By Y. Nerusul. University of California, Los Angeles. 2018.

Describe medical poisoning caused by acetaminophen generic tamoxifen 20 mg online, salicylates & barbiturates with their toxicological laboratory investigations generic 20 mg tamoxifen amex. Explain the environmental toxins like carbon monoxide buy cheap tamoxifen 20 mg on line, & food born toxins with their toxicological laboratory investigations buy tamoxifen 20 mg cheap. Understand the common drugs of abuse like alcohol, nicotine, & opioids with their toxicological laboratory investigation. Introduction The rapid industrialization and successful green revolution have introduced a large variety of chemicals into our environment. The species and varieties of environmental chemicals are as many as we can visualize. We may however, characterize them as: industrial chemicals which include organic and inorganic substances, metals, gases, fumes, solvents, and intermediates; agrochemicals, a major input of farming industry, comprising a variety of pesticides, fertilizers and growth promoters; pharmaceuticals, in innumerable number; and food additives, plastics, cosmetics etc. This chapter is meant for discussion of some of the important toxicants of public health hazard. Industrial toxicants Industrial chemicals causing diseases have existed ever since man began manufacturing on a large scale & during the industrial revolution occupational diseases became common. Many of the chemicals used in industry are chemically reactive molecules & are likely to interact with biological systems & cause damage in some cases at the site of exposure. There are now many thousands of chemical substances used in industry ranging from metals & inorganic compounds which risk people who work with it. Heavy metal poisoning Some metals such as iron are essential for life, while others such as lead are present in all organisms but serve no useful biologic purpose. Some of the oldest diseases of humans can be traced to heavy metal poisoning associated with metal mining, refining and use. Lead Poisoning Lead poisoning is one of the oldest occupational and environmental diseases in the world. Despite its recognized hazards, lead continues to have widespread commercial application (like ingested lead paints, pica, and lead pipes etc…). Environmental lead exposure, ubiquitous by virtue of the anthropogenic distribution of lead to air, water and food, has declined considerably due to diminished use of lead in gasoline and other applications. Lead is slowly but consistently absorbed via the 52 Toxicology respiratory and gastrointestinal tracts. Lead exerts multi systemic toxic effects through at least three mechanisms by; o Inhibiting enzyme activity (e. Lead interference with the biosynthesis of heme The sign and symptoms of lead poisoning may include anorexia, apathy, behavioral changes, persistent vomiting, convulsions (acute poisoning) & ataxia, wrist & ankle drop, chronic nephritis (chronic poisoning) Laboratory findings A. It is not present in iron deficiency anemia so it is valuable for differentiating the two forms of anemia. B) Serum Lead level Levels of 30-60µg/dl are regarded as significant for lead toxicity. Levels below the toxic range do not rule out toxicity because 90% of lead is stored in bone. Unexpectedly high lead levels may be due to contamination of the blood specimen with lead prior to laboratory analysis. Protoporphyrin accumulates as a result of the lead inhibition of the enzyme ferrochelases, which binds to porphyrin, forming hemoglobin. Lead inhibition of the enzyme coproporphyrinogen oxidase has been proposed as a cause for increased coproporphyrin. Spot 50 µl of acidified solution on to phase-separating filter- paper and add 50 µl of sodium rhodizonate solution. However, the test is not specific: barium salts give a brown colour and a number of other metals also give coloured complexes. Sensitivity Lead, 2 mg/l Quantitative tests Principle 56 Toxicology Whole blood that represents calibrators, controls, or victim specimens is mixed with ammonium phosphate and Triton X-100 to prepare it for graphite furnace atomic absorption analysis. The final step of analysis causes vaporization of lead, which absorbs energy at the 283. Absorbance of energy at this wavelength is specific for lead and proportional to its concentration.

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It is believed that when the patient is flat in bed tamoxifen 20 mg fast delivery, respiration often is more free and turning is easier cheap 20mg tamoxifen with visa, advantages that are important in the prevention of respiratory complications discount 20mg tamoxifen amex. Prone Position: In the prone position buy 20mg tamoxifen visa, the client lies on the abdomen with the head turned to one side. Both children and adults often sleep in this position, sometimes with one or both arms flexed over their heads (Figure 34­16). When used periodically, the prone position helps to prevent flexion contractures of the hips and knees, thereby counteract­ing a problem caused by all other bed positions. The prone position also promotes drainage from the mouth and is especially useful for unconscious clients or those clients recovering from surgery of the mouth or throat. Fowler’s Position: Off all the positions prescribed for a patient, perhaps the most common, as well as the most difficult to maintain is the Fowler’s position. The patient’s with abdominal drainage usually are put in Fowler’s position as soon as they have recovered conciousness, but great caution must be observed in raising the bed. Hand washing is a vigorous, brief rubbing together of all surfaces of hands lathered in soap, followed by rinsing under a stream of water. The purpose is to remove soil and transient organisms from the hands to reduce to microbial counts over time. Situation for hand washing: Garnerand Favero recommend that nurses wash hands in the following situations. Medical Hand Washing Equipments: 1) Easy to reach sink with warm running water 2) Antimicrobial soap / Regular soap. Use circular movements to wash palms, back of hands, wrists, forearms and interdigital spaces for 20­25 Seconds. Ask the assisting nurse to bring the gown over shoulders 3) The assisting nurse fastens the ties at the neck. Assess the patients for following: § Muscle strength § Joint mobility and contracture formation(arthritis) § Paralysis or paresis § Orthostatic hypotension(risk of fainting) § Activity tolerance § Level of comfort(pain) § Vital signs 2. Assess the patients sensory status § Adequacy of central and peripheral vision § Adequacy of hearing § Loss of peripheral sensation § Cognitive status 3. Assess for any contra indications to lift or transfer § Check for the doctors order § Assess patients level of motivation § Patients eagerness § Whether patient avoids activity § Assess previous mode of transfer § Assess patients specific risk for falling when transferred § Assess special equipments needed to transfer § Assess for safety hazards § Perform hand hygiene § Explain procedure to patient § Transfer the patient After care: § Following each transfer assess the patients body alignment, tolerance, fatigue, comfort § If the patient is transferred to bed after transfer, side rails are raised 41 § If the patient is transferred to wheel chair the brakes are released before moving the patient § Record the procedure accurately. The patients performance is also recorded § Any difficulty of disruption occurred during the transfer is also recorded with date and time § The patients comfort, vital signs are all recorded Procedure: § Transferring a patient from a bed to stretcher § An immobilized patient who must be transferred from a bed to a stretcher requires a three person carry or two person carry § Another method is using a sheet to lift Transferring a patient from a bed to stretcher: § Three of you should stand side by side facing of patients bed § Each person assumes responsibility for one of three areas a) Head and Shoulders b) Hips and thighs c) Ankles § Perform three­person carry from bed to stretcher(Bed at Stretcher level) § Three persons stand side by side facing side of patients bed 1. Each person assumes responsibility for one of three areas: head and shoulders, hips and thighs, and ankles 2. Each person assumes wide base of support with foot closer to stretcher in front and knees slightly flexed 3. Arms of lifters are placed under clients head and shoulders, hips and thighs, and ankles with fingers securely around other side of clients body(see illustration) 4. Have the wheel chair(lock the brakes at its 45° angle to bed § Apply transfer belt(if present) § Ensure that the patient has stable non skid shoes. For a man who has not been able to reach the toilet facilities he may stand at the bedside and void into a plastic of metal receptacle for urine. If he is unconscious or unable to stand at bedside the assistant needs to assist him to use the urinal. Purpose: § Provide a container for collection of urine § To measure the urine output § For observation of color and consistency of urine Indications: For patient with impair mobility due to surgery, fracture, injury Elderly man (aging impairs micturation) may require urinal more frequently to avoid urinary incontinence For mobile person who is able to go to bathroom, does not require urinal. The pan is approximately 5cm deep Fracture pan Designed for patients with body or leg casts, the shallow upper end approximately 1­3cm deep that slips easily under the patient Offering bedpan A bedpan for patients confined to bed provides a means to collect stool Female bedpan to pass urine and feces, For male bedpans only for defecation Sitting on a bedpan can be extremely uncomfortable. Purposes The nursing assistance paces and removes the bedpan to bed to bed ridden patients For bowel elimination when the patient is not permitted to go out of bed Obtain a stool specimen During bowel training, it facilitates bowel incontinence Indication: For the patients restricted to bed must use bedpan for defecation. To make a ‘reef knot’ take the ends of the bandage one in each hand cross the end in the right hand under and then over the end in the left hand thus making a turn. Then cross the end now in the right hand over and then under the end in the left hand thus making a second turn. Preparation of the Patient § Explain the sequence of the procedure to the patient and explain how the patient can assist you.

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Supplementary Feeding • Wash hands before the preparation of child’s food • Start supplementary feeding when the baby reaches 6 months of age cheap tamoxifen 20mg. It is a means of promoting the health of the women and families and part of a strategy to reduce the high maternal discount 20 mg tamoxifen visa, infant and child morbidity and mortality discount tamoxifen 20mg on-line. Objectives: General: Is to reduce morbidity and mortality of mothers and children by spacing child bearing purchase tamoxifen 20mg fast delivery, preventing unplanned and unwanted pregnancy. Specific: • To increase awareness, knowledge and skills of the community to utilize family planning services, • To increase utilisation of family planning services by households, • To prevent mothers from having too many pregnancies and children • To avert population growth rate, 33 Family Health • Prevent unwanted pregnancies and high risk abortions, • Promote active participation of males in family planning activities. Traditional family planning methods Breast-feeding method: When a mother breast-feeds her baby, the message concerning the feeding goes from the nipple to the vagus nerve and proceeds to the front-part of the pituitary gland in the brain. Then the pituitary gland 35 Family Health initiates the production of prolactin hormone to activate the milk producing glands in the breasts. The prolactin hormone again reduces the secretion of luteinizing hormone which initiates the normal menstrual cycle. The calendar method: If a woman has a regular cycle of 27 days, it is possible to know by subtracting from 27-18 and 27-11 the first and last days of ovulation respectively. Based on this calculation , the woman should avoid sexual intercourse between day 9 and day 19 of the menstrual cycle in order to prevent pregnancy. By the same token, women who have regular menstrual cycles of 28 days, to 30 days should avoid sexual intercourse between 10-17 days and 12-19 days respectively; this time they are safe to do sexual intercourse during the remaining 36 Family Health respective days. Using this natural / traditional method requires a strong discipline, thrust and good understanding between husband and wife or sexual partners. Withdrawal Method: This method uses the withdrawal or the pulling out of the male genital (penis) from the vagina, interrupting sexual intercourse just before ejaculation so that sperm does not enter the vagina. Modern Contraceptive Methods Combined oral contraceptive pills: Combined oral contraceptive is prepared from two hormones, estrogen and progestin. Mechanisms of action • Prevents ovulation; • Thicken cervical mucus making it difficult for the sperm to pass through; • Makes the lining of the uterus too thin for the fertilized egg to implant itself making it difficult for further development. In the first three rows are the combined oral 38 Family Health contraceptive pills, while the seven pills in the last row are body supportive pills made of minerals. Effectiveness • It is highly effective; • Avoids the fear of unwanted pregnancy during sexual intercourse; • Can be taken by any female that has reached puberty-age; • Pregnancy resumes immediately after interrupting the pills; • Prevents extra-uterine pregnancy; • Prevents unwanted pregnancy resulting from casual or unexpected sexual intercourse. Adverse effects • Nausea (the first three months); • Irregular menstruation or missed menses, • Headache; • Tenderness of the breast; • Weight increase; and • It is not the choice for breast-feeding mothers. Emergency contraception: Emergency contraception is a combined oral contraceptive pills method that women can use to prevent pregnancy expected from unprotected sexual intercourse /violence, rape/. However, it should be underlined that the use of such method is only limited to unprotected sexual intercourse, but is never for regular usage. Weaknesses • If previous pregnancy occurs, • Heart diseases, • High blood pressure, • Breast-feeding mother; and • Women who smoke and who are over 35 years old. Progestin only pill The content of progestin in the contraceptive pills is less than what is contained in the combined oral contraceptive pills. Weaknesses • Requires taking one pill every day without interruption and always at exactly the same time of the day and so is hard to always remember; • Less effective to prevent pregnancy compared to the combined oral contraceptive pills; and • Has problems such as irregularity of menstrual cycles, 42 Family Health Who uses single oral contraceptive pills? Procedures in the provision of single oral contraceptive pills: • Introduce yourself and greet politely the family planning service client; • Assess the client’s knowledge about family planning services and ask about her health conditions; • Ask if the client is on menstruation; • Register the client; • Show and demonstrate to the client the single oral contraceptive pills in the package; 43 Family Health • Carefully explain to the client to take one of the following steps; - To start taking the single contraceptive pills 24 hours after her menstruation started; or th - Start on the 5 day of menstrual period; • Carefully explain to the client to take every evening at the same time before sleep or sexual intercourse one pill from the package with water and without chewing; • The client should take regularly contraceptive pill every evening at the same time with or without sexual intercourse; • If the client forgets to take her pill, she must be told to take the missed pill and also continue on her normal schedule; • Even if the client forgets to take two successive pills, she must be told to take pills and continue on her normal schedule. In addition she must be advised to use condom; • A woman must be told to go to the health extension worker to seek advice when she faces health problems while on the single oral contraceptive pills; and • Carefully inform a woman who has received one-month supply of single oral contraceptive pills, to take the pills according to instructions and to come back on the exact date of next appointment. Mechanism of action • Condom holds the sperm and prevents it from spilling in the vagina and the cervix. Weaknesses • Most people are reluctant to use condoms; • Can be broken due to inappropriate use during sexual intercourse; 45 Family Health • Disposal of condoms need precaution • Creates itching feeling on the genitals of some males. Mechanism of action • Prevent ovulation; • Makes cervical mucus too thick and difficult for the sperm to pass through to the uterus; and • Makes the lining of the uterus too thin for the fertilized egg to implant itself. Who can use the injectables Clients who want to delay pregnancy for a specified time period; Clients who cannot take contraceptive estrogen containing contraceptive; Those who want to space birth; Comfortable and better quality contraceptive for many clients; Contraindications: Pregnancy or suspected for pregnancy; Vaginal bleeding that have not been medically cheeked and confirmed for any type of cause; 47 Family Health Breast cancer or suspected for breast cancer; If menstrual cycle has already stopped not because of pregnancy or breast feeding; Liver diseases or gall bladder diseases; Heart diseases; High blood pressure; and Post-natal and breastfeeding mothers should not use at least for six months. Implantable contraceptives: Noreplant is long acting contraceptives that contain progesterone hormone. Mechanism of action • Prevents the release of egg from the ovaries; and 48 Family Health • Thickens the cervical mucus and difficult for the sperm to pass through to the uterus; Advantages • Highly effective in preventing pregnancy; • Serves for a long period and avoids concern about frequent appointments and its daily administration; • Prevents excess menstrual bleeding; • The user can ask for the removal of the implants at any time when she decides to have a child or other reason. Contraindication: • Women suspected for pregnancy; • Those hiving cancer of the uterus, heart diseases and, liver diseases; • Those who have uterine bleeding for unknown causes; and • Are epileptic and are on anti-epileptic drug regularly.

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Purging A technique by which undesirable cells that are present in the blood or bone marrow products are removed cheap 20 mg tamoxifen with mastercard. Pyknotic Pertaining to degeneration of the nucleus of the cell in which the chromatin condenses to a solid purchase tamoxifen 20mg on-line, structureless mass and shrinks cheap 20mg tamoxifen mastercard. These limits are used to determine if a test method is in control buy 20mg tamoxifen free shipping, and to minimize the chance of inaccurate patient results. R (relaxed) structure Conformational change in hemoglobin that occurs as the molecule takes up oxygen. Random access Capability of an automated hematology instrument to process specimens independently of one another; may be programmed to run individual tests (e. The nucleus is often elongated and irregular with a finer chromatin pattern than that of the resting lymphocyte. Often this cell is increased in viral infections; also called a virocyte, or stimulated, transformed, atypical, activated, or leukocytoid lymphocyte. Reagent blank Measurement of absorbance due to reagent alone; eliminates false increase in sample absorbance due to reagent color. Refractive Index The degree to which a transparent object will deflect a light ray from a straight path. Reportable range Range that is defined by a minimum value and a maximum value of calibration material. The calculation corrects the reticulocyte count for the presence of marrow reticulocytes in the peripheral blood. Ribosomes appear singly or in reversibly dissociable units and may be free in the cytoplasm or attached to endoplasmic reticulum. The cytoplasm of blood cells that contain a high concentration of ribosomes stains bluish purple with Romanowsky stains. Ringed sideroblasts Erythroblasts with abnormal deposition of excess iron within mitochondria resulting in a ring formation around the nucleus. Romanowsky-type stain Any stain consisting of methylene blue and its oxidation products and eosin Y or eosin B. This is due to abnormal coating of the cell’s surface with increased plasma proteins, which decreases the zeta potential between cells. Russell bodies A globule filled with immunoglobulin found in pathologic plasma cells called Mott cells (see Mott cell). Schistocyte Fragment of an erythrocyte; a schistocyte may have a variety of shapes including triangle, helmet, and comma. Secondary fibrinolysis A clinical condition characterized by excessive fibrinolytic activity in response to disseminated intravascular clotting. Secondary hemostatic A primary platelet aggregate that has been plug stabilized by fibrin formation during secondary hemostasis. Secretion Energy dependent discharge or release of products usually from glands in the body but also pertaining to the contents of platelet granules that are released after stimulation of the platelets by agonists; also, the product that is discharged or released. They selectively hydrolyze arginine- or lysine- containing peptide bonds of other zymogens converting them to serine proteases. Shelf life The time period for which a reagent or control is stable given appropriate storage conditions. Shelf life will change once the reagent or control is reconsitituted if lypholyzed or opened if liquid. Sickle cell formation may be observed in wet preparations or in stained blood smears from patients with sickle-cell anemia. Sickle-cell anemia A genetically determined disorder in which hemoglobin S is inherited in the homozygous state. Sickle-cell trait A genetically determined disorder in which hemoglobin S is inherited in the heterozygous state. Increased numbers of smudge cells are observed in lymphoproliferative disorders like chronic lymphocytic leukemia. Spur cell anemia An acquired hemolytic condition associated with severe hepatocellular disease such as cirrhosis, in which there is an increase in serum lipoproteins, leading to excess of erythrocyte membrane cholesterol. Determining the stage of disease usually involves radiologic studies, peripheral blood examination, and bone marrow aspiration and biopsy. Starry sky Morphologic appearance characteristic of high- grade lymphoma produced by numerous tingible body macrophages (stars) and a diffuse sheet of neoplastic cells (sky).

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