By U. Anktos. Bank Street College of Education. 2018.
Immediately after bathing while the toenails are soft purchase 100 mg kamagra gold free shipping, clip the nails straight across order 100 mg kamagra gold with amex, and smooth them to the shape of the toe discount 100mg kamagra gold otc. Measures that increase circulation to the lower extremities should be instituted buy kamagra gold 100mg without prescription, including - Avoid smoking - Avoid crossing legs when sitting - Protect extremities when exposed to cold - Avoid immersing feet in cold water - Use socks or stockings that do not apply pressure to the legs at specific sites or constrict kamagra gold 100mg otc. Nursing Process The Patient with Newly Diagnosed Diabetic Mellitus Assessment - The history and physical assessment focus on • sign and symptom of prolonged hyperglycemia and • physical, social and emotional factors that may affect the patient ability to learn and perform diabetes self care activities - The patient is interviewed and asked for a description of 59 1) Symptoms that preceded the diagnosis of diabetes i. M (this is to see his/her conceptions or identify any misinformation) -Coping skill- by asking to patient how to deal with difficult situations Not all patients may have similar nursing diagnosis because nursing process is client specific and individualized. But possible N/ Dxs include: Based on the assessment data, the patients major nursing diagnosis may include the following. Maintaining fluid and electrolyte balance - Measuring Intake and output - Administering I/v fluid and electrolytes as ordered - Encouraging oral fluid intake - Monitor lab values of serum electrolyte ( esp, Na and k) - Vital sign monitoring 2. Improving nutritional intake - Diet is planned for the control of glucose • Take in to consideration the patients life style, cultural back ground, activity level and food preference - Patient is encouraged to eat full meals and snack as based on the kcal need. Improving self care - Patient teaching to prepare for self care - Special equipment is used for instruction on diabetic injection skill - Low literacy information is used - Families are instructed to enable them to assist in diabetic management to profile syringe to monitor blood glucose - Follow up education is arranged - Consideration is given for financial limitation or physical limitation (such as center for visually impaired) Other members of the health care team are informed about variation in the timing of meal and the work schedule (e. Reducing Anxiety - Nurse provide emotional support and gives time for client - Patient and family are assisted to focus on learning self care behavior - Encouraged to perform the skills that are most feared and reassured and self injection and puncturing a finger for glucose monitoring 5. Simple pathophysiology - Definition - Normal blood glucose level - Effects of insulin and exercise - Effects of food and stress, including illness and infection 63 B. Pragmatic information - Where to buy and store insulin, syringes, glucose monitoring supplies when to call the Nurse or physician. Hyperglycemia and ketoacidosis - Monitor blood glucose level and urine ketonuria - Medication are administered as prescribed - Pt is monitored for sign and Symptom of impending hypergly cemia and keto acidosis 4. Hypoglycemia Cause – skip or delay meal - Not follow the prescribed diet - Greatly increase the amount of exercise with out modifying diet or insulin Management- Juice or glucose tablet - Encourage the pt to eat full meal and snacks as prescribed per diabetic diet - See the above descriptions for the details 5. Achieve fluid and electrolyte balance a, Demonstrate I/o balance b, Exhibit electrolyte values that are with in normal limit c, Vital signs remain stable 2. Achieves metabolic balance a, Avoid extremes of glucose level( Hpo/hyperglycemia b, Demonstrate rapid resolution of hypoglycemia episode c, Avoid further weight loss 3. Identifies factors that cause the blood glucose level - to fall (insulin, exercise) - to rise ( food, illness and infection ) d- describes the major treatment modalities - diet - Exercise - Monitoring - Medication - Education Treatment Modalities (insulin, diet, monitoring, Education) a, Demonstration proper technique for drawing up and injecting insulin b, Verbalize insulin injection rotation plan c, Verbalize understanding of classification of food group d, Verbalize appropriate schedule for eating snacks and meals e. Verbalizes symptoms of hypoglycemia (shakiness, sweating headache, hunger, Numbness or tingling of lips or finger, weakness, fatigue, difficult concentration, Change of mood and dangers of untreated hypoglycemia (seizure and coma) b. Identify appropriate circumstance for calling the physician eg- when ill, when glucose level repeatedly increasing 4. States measures to prevent occurrence of complications Keys for the pretest and post test questions for Nurses 1. A- site of injection -Preparations of medication -Rotations -About syringe and needle -Some problems with insulin injections B)-Too much insulin -Too little food or -Excessive physical exercise -Delay of meal or omitting of snacks C) Sweating -Tremor -Tachypnea -Confusion -Seizure -Loss of consciousness 68 D) Having snack, not delaying the meal, right dose of medications, having Candies at hand F)-assess foot daily for sensation, redness and broken skins -Wash dry feet daily - If skin is dry apply a thin coat of lubricating oil -Tie shoes loosely but firmly -If your feet perspire, change shoe and stocking during the day -Wear shoe and stocking that gives room for the movement of the toe Part-ii True or false A. Purpose of the module Diabetes mellitus is a diverse group of hyper glycemic disorders with different etiologies and clinical pictures; there fore timely diagnosis and management based on true laboratory results are crucial. This Satellite Module on Diabetes Mellitus is intended to resolve the critical shortage of clinical chemistry reference materials both for students and for other professionals of the same field working in different health institutions 1. Pre- test questions Instructions: choose the appropriate answer from the alternatives given for each question and write the answers on a separate sheet of paper. Why is there a discrepancy between the whole blood glucose concentration and the plasma glucose concentration? Which one of the following organs uses glucose from digested carbohydrates and stored it as glycogen for later use as a source of immediate energy by the muscles? Learning objectives After studying this satellite module the student will be able to:- Æ Collect, preserve or prepare the correct specimens for diagnosis of diabetes mellitus Æ Perform different clinical chemistry tests in management of diabetes mellitus Æ Practice different quality control procedures in laboratory diagnosis of diabetes mellitus 4. The blood specimen can be collected both from vein or capillary, it depends on the type of sample the test procedure needs, and if serum or plasma is needed Venus blood should be collected with clean, dry, capped test tube, and with or with out anticoagulant. Urine samples are also possible to collect using, a clean, dry, free of any disinfectant, large and wide mouth container so as to do both qualitative and quantitative determination of glucose and others 4. To more completely detect diabetes mellitus, stressing the system with a defined glucose load tests carbohydrate metabolic capacity. To do this, a high- carbohydrate drink or meal is given to the patient, blood is collected 2 hours after ingestion, and the glucose concentration is determined. In the fasting state the arterial (capillary) blood glucose concentration is 5 mg/dl higher than the venous concentration. Preparation and preservation Samples for glucose determination The following factors which affects the stability of glucose in body fluid must be take in to account, such as: • Those glycolytic enzymes found particularly in the red cells, which under goes glycolysis at an average rate of approximately 10 mg/dl/hr in whole blood or 5 mg/dl/hr in sufficiently centrifuged plasma which still contain leukocytes Keeping these considerations in mind, there are several ways to prevent or retard glycolysis in specimen to be analyzed. For example: • Sample for glucose analysis should be delivered to the laboratory as soon as possible after being drowned from the patient.
The inspired oxygen 43 Chapter 2 Anaesthesia Connection to scavenging system Adjustable expiratory valve Fresh gas input Reservoir bag Figure 2 order 100mg kamagra gold fast delivery. Note the port on the expiratory valve (white) to allow connection to the anaesthetic gas scavenging system 100 mg kamagra gold amex. A wide variety of anaesthetic ventilators are avail- • The inspired anaesthetic concentration must be able discount kamagra gold 100mg free shipping, each of which functions in a slightly different monitored buy kamagra gold 100 mg cheap, particularly when a patient is being way discount kamagra gold 100 mg. One of During spontaneous ventilation, gas moves into the commonly used preparations changes from the lungs by a negative intrathoracic pressure. A positive pressure is applied to the anaesthetic gases to overcome airway resistance and elastic 44 Anaesthesia Chapter 2 Fresh gas I input Soda E lime Expiratory valve Reservoir bag Figure 2. The internal arrangement of the pipe-work in the system al- lows most of the components in the diagram to be situated on the top of the absorber. In both sponta- requires a source of energy: gravity, gas pressure or neous and mechanical ventilation, expiration oc- electricity. Un- Gravity derventilation will lead to hypercapnia, causing a The Manley is a typical example of a ventilator respiratory acidosis. Gas from the anaes- globin dissociation curve are the opposite of above, thetic machine collects within a bellows that is along with stimulation of the sympathetic nervous compressed by a weight. At a predetermined time a system causing vasodilatation, hypertension, valve opens and the contents of the bellows are tachycardia and arrhythmias. In patients with pre-existing lung disease this may cause a pneumothorax, and, long Gas pressure term, a condition called ventilator-induced lung Gas from the anaesthetic machine collects in a bel- injury. Minimizing theatre pollution Unless special measures are taken, the atmosphere Electricity in the operating theatre will become polluted with Electrical power opens and closes valves to control anaesthetic gases. The breathing systems described the ﬂow (and volume) of gas from a high-pressure and mechanical ventilators vent varying volumes source. Alternatively, an electric motor can power a of excess and expired gas into the atmosphere, the piston within a cylinder to deliver a volume of gas patient expires anaesthetic gas during recovery to the patient (Fig. An inspired oxygen con- • use of air conditioning in the theatre; centration of around 30% is used to compensate • scavenging systems. Over- ventilation results in hypocapnia, causing a respi- These collect the gas vented from breathing sys- ratory alkalosis. This ‘shifts’ the oxyhaemoglobin tems and ventilators and deliver it via a pipeline dissociation curve to the left, increasing the af- system to the external atmosphere. Hypocapnia will widely used is an active system in which a low neg- induce vasoconstriction in many organs, includ- ative pressure is applied to the expiratory valve 46 Anaesthesia Chapter 2 A C B Figure 2. The use of such systems does not eliminate the problem of pollution; it merely shifts Measurement and monitoring are closely linked it from one site to another. A measuring instrument ics, particularly nitrous oxide, are potent destroy- becomes a monitor when it is capable of delivering 47 Chapter 2 Anaesthesia A B Figure 2. During anaesthesia, both the • anaesthetic technique used; patient and the equipment being used are moni- • present and previous health of the patient; tored, the complexity of which depends upon a va- • equipment available and the anaesthetist’s riety of factors including: ability to use it; 48 Anaesthesia Chapter 2 Monitoring is not without its own potential hazards: faulty equipment may endanger the pa- tient, for example from electrocution secondary to faulty earthing; the anaesthetist may act on faulty data, instituting inappropriate treatment; or the patient may be harmed by the complications of the technique to establish invasive monitoring, for ex- ample pneumothorax following central line inser- tion. Ultimately, too many monitors may distract the anaesthetist from recognizing problems occur- ring in other areas. Finally, additional equipment will be required in • preferences of the anaesthetist; certain cases, to monitor, for example: • any research being undertaken. Monitoring should commence before the induction of anaesthesia and continue until the This is easily applied and gives information on patient has recovered from the effects of anaes- heart rate and rhythm, and may warn of the pres- thesia, and the information generated should be ence of ischaemia and acute disturbances of certain recorded in the patient’s notes. It can be tors supplement clinical observation; there is no monitored using three leads applied to the right substitute for the presence of a trained and experi- shoulder (red), the left shoulder (yellow) and the enced anaesthetist throughout the entire operative left lower chest (green), to give a tracing equivalent procedure. The pulse oximeter therefore This is the most common method of obtaining the gives information about both the circulatory and patient’s blood pressure during anaesthesia and respiratory systems and has the advantages of: surgery. A pneumatic cuff with a width that is 40% • providing continuous monitoring of oxygena- of the arm circumference must be used and the inter- tion at tissue level; nal inﬂatable bladder should encircle at least half • being unaffected by skin pigmentation; the arm. If the cuff is too small, the blood pressure • portability (mains or battery powered); will be overestimated, and if it is too large it will be • being non-invasive. Auscultation of the Korotkoff Despite this, there a number of important limita- sounds is difﬁcult in the operating theatre and au- tions of this device: tomated devices (Fig. An • There is failure to realize the severity of hypoxia; electrical pump inﬂates the cuff, which then un- dergoes controlled deﬂation. A microprocessor- controlled pressure transducer detects variations in cuff pressure resulting from transmitted arterial pulsations. Initial pulsations represent systolic blood pressure and peak amplitude of the pulsa- tions equates to mean arterial pressure. The frequency at which blood pressure is estimated can be set along with values for blood pressure, outside which an alarm sounds.
Endocrine surgeons treat endocrine disease through the removal purchase kamagra gold 100mg without prescription, or resection cheap kamagra gold 100 mg on-line, of the affected endocrine gland buy 100 mg kamagra gold fast delivery. Patients who are referred to endocrinologists may have signs and symptoms or blood test results that suggest excessive or impaired functioning of an endocrine gland or endocrine cells order kamagra gold 100 mg online. The endocrinologist may order additional blood tests to determine whether the patient’s hormonal levels are abnormal buy 100 mg kamagra gold free shipping, or they may stimulate or suppress the function of the suspect endocrine gland and then have blood taken for analysis. Some endocrine disorders, such as type 2 diabetes, may respond to lifestyle changes such as modest weight loss, adoption of a healthy diet, and regular physical activity. Other disorders may require medication, such as hormone replacement, and routine monitoring by the endocrinologist. These include disorders of the pituitary gland that can affect growth and disorders of the thyroid gland that can result in a variety of metabolic problems. Some patients experience health problems as a result of the normal decline in hormones that can accompany aging. These patients can consult with an endocrinologist to weigh the risks and benefits of hormone replacement therapy intended to boost their natural levels of reproductive hormones. In addition to treating patients, endocrinologists may be involved in research to improve the understanding of endocrine system disorders and develop new treatments for these diseases. Once the hormone binds to the receptor, a chain of events is initiated that leads to the target cell’s response. Hormones play a critical role in the regulation of physiological processes because of the target cell responses they regulate. These responses contribute to human reproduction, growth and development of body tissues, metabolism, fluid, and electrolyte balance, sleep, and many other body functions. These chemical groups affect a hormone’s distribution, the type of receptors it binds to, and other aspects of its function. An example of a hormone derived from tryptophan is melatonin, which is secreted by the pineal gland and helps regulate circadian rhythm. Tyrosine derivatives include the metabolism-regulating thyroid hormones, as well as the catecholamines, such as epinephrine, norepinephrine, 738 Chapter 17 | The Endocrine System and dopamine. Epinephrine and norepinephrine are secreted by the adrenal medulla and play a role in the fight-or-flight response, whereas dopamine is secreted by the hypothalamus and inhibits the release of certain anterior pituitary hormones. Peptide and Protein Hormones Whereas the amine hormones are derived from a single amino acid, peptide and protein hormones consist of multiple amino acids that link to form an amino acid chain. Peptide hormones consist of short chains of amino acids, whereas protein hormones are longer polypeptides. For example, the reproductive hormones testosterone and the estrogens—which are produced by the gonads (testes and ovaries)—are steroid hormones. The adrenal glands produce the steroid hormone aldosterone, which is involved in osmoregulation, and cortisol, which plays a role in metabolism. Because blood is water-based, lipid- derived hormones must travel to their target cell bound to a transport protein. This more complex structure extends the half-life of steroid hormones much longer than that of hormones derived from amino acids. Pathways of Hormone Action The message a hormone sends is received by a hormone receptor, a protein located either inside the cell or within the cell membrane. The receptor will process the message by initiating other signaling events or cellular mechanisms that result in the target cell’s response. Hormone receptors recognize molecules with specific shapes and side groups, and respond only to those hormones that are recognized. The same type of receptor may be located on cells in different body tissues, and trigger somewhat different responses. Thus, the response triggered by a hormone depends not only on the hormone, but also on the target cell. The response may include the stimulation of protein synthesis, activation or deactivation of enzymes, alteration in the permeability of the cell membrane, altered rates of mitosis and cell growth, and stimulation of the secretion of products. Pathways Involving Intracellular Hormone Receptors Intracellular hormone receptors are located inside the cell. Steroid hormones are derived from cholesterol and therefore can readily diffuse through the lipid bilayer of the cell membrane to reach the intracellular receptor (Figure 17. Thyroid hormones, which contain benzene rings studded with iodine, are also lipid-soluble and can enter the cell. The location of steroid and thyroid hormone binding differs slightly: a steroid hormone may bind to its receptor within the cytosol or within the nucleus. Pathways Involving Cell Membrane Hormone Receptors Hydrophilic, or water-soluble, hormones are unable to diffuse through the lipid bilayer of the cell membrane and must therefore pass on their message to a receptor located at the surface of the cell.
In principle the same flow scheme applies to both the food industry and to locally produced foods for private consumption (19) Hazards: Production of • Nutrients Raw Materials • Natural toxins • Microbial toxins • Environmental contaminants Food Processing Hazards: • Reaction products • Contaminants • Additives Storage and Transport Hazards: • Chemical contamination • Microbial contamination Hazards: Food Consumption • Chemical contamination • Microbial contamination Risks: • Intoxication by chemical contaminates Food Preparation • Food-borne infections • Food poisoning Fig order 100 mg kamagra gold free shipping. Major contamination sources are (7 generic 100 mg kamagra gold, 19 generic 100 mg kamagra gold free shipping,4): ¾ Water: water serves as a cleaning medium during sanitation operation and is an ingredient added in the formulation of various foods buy kamagra gold 100mg on line. If a safe water supply is not used it then becomes a source of contamination of the food (chemical or biological agents) purchase kamagra gold 100 mg with amex. Examples are microorganisms causing typhoid and paratyphoid fevers, dysentery, and infectious hepatitis. If raw sewage drains or flows into potable water lines, wells, rivers, lakes, and ocean bays the water and living organisms such as seafood are contaminated. This contamination can result from unclean air surrounding the food or from contamination through improper sanitary practices. The hands, hair, nose, and mouth harbor microorganisms that can be transferred to food during processing, packaging, preparation, and service by touching, breathing, coughing, or sneezing. This is because the human body is warm; microorganisms proliferate rapidly, especially in the absence of good hygienic practices. The amounts and types of these agents vary with place and method of harvesting, type of food ingredient, processing technique, 93 and handling. There could be hazards connected to these ingredients if there is lack of awareness of the incoming individual ingredients. These pests transfer contaminants to food through their waste products; mouth feet, and other body parts; and during regurgitation onto clean food. Like flies and cockroaches, they transfer filth from garbage dumps and sewers to food or food processing and food service areas. Meat of animals can get contaminated during slaughtering, cutting, processing, storage, and distribution. Other contamination can occur by contact of the carcass with the hide, feet, manure, dirt, and visceral contents. Like wise drugs used to prevent disease and promote growth in animals may also become potential risk for human health due to persisting of these drugs in the meat or milk products. There are two related models that illustrate the relationship among factors that cause food-borne diseases. Chain of infection: This is a series of related events or factors that must exist or materialized and be linked together before an infection will occur. Transmission of the causative agent from the environment in which the food is produced, processed, or prepared to the food itself. Moreover, the contaminated food must remain in a suitable temperature range for a sufficient time to permit growth to a level capable of causing infection or intoxication (7). The presence of the disease agent is indispensable, but all of the steps are essential in the designated sequence before food-bore diseases can result (see also figure 3. Web of causation: This is a complex flow chart that indicates the factors that affect the transmission of food-borne diseases. This presentation of disease causation attempts to incorporable all of the factors and their complex interrelationships (7). The major ones are (4,13): ¾ Preparation of food more than half a day in advance of needs ¾ Storage at ambient t temperature ¾ Inadequate cooling ¾ Inadequate reheating ¾ Use of contaminated processed food (cooked meats and poultry, and the like) ¾ Undercooking ¾ Cross contamination from raw to cooked food from utensils, and contamination from other food contact surfaces in kitchen environment ¾ Infected food handlers or poor personal hygiene of food handlers ¾ Unsanitary dishware, utensils and equipment ¾ Improper food handling procedures such as unnecessary use of the hands during preparation and serving of food ¾ Improper food storage that may lead to cross contamination by agents of diseases (micro-organisms, poisonous chemicals), or exposure to moisture that may facilitate microbial growth ¾ Insects and rodents 96 3. Food quality from a more scientific point of view includes a number of safety aspects such as the presence of environmental contaminants, pesticide residues, use of food additives, microbial contamination, and nutritional quality. In practical terms, safe food can be defined as food that, after being consumed, causes no adverse health effects (19). The government is responsible for the establishment of standards or codes of practice as well as the enforcement of laws and regulations. Furthermore, it should encourage the food industry to undertake voluntary measures to improve food safety. Consumers in turn should be well aware of the quality of the food they buy, prepare and consume and should adopt appropriate practices of food handling at home. At the industry level, all segments, including agriculture, should establish some system for safety assurance of their products and employ appropriate procedures and technologies (19).
In addition to supportive care and stabilization buy discount kamagra gold 100mg online, pre operative management includes thorough evaluation of the anatomy and physiology of the heart and the physiologic status of the patient as a whole so that appropriately planned and timed surgery can take place order kamagra gold 100 mg without prescription. Basic principles of pediatric critical medical and nursing care remain relevant in the pediatric congenital cardiac patient purchase 100 mg kamagra gold free shipping. Pediatric cardiac patients are cared for in specialized cardiac intensive care units and in multidisciplinary intensive care units buy cheap kamagra gold 100mg on line. There is some data that institutions that perform more surgeries have improved outcomes (info here—based on surgeon purchase kamagra gold 100 mg without a prescription, unit, hospital?? Regardless of the focus of the unit, a commitment to ongoing education and training, as well as a collaborative and supportive environment is essential. We feel strongly that a unit dedicated to the care of infants and children is best able to care for these patients (down on the adult units caring for kids). Oxygen delivery is therefore primarily dependent on systemic cardiac output, - 58 - hemoglobin concentration, and oxygen saturation. Stroke volume is in turn dependent on preload, afterload, and myocardial contractility. Both pulmonary blood flow (Qp) and systemic blood flow (Qs) are determined by these fundamental forces. In the patient with two ventricles, ventricular interdependence, or the affect of one ventricle on the other, may play a role in pulmonary or systemic blood flow. In some situations, including the post operative state, the pericardium and restriction due to the pericardial space may also play a role in ventricular output. When evaluating the loading conditions of the heart and myocardial contractility, it is important to consider the two ventricles independently as well as their affect on one another. In previously healthy pediatric patients without heart disease, right atrial filling pressures are commonly assumed to reflect the loading conditions of the left as well as the right ventricle. Pre-existing lesions and the affects of surgery may affect the two ventricles differently. For example, the presence of a right ventricular outflow tract obstruction will lead to hypertrophy of the right ventricle. That right ventricle will be non-compliant, and the right atrial pressure may therefore not accurately reflect the adequacy of left ventricular filling. Oxygen content (CaO2) is primarily a function of hemoglobin concentration and arterial oxygen saturation. Thus, patients who are cyanotic can achieve adequate oxygen delivery by maintaining a high hemoglobin concentration. Arterial oxygen saturation is commonly affected by inspired oxygen content, by mixed venous oxygen content of blood, by pulmonary abnormalities, and by the presence of a R to L intracardiac shunt. Arterial oxygen content in the patient with a single ventricle and parallel pulmonary and systemic circulations will depend on the relative balance between the circulations as well. In the patient with intracardiac shunt or the single ventricle patient, arterial oxygen content is also affected by the relative resistances of the pulmonary and systemic circuits, as this determines how much blood flows through the lungs relative to the systemic output. Low mixed venous oxygen content contributes to desaturation and suggests increased oxygen extraction due to inadequate oxygen delivery, which in turn is either due to inadequate systemic cardiac output or inadequate hemoglobin concentration. A thorough understanding of these fundamental principles of cardiac output and oxygen delivery is essential for the perioperative care of the patient with congenital heart disease. General Principles of Anatomy and Pathophysiology Affecting Pre-operative and Post- operative Management An understanding of the anatomy and pathophysiology of the congenital cardiac lesion under consideration allows one to determine the pre-operative care or resuscitation needed and to predict the expected post-operative recovery. Acyanotic Heart Disease Children with acyanotic heart disease may have one (or more) of three basic defects: 1) left-to-right shunts (e. These lesions may lead to decreased systemic oxygen delivery by causing maldistribution of flow with excessive pulmonary blood flow (Qp) and diminished systemic blood flow (Qs) (Qp/Qs >1), by impairing oxygenation of blood in the lungs caused by increased intra and extravascular lung water, and decreasing ejection of blood from the systemic ventricle. Maldistribution of Flow: Qp/Qs >1 In infants with left-to-right shunts, pulmonary blood flow (Qp) increases as pulmonary vascular resistance (Rp) decreases from the high levels present perinatally. As pulmonary flow increases, left ventricular volume overload may occur with cardiac failure, decreased systemic output, pulmonary congestion and edema. If pulmonary pressures exceed systemic pressures, right to left shunting predominates and the patient becomes cyanotic. Depending on the type and size of the lesion, pulmonary over circulation that remains uncorrected may lead to pulmonary vascular obstructive disease as early as 6 months of age. Pulmonary over circulation can lead to congestive heart failure through several mechanisms. Increased Qp leads to left (systemic) ventricular volume overload and raises left ventricular end diastolic, left atrial, and pulmonary venous pressures. The increases in pulmonary artery and pulmonary venous pressures raise the pulmonary hydrostatic pressure gradient and these promote transudation of fluid into the interstitial space and ultimately lead to alveolar edema.
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