early stages relieves the pain. Physical Disability Site Progressive limitation of ambulation occurs in large Joints most commonly involved are distal and proximal weight-bearing joints. Page 49 Relief Diagnostic Criteria Acute attacks respond well to nonsteroidal anti No official diagnostic criteria exist for osteoarthritis, inflammatory drugs, with or without local corticosteroid although criteria have been proposed for osteoarthritis of injections. Attacks of aching, sharp, and throbbing pain with acute or chronic recurrent inflammation of a joint caused by Differential Diagnosis calcium pyrophosphate crystals. Acute severe parox Signs ysmal attacks of pain occur with redness, heat, swelling, Aspiration of calcium pyrophosphate crystals from the and tenderness, usually in one joint. Shoulders, hips, and wrist joints are incompletely leaving chronic, progressive crippling ar affected next most often. In the adult, spontaneous hemorrhages Diagnostic Criteria and pain occur in association also with minor or severe 1. The in an aspirate or biopsy of a tophus by methods simi pain associated with them is extremely difficult to treat lar to those in 1. Reactive and Chronic Hemarthrosis: ing occurs into a muscle or potential space. Numerous psy control using analgesics and transcutaneous nerve stimu chosomatic complaints are associated with the chronic lation is also useful, and physiotherapy is of consider and acute pain of chronic synovitis, arthritis, and he able assistance in managing both symptoms and signs. Chronic Destructive Signs Arthropathy: Replacement therapy is of little assistance Reactive Synovitis: There is a chronic swelling of the in relieving pain and disability. Carefully selected anti joint with a boggy consistency to the swelling, which inflammatory agents and rest are the major therapies of is tender to palpation. In these include regular physiotherapy, exercise, and mak chronic arthropathy there is cartilage destruction and ing full use of available social and professional opportu narrowing of the joint space. Cysts, rarefactions, subcondy lar cysts, and an overgrowth of the epiphysis are noted. Social and Physical Disability this progresses through to fibrous joint contracture, loss Severe crippling and physical disability, with prolonged of joint space, extensive enlargement of the epiphysis, school and work absences, have traditionally been asso and substantial disorganization of the joint structures. Phase one involves an early synovial soft duction of concentrated clotting factor transfusions has tissue reaction caused by intraarticular bleeding. Associated with this type of phase two Prevalence: is approximately 3 per 1000 of population. After three or four weeks it is described as mophilic factor deficiency, no other diagnosis is possi itchy or tingling. Relief may be promoted by the use of opioid premedication prior to procedures, Code X34. Complications Burns (1-15) If healing occurs, it is unusual to have persistent pain unless deep structures (muscle, bones, major nerves) are Definition involved. Electrical burns may cause considerable damage Associated Symptoms to deeper tissues by direct effect and by occlusion of Many patients have anxiety, depression, irritability, or blood vessels. Anxiolytics may help but should be Differential Diagnosis avoided since some patients become depressed and oth Possibly hysterical conversion pain or pain of psycho ers develop dependence. Tricyclic antidepressants are logical origin may prolong or exacerbate the original frequently very useful. This may be more important in Complications work-related injuries or where there is litigation. Note: b coding used to allow the a coding to be em ployed if an acute syndrome needs to be specified. Intensity: from sence of an organic or delusional cause or tension mild to severe. No physical signs point over the cranium or face, can involve tongue or or laboratory findings. Complications In accordance with causal condition; usually lasts for a Main Features few weeks in manic-depressive or schizo-affective psy Prevalence: true population prevalence unknown. Estimates of 11% and 43% have been found remits to be succeeded by a paranoid or schizophrenic in psychiatric departments, depending on the sample. Time Pattern: Pain is usually con Etiology tinuous throughout most of the waking hours but fluctu Manic-depressive, schizophrenic, or possibly other psy ates somewhat in intensity, does not wake the patient choses. Those required for diagnosis are pain, without a lesion Associated Symptoms or overt physical mechanism and founded upon a delu Loss of function without a physical basis (anesthesia, sional or hallucinatory state.

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• Secretin stimulation test
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• Muscle weakness
• Measles
• Microscopic examination of mouth scrapings

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There is however some scope to minimize the spread during an epidemic with isolation and respiratory precautions during outbreaks. While some of the serious neurological complications are unavoidable in a 26 rd Survival and Austere Medicine 3 ed 2017 small number of patients, basic care such as maintaining hydration can also prevent complications such as dehydration. The greatest advances in medicine Several years ago the British Medical Journal ran a poll trying to identify top medical advances of the last 200 years. Each of these four references gives you insights, one way or another, into low-tech austere health care. First, it gives you an insight into the likely clinical problems that you may see in a survival situation, and how much can be dealt with in that sort of austere environment. Second, it demonstrates how medically speaking it is the small things and simple knowledge which save lives and some of the biggest killers can be mitigated with these relatively low level interventions or strategies. These topics are well covered in 100s of books about getting fit and staying healthy, but if you do not take some action in this regard all your other preparations may be in vain when you drop dead of a heart attack from the stress of it all. Not only will this benefit you, but also the lives of many others whom you aim to help! Once you understand how the body is put together and how it works, you are in a much better position to understand disease and injury and apply appropriate treatments. Then you should try and obtain some more advanced medical education and practical experience. The ideal is a trained health care professional and anything else is taking risks, but in a survival situation any informed medical care is better than no medical care. Formal Training Professional medical training: the gold standard option is undertaking college study in a medical area. While in theory the content is the same, there is wide variation in quality of teaching over different sites. Covering similar material in much less detail it is a good start but not overly in-depth. Various community education groups offer the course and the Red Cross also offers a variation. These courses give a basic background in anatomy and physiology, medical terminology, and the essentials of emergency medicine. Some other providers of these types of courses include: Insight training. There are probably several other more advanced courses available but we have had difficulty obtaining information on them. For relatively little time per month you get good training and access to basic equipment. They offer the basic Immediate Care course and the more advanced Pre-hospital Emergency Care course. The word of mouth of someone you trust is probably the best way to try and find a good course. Do they have arranged clinical placements or do you learn everything on a mannequin Wilderness First Responder: this a 10-day course offered by the Wilderness Medicine Institute at various sites around Australia. Not delivered at a particularly advanced level, but goes well beyond a standard first aid course and is focused on remote work. While not the same as hands on experience, simply experiencing the sights and sounds of illness and injury will help prepare you for if you must do it yourself. It is common for doctors to be asked to talk to various groups on different topics so an invitation to talk to a "tramping club" about pain relief or treating a fracture in the bush would not be unusual. Volunteering: Many ambulances and fire services have volunteer sections or are completely run by volunteers. It is also often possible to arrange "ride-alongs" with ambulance and paramedic units as the 3rd person on the crew and observe patient care even if you are not able to be involved. Someone within the group, ideally with a medical background, should be appointed medic. The medic should also be responsible for the development and rotation of the medical stores, and for issues relating to sanitation and hygiene. Regarding medical matters and hygiene their decisions should be absolute, and their advice should only be ignored in the face of a strong tactical imperative. In the next few pages we cover some of less obvious, but important concepts around providing health care. Risk Assessment/Needs Assessment: As alluded to in the introduction what you plan for depends on what you are worried about. As part of your medical preparations you should undertake a detailed needs assessment. What they complained of, the history and examination, what you diagnosed, and how you managed them, a very clear note of any drugs you administer, and a description of any surgical procedure you perform should all be recorded. First is that for the ongoing care of the patient often it is only possible to make a diagnosis by looking over a course of events within retrospect and it is also important to have a record of objective findings to compare to recognise any changes over time in the patient condition. When things return to normal it may be important to justify why certain decisions were made. It is also useful to have medical records on members of your group prior to any event including things such as blood groups and any existing or potential medical problems. For both functional and infection control reasons, it is worth having a dedicated area. Within civilian peace time ethical values, the approach is simple = the greatest good to the greatest number. Do you pour all of your resources into possibly saving your wife/ child /best friend now, who has a 10% chance of survival with maximal therapy or do you save your resources and potentially save 10 other people who have a 90% chance of survival with minimal therapy in the future. The Doctor/Medic-Patient Relationship: Another important area is confidentiality and trust. What if the outcome if you do nothing is death, how much should you do with limited training But you need to have thought about how far you will go and under what circumstances. If you then list each component in a flow chart you can perform the complicated task by completing each of the simpler tasks. We are not trying to be glib here, it is important to understand that many relatively complicated things in medicine can be easily broken down into much simpler individual parts. Writing a checklist immediately before you need to do something is not ideal, but overtime preparing detailed checklists which cover a procedure is not hard. Step 1 of the technical procedure Step 2 of the technical procedure Have I done everything need after the procedure Fortunately, it is possible to manage 90% of medical problems with only a moderate amount of basic equipment and drugs. In a remote austere situation, it can be managed by manipulation with analgesia, and immobilization with an external splint for 6-8 weeks, and as a result the patient may be in pain for a few weeks, and have a limp for life but still have a functioning leg. Although in each case management maybe sub-optimal and may have some risk in a survival situation it can be done and may be successful with limited medication and equipment. However, there are some core fundamentals (every electrician has a screwdriver for example). Likewise, every medical provider has tape and gauze in their kit regardless of what else. Below are some suggestions for legally obtaining medicines for use in a survival medicine situation. Demonstrate an understanding of what each drug is for and that you know how to safely use it. While it is unlikely that a single course of antibiotics would be a problem, extreme care should be exercised with more uncommon drugs or large amounts. The best way is to ensure that the medications are still sealed in the original manufactures packaging. We cannot recommend this method, but obviously for some it is the only viable option. There are some dogs that have recurrent problems treatable with antibiotics staph skin infections, bacterial gastroenteritis, etc. Some may be willing to dispense antibiotics (a short course of metronidazole) if their client is taking a known anxious dog on a trip and may develop antibiotic responsive diarrhoea. A discussion with a dozen doctors suggests that options ii, iii and iv would be acceptable to most of those spoken to . In fact, many were surprisingly broad in what they would be prepared to supply in those situations. Several commercial survival outfitters offer first aid and medical supplies; however, I would shop around before purchasing from these companies as their prices, in my experience, are higher than standard medical suppliers. The most important point is to be able to demonstrate an understanding of how to use what you are requesting. The commercial kits cost 2-3 times more than the same kit would cost to put together yourself and frequently contain items which are of limited value. Between Amazon, eBay and other online wholesalers it is possible to purchase all non-medication items (and most the non-prescription medications) for considerably less than in pre assembled kits. We cannot endorse using medications which have expired, but having said that, most medications are safe for at least 24-36 months following their expiration date. As with food the main problem with expired medicines is not that they become dangerous but that they lose potency over time and the manufacturer will no longer guarantee the dose/response effects of the drug. Broadly, "toxicity" when talking about drugs generally, means an increase in adverse effects as opposed to the drug becoming poisonous, i. Regarding toxicity in expired medication, we are referring to toxicity in the more common usage i. However, it is thought that the toxicity with degrading tetracycline was due to citric acid, which was part of the tablet composition. Citric acid is no longer used in the production of tetracycline, therefore, the dangers of toxicity with degradation of tetracycline is no longer a problem. There are almost certainly other medications, which do break down, and become toxic after their expiry date. If you have ever been hospitalised or had a close relative in hospital for even a relatively minor problem look at the billing account for medical supplies and drugs to get an idea how much can be consumed with even a relatively small problem. Lack of Supply and the Skill of Improvisation: the key tenant of austere medicine is improvisation. If in a fixed location consider buying a rolling mechanics tool chest and using it as a crash cart. When you have selected the bags that suit you, one approach to organising your medical supplies is: Personal bag/blow out kit: Carry this with you at all time. It contains more advanced first aid gear and some medical items than a basic level medical kit. A brief note about airway management: Before describing in detail packing lists for several possible kits we should discuss briefly airway management and the equipment associated with it. If simple devices are not sufficient then the patient is likely to die regardless and introducing relatively complicated airway devices will not help. If your community plans to be self-sufficient farmers and ranchers who garden, cut firewood, make their own tools and butcher livestock preparing for wound care and trauma will be more of priority. In this section, we will look at two different approaches to setting up medical kits. There is also frequent confusion over which surgical instruments to buy, how many of each, and what some do, so we have gone into more detail looking at some possible surgical kits, and what level of care can be delivered with each. The main problem likely to arise is covering the cost of the extra medication which may be expensive and not covered by insurance. If you have a chronic medical problem such as asthma, you must ensure you have an adequate supply of your medication. With relatively simple equipment and supplies you can stop bleeding, splint a fracture, and provide basic patient assessment. Often when combined with basic airway opening manoeuvres these are sufficient to maintain the airway of an unconscious person. The face shields are recommended if you need to perform mouth-to-mouth on someone. It is also useful for irrigating eyes which have been exposed to chemicals, dust, or other foreign bodies. The second reason is to try and reduce infection from the bacteria you have on your hands when dealing with wounds. They give you the ability to provide basic airway management, clean a wound, control bleeding, and splint, and immobilise fractures and sprains. Between this and the larger more comprehensive advanced kit there is a wide spectrum depending on knowledge or experience. A smaller medical kit for your bug-out bag could be made up from the above by adding some medications (such as acetaminophen, Benadryl, and some Loperimide) and some instruments to a small first aid kit. Small sheets of Tegaderm (transparent / adhesive dressings) are useful as an alternative and provide a clear view of the wound. Povidone solution (iodine solution) you can clean and disinfect wounds and at a pinch, do the same for water. A big risk of infection is potentially fatal so you really need the ability to clean. You can pack rolls of Kerlix gauze and cut squares off as you require them and it reduces the need to carry individual squares. Elasticated (cohesive) roller bandages to bandage on dressings, to strap an ankle, to impregnate with crushed up gib-board to make a homemade plaster bandage to plaster a broken arm. You need all to suture properly but they do enable you, when combined with a scalpel blade, to do most minor surgery.