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By B. Mezir. Berea College.

And of course this book would not have been possible without the encouragement and support of Routledge order avalide with amex, in particular Alison Poyner and Moira Taylor 162.5 mg avalide otc. It develops issues that may have been introduced during pre-registration courses buy online avalide, but which can too easily be lost in the technical demands of intensive care. The first chapter therefore explores the values underlying intensive care nursing; the second chapter develops these through outlining two influential moments in psychology. The third chapter examines issues about the environment in which intensive care patients are nursed. The human needs and problems of nursing rituals are explored in the chapters on pain management, pyrexia, nutrition, mouthcare, eyecare and skincare. The next two chapters then explore the extremes of age: paediatrics and older adults. Chapter 1 Nursing perspectives Introduction This book explores issues for intensive care nursing practice, and this first section establishes its core fundamental aspects. To help readers to do this, this first chapter explores what nursing means in the context of intensive care and the following chapter outlines two schools of psychology (behaviourism and humanism) that have influenced healthcare and society. Acknowledging and continuously re-evaluating our individual values and beliefs is part of human growth, so that examining nursing’s values and beliefs within the context of our own area of practice is part of our professional growth. This is something that each nurse can usefully explore and there are a number of published exercises available in this respect (e. Manley 1994), but essentially it means working out a nursing philosophy for oneself. What is meant by this is not some esoteric message hung neatly on a wall and seldom read or practised—such as ‘man is a bio-psycho-social being’—but, rather, simple values which may be more meaningful—such as ‘remember our patients are human’. Care can (and should) be therapeutic, but therapy (cure) without care is almost a contradiction in terms. These units offered potentially life-saving intervention during acute physiological crises, with the emphasis on medical need and availability of technology. As the technology and medical skills of the speciality developed, so technicians were needed to maintain and operate machines. However, the fact that technology provides a valuable means of monitoring and treatment should not allow it to become a substitute for care. For nursing to retain a patient-centred focus, it is the patients themselves and not the machines that must remain central to the nurse’s role. Healthcare assistants (and, potentially, robots) can be trained to perform technological tasks—and are cheaper to employ. Doctor-nurse relationships Ford and Walsh (1994) observed that nurses working in high dependency areas often have good relationships with medical staff. But Ford and Walsh suggest this good relationship is on the terms of the medical staff. For example, nursing’s focus on the emotional costs to intensive care patients may limit the wider recognition of nursing as a profession (Phillips 1996). However, while recognising and respecting the valuable and unique role of doctors, this collaboration by nurses should not mean subservience (i. Intensive care nursing 4 Psychology The increasing emphasis by the nursing profession on psychology and the psychological needs of patients, whether conscious or unconscious, makes psychological care an essential part of holistic care—a focus noticeably absent in the medical and technological perspectives above. However, psychology and physiology are not two separate and distinct pigeon-holes that some nursing (and other) course timetables might suggest, and the subject of homeostatic imbalances from psychological distress is explored in Chapter 3. In recognising both the physical and psychological needs of patients, nurses can add a humane, holistic perspective into their care, preparing their patients for recovery and discharge. The importance of assessing and planning nursing care is a recurring theme in many of the later chapters of this book. Following Ashworth’s seminal study of 1980, psychological stresses specific to, or accentuated by, intensive care have been widely discussed in nursing literature. To this end, it is often necessary, unfortunately, to add knowingly to the patient’s suffering, but this is one of the costs of critical illness (Carnevale 1991). Nursing perspectives 5 Holistic care The intrinsic needs of patients derive from their own physiological deficits, including many ‘activities of living’ (e. Waldmann and Gaine (1996) describe one patient, unable to drink, feeling tortured by hearing a can opened—opening cans of enterai feed away from a patient’s hearing may reduce such unintentional, but unnecessary, suffering. Thus, nurses need to question every nursing action proactively, no matter how small and apparently insignificant it may seem to be. Psychological approaches to nursing should be individually planned and implemented according to each patient’s needs. These needs can be assessed through the patients themselves and augmented by information from families and friends. Different nurses will feel comfortable with different approaches, but all should recognise the individual human being within each patient. Unlike the other medical and paramedical professions, nurses do not treat a problem or a set of problems. A fundamental role of a nurse, therefore, is to be with and for the patient; this is compatible with the advocacy role promoted by A Strategy for Nursing (DoH 1989). This role is facilitated by making patients the focus in the organisation of care (such as through primary/named nursing). This constant presence of a specific nurse at the patient’s bedside should allow more holistic, patient-centred care. Intensive care nursing 6 Relatives Relatives, together with friends and significant others, form an important part of each person’s life, and they too are similarly distressed by the patient’s illness. The psychological crises experienced by relatives necessitate skilful psychological care, such as the provision of information to allay anxiety and make decisions, and facilities to meet their physical needs (Curry 1995). Relatives should be offered the opportunity to be actively involved in the patient’s care (Hammond 1995) without being made to feel guilty or becoming physically exhausted, rather than left sitting silently at the bedside, afraid to touch their loved ones in case they interfere with some machine. Having recognised the primacy of the patient, nurses can then develop their valuable technological skills, together with other resources, in order to fulfil their unique role in the multidisciplinary team for the benefit of patients. The beliefs, attitudes and philosophical values of nurses will ultimately determine nursing’s economic value. This chapter is placed Nursing perspectives 7 first in order to establish fundamental nursing values, prior to considering individual pathologies and treatments; nursing values can (and should) then be applied to all aspects of holistic patient care. Henderson, famous for her earlier definition of the unique role of the nurse, wrote a classic article about nursing in a technological age (Henderson 1980).

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Many components of the specific immune defenses also contribute to nonspecific or natural defenses such as natural antibodies trusted 162.5mg avalide, complement purchase 162.5 mg avalide mastercard, interleukins safe 162.5 mg avalide, interferons, macrophages, and natural killer cells. For example, a person who has had measles once will not suffer from measels a second time, and is thus called immune. However, such spe- cific or acquired immune mechanisms do not represent the only factors which determine resistance to infection. The canine distemper virus is a close relative of the measles virus, but never causes an infection in humans. Our immune system recognizes the pathogen as foreign based on certain surface structures, and eliminates it. Humans are thus born with resistance against many microorganisms (innate immunity) and can acquire resistance to others (adaptive or acquired im- munity; Fig. Activation of the mechanisms of innate immunity, also known as the primary immune defenses, takes place when a pathogen breaches the outer barriers of the body. Specific immune defense factors are mobilized later to fortify and regulate these primary defenses. Responses of the adaptive immune system not only engender immunity in the strict sense, but can also contribute to pathogenic processes. The terms immuno- pathology, autoimmunity, and allergy designate a group of immune Kayser, Medical Microbiology © 2005 Thieme All rights reserved. The latter comprises cellular (T-cell responses) and humoral (anti- bodies) components. Specific Tcells, together with antibodies, recruit non-specific effector mechanisms to areas of antigen presence. However, a failed immune response may also be caused by a number of other factors. For instance, certain viral infections or medications can suppress or attenuate the immune response. This condition, known as immunosuppression, can also result from rare genetic defects causing congenital immunodeficiency. The inability to initiate an immune response to the body’s own self anti- gens (also termed autoantigens) is known as immunological tolerance. Anergy is the term used to describe the phenomenon in which cells in- volved in immune defense are present but are not functional. The stimulating substances are known as antigens and are usually proteins or complex carbohydrates. Presented alone, an epitope is not sufficient to stimulate an immu- nological response. Instead responsiveness is stimulated by epitopes con- Kayser, Medical Microbiology © 2005 Thieme All rights reserved. This is why the epitope component of an antigen is terminologically distinguished from its macromolecular carrier; together they form an immunogen. These cells can only recognize protein 2 antigens that have been processed by host cells and presented on their sur- face. The T-cell receptors recognize antigen fragments with a length of 8–12 sequential amino acids which are either synthesized by the cell itself or pro- duced subsequent to phagocytosis and presented by the cellular transplan- tation antigen molecules on the cell surface. The T cells can then complete their main task—recognition of infected host cells—so that infection is halted. Our understanding of the immune defense system began with studies of infectious diseases, including the antibody responses to diphtheria, dermal reactions to tuberculin, and serodiagnosis of syphilis. Characteriztion of pathological antigens proved to be enormously difficult, and instead erythro- cyte antigens, artificially synthesized chemical compounds, and other more readily available proteins were used in experimental models for more than 60 years. Major breakthroughs in bacteriology, virology, parasitology, biochem- istry, molecular biology, and experimental embryology in the past 30–40 years have now made a new phase of intensive and productive research pos- sible within the field of immune defenses against infection. The aim of this chapter on immunology, in a compact guide to medical microbiology, is to present the immune system essentially as a system of defense against in- fections and to identify its strengths and weaknesses to further our under- standing of pathogenesis and prevention of disease. The Immunological Apparatus & The immune system is comprised of various continuously circulating cells (T and B lymphocytes, and antigen-presenting cells present in various tis- sues). T and B cells develop from a common stem cell type, then mature in the thymus (Tcells) or the bone marrow (B cells), which are called primary (or central) lymphoid organs. The antigen-specific activation of B and/or T cells in- volves their staggered interaction with other cells in a contact-dependent manner and by soluble factors. They secrete antibodies into the blood (soluble antibodies) or onto mucosal surfaces once they have fully matured into plasma cells. Antibodies recognize Kayser, Medical Microbiology © 2005 Thieme All rights reserved. Chemically, B-cell receptors are globulins (“immunoglobulins”) and comprise an astounding variety of specific types. Despite the division of immunoglobulins into classes and subclasses, they all share essentially the same structure. Naive Tcells circulate through the blood, spleen, and other lymphoid tissues, but cannot leave these com- partments to migrate through peripheral nonlymphoid tissues and organs unless they are activated. Self antigens (autoantigens), presented in the thy- mus and lympoid tissues by mobile lymphohematopoietic cells, induce T-cell destruction (so-called negative selection). Antigens that are expressed only in the periphery, that is outside of the thymus and secondary lymphoid or- gans, are ignored by T cells; potentially autoreactive T cells are thus directed against such self antigens. New antigens are first localized within few lym- phoid tissues before they can spread systemically. These must be present in lymphoid tissues for three to five days in order to elicit an immune response. An immune response can be induced against a previously ignored self antigen that does not normally enter lymphoid tissues if its entry is induced by cir- cumstance, for instance, because of cell destruction resulting from chronic peripheral infection. It is important to remember that induction of a small number of T cells will not suffice to provide immune protection against a pathogen. This can be better understood by examining how the individual com- ponents of the immune response function. The human immunological system can be conceived as a widely dis- tributed organ comprising approximately 1012 individual cells, mainly lym- phocytes, with a total weight of approximately 1kg. Leukocytes arise from pluripotent stem cells in the bone marrow, then differentiate further as two distinct lineages. The myeloid lineage constitutes granulocytes and mono- cytes, which perform important basic defense functions as phagocytes (“scavenger cells”). The lymphoid lineage gives rise to the effector cells of the specific immune response, T and B lymphocytes.

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A full professor at the University of Chica- go from 1952 buy avalide australia, Bettelheim retired from both teaching and directorship of the Orthogenic School in 1973 cheap 162.5 mg avalide amex. Follow- ing the death of his wife in 1984 and after suffering a stroke in 1987 discount avalide 162.5mg with visa, Bettelheim committed suicide in 1990. Bilingualism/Bilingual education Use of a language other than English in public school classrooms. The 1970s saw record levels of im- Chicago, and then an associate professor at Rockford migration, bringing an estimated 4 million legal and 8 College from 1942 to 1944. To accom- modate this dramatic surge in the nation’s population of In 1943, Bettelheim gained widespread recognition foreign language speakers, language assistance has been for his article, “Individual and Mass Behavior in Ex- mandated on the federal, state, and local levels in areas treme Situations,” a study of human adaptability based ranging from voting and tax collection to education, so- on his concentration camp experiences. Altogether, over 300 been both lauded and criticized—of unconditionally ac- languages are spoken in the United States. Love Is Not Enough (1950), Tru- ants from Life (1954), and The Empty Fortress (1967) are Organized opposition to bilingualism, which collec- based on his work at the Orthogenic School. The In- tively became known as the English-Only movement, formed Heart (1960) deals with Bettelheim’s concentra- began in the 1980s. Hayakawa of Cali- teachers also help the students improve their skills in fornia introduced a constitutional amendment to make their native language. Two influential the students’ native languages not only to teach them the English-Only lobbying groups were formed: U. Eng- standard curriculum but also for special classes about lish, in 1983, and English First, in 1986. Two-way the passage of Proposition 63, English became the offi- or dual language programs enroll students from different cial language of California. By the mid-1990s, 22 states backgrounds with the goal of having all of them become had passed similar measures. For House of Representatives, by a margin of 259-169, example, Spanish-speaking children may learn English passed a bill to make English the official language of the while their English-speaking classmates learn Spanish. They accuse school systems of continu- fire is bilingual education, which costs taxpayers an esti- ing to promote bilingual programs to protect the jobs of mated $200 million a year in federal funds and billions of bilingual educators and receive federal funding allocated dollars in state and local expenditures. As evidence of this charge, they cite tion programs, which allow students to pursue part of barriers placed in the way of parents who try to remove their study in their first language and part in English, their children from bilingual programs. The constitu- in New York City have claimed that their children are tionality of bilingual education was upheld in a 1974 being railroaded into bilingual programs by a system that Supreme Court ruling affirming that the city of San Fran- requires all children with Spanish surnames, as well as cisco had discriminated against 18,000 Chinese-Ameri- children of any nationality who have non-English-speak- can students by failing to make special provisions to help ing family members, to take a language proficiency them overcome the linguistic barriers they faced in exam. However, the court did not specify what these quired to enroll in bilingual classes even if English is the provisions should be, and educators have evolved several primary language spoken at home. Critics of bilingual in- different methods of instruction for students with first struction also cite a 1994 New York City study that re- languages other than English. English, and the students are expected to pick up the lan- In spite of the criticism it has aroused, bilingual edu- guage through intensive exposure. Defend- gual, the students may be allowed to ask questions in ers cite a 1991 study endorsed by the National Academy their native language, but the teacher is supposed to an- of Sciences stating that children who speak a foreign lan- swer them in English. A later study, con- ual approach to mastering English, using it in conjunction ducted at George Mason University, tracked 42,000 chil- with the student’s first language. English-only instruction dren who had received bilingual instruction and reported may be offered, but only in some, rather than all, classes. Programs with two- teaching methods aimed at meeting the needs of foreign way bilingual education have had particularly impressive language speakers are considered bilingual education, results. Oyster Bilingual Elementary School in Washing- participants in debates about bilingual education often ton, D. Its sixth graders read at a students study English but are taught all other academic ninth-grade level and have tenth-grade-level math skills. His 1903 book, L’Etude experimentale de l’intelligence, was based on his studies of them. Alfred Binet In 1905, Binet and Theodore Simon created the first 1857-1911 intelligence test to aid the French government in estab- French psychologist and founder of experimental lishing a program to provide special education for men- psychology in France and a pioneer in intelligence tally retarded children. In training—mostly at Jean-Martin Charcot’s neurological 1916, the American psychologist Lewis Terman used clinic at the Salpetriere Hospital—was in the area of ab- the 1908 Binet-Simon scale as the basis for the Stanford- normal psychology, particularly hysteria, and he pub- Binet Intelligence Scale, the best-known and most re- lished books on hypnosis (Le magnetisme animal, with searched intelligence test in the United States. Fere in 1886) and suggestibility (La suggestibilite, authored Les enfants anormaux (Abnormal Children) 1900). From 1895 until his death in 1911, Binet served (1907) with Simon and published Les idees modernes as director of France’s first psychological laboratory at sur les enfants (Modern Ideas on Children) in 1909. Binet See also Intelligence quotient; Mental retardation had been interested in the psychology of—and individual differences in— intelligence since the 1880s and pub- Further Reading lished articles on emotion, memory, attention, and Wolf, Theta Holmes. With one eye closed, align the pencil with Binocular depth cues are based on the simple fact the edge of a doorway, window, or other vertical line in that a person’s eyes are located in different places. Close the eye, open the other, and observe cue, binocular disparity, refers to the fact that different the position of the pencil: it will have jumped. Binocu- optical images are produced on the retinas of both eyes lar disparity describes this phenomenon of different im- when viewing an object. Biofeedback has been applied with The second cue, called binocular convergence, is success to a variety of clinical problems, ranging from based on the fact that in order to project images on the migraine headaches to hypertension. The closer the perceived object is, the more they formation about physiological processes of which they must rotate, so the brain uses the information it receives are normally unaware, such as blood pressure or heart about the degree of rotation as a cue to interpret the dis- rate. Yet another cue to depth recorded, and the information is relayed back to the per- perception is called binocular accommodation, a term son through a changing tone or meter reading. With that refers to the fact that the lens of the eye changes practice, people learn strategies that enable them to shape when it brings an image into focus on the retina. The muscular activity necessary for this accommodation For example, persons trying to control their blood pres- acts as a signal for the brain to generate perception of sure levels may see a light flash whenever the pressure depth and distance. They may then try to remem- See also Vision ber and analyze what their thoughts or emotions were at that moment and deliberately repeat them to keep the Further Reading pressure level low. The Object Stares Back: On the Nature of See- The biofeedback training may continue for several ing. Even- tually they will need to produce the desired response without electronic feedback, a goal which can be accom- Biofeedback plished through various methods. They may practice the learned response at the end of the training session or at A technique that allows individuals to monitor home between sessions. There can also be random trials their own physiological processes so they can learn to control them. An alternate strate- gy is the gradual and systematic removal of the feedback signal during the training sessions over a period of time. Biofeedback originated with the field of psy- After the initial training is completed, subjects may re- chophysiology, which measures physiological responses turn to the biofeedback facility to assess their retention as a way of studying human behavior.

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Additional Modified Tinsdale medium and tellurite blood agar if diphtheria is suspected effective avalide 162.5 mg. Sabouraud agar if thrush is suspected • Inoculate the swab on sabourad agar 0 • Incubate at 35-37 c for up to 48hours checking for growth after overnight incubation 2 order avalide with amex. Examine the specimen microscopically Gram smear Examine the smear for pus cells and Vincent’s organisms: • Vincent’s organism are seen as Gram negative spirochaetes ( B order avalide once a day. Additional Albert stained smear Examine the smear for bacteria that that could be C. Blood agarculture • look for beta-haemolytic colonies that could be group Astreptococcu(S. Sabouraud agar culture Look for candid albicans 130 Collection transport and examination of Nasopharyngeal aspirates and Nasal swabs Nasopharyngeal Aspirates and perinasal swabs Possible pethogens Grampositive G ram negative Streptococcus pneumonia Haemophylus influenzae Corynebacterium diphtheriae Neisseria meningitidis (carriers) Bordetella pertussis Bordetella parapertussis Klebsiella species Also M. Anterior Nasal Swabs Possible pathogens • Most anterior nasal swabs are examined to detect carriers of pathogens 131 Gram positive Gram negative S. Using a sterile cotton or alginate wool swab attached to an easily bent pieces of wire, gently pass the swab along the floor of one nostril directing the swabdown wards and backward as far as the Nasopharynx. Using a steile cotton wool swab moistened with sterile peptone water, gently swab the inside surface of the nose. Examine and report the cultures Blood agar and chocolates agar cultures(routine) Look for coloniess that could be H. Collection, Transport and examination of Ear Discharges Possible pathogens Gram positive Gram negative S. A fungal infection of the ear is called otomycosis ™ External Ear infection are more commonly caused by: S. The following organisms may be found as commensals in the external ear: Gram positive Gram negative Viridans streptococci Escherichia coli and other coliforms S. Place it in container of Amies transport medium, breaking off the swab stick to allow the bottle top to be replaced tightly. Label the specimens and send them with its request form to the laboratory Within 6 hours. Additional: Chocolate agar if the patient is a child: Inoculate the specimen on chocolate (heated blood) agar for the isolation of H. Incubate the plate in a carbon dioxide enriched atmosphere at 0 35-37 c for up to 48 hours, examining for growth after overnight incubation. Incubate the plate anerobically for up to 48hours, checking for growth after overnight incubation. Sabouraud agar if a fungal infection is suspected Inoculate the specimen on sabouraud agar, and incubate at room tempreture for up to 6 days. Examine the specimen Microscopically Gram smear - Make an evenly spread of the specimen on a shide. Additional: Potassium hydroxide preparation if a fungal infection is suspected - Mix a small amount of the specimen with a drop of potassium hydroxide, 200g/l (20%W/v) on a slide, and cover with a coverglass. Look for: • Brnaching septate hyphae with small round spores, that could be Aspergillns speies • Pseudohyphae with yeast cells, that could be candida specis (Gram positive) 140 • Branching septate hyphae, that could be a species of der matophyte • Branching aseptate hypae, that could be a species of phycomycete. Inflammation of the the delicate membrane lining the eyelid and covering the eyeball conjunctiva is called conjunctivitis. It causes a severe purulent conjunctivitis that can lead to blindness if not treated. Herpes simplex virus can cause severe inflammation of the cornea (Keratitis) Commensals - That may be found in the eye discharges: Gram positive Gram negative Viridans streptococci Non-pathogenic neisseriae Staphylococci Moraxella speires Collection and transport of eye specimen • Eye specimen should be collected by medical officer or experienced nurses. Using a dry sterile cotton wool swab, collect a specimen of discharge (if an inflant, swab the lower conjunctival surface). Make a smear of the discharge on slide (frosted-ended) for staining by the Gram technique. As soon as possible, deliver the inoculated plates and smear(s) with request form to the laboratory. Culture the specimen Routine: Blood agar and chocolate agar • Inoculate the eye discharge on blood agar and chocolate (heated blood) agar. Loeffler serum slope if Moraxella infection is suspected: • Inoculate the eye discharge on a loeffler serum slope. Microscopically examination Routine: Gram smear Look for:- • Gram negative intracellular diplococci that could be N. If found, a presumptive diagnosis of gonococcal conjunctioitis can be made A cervical swab from the mother should also be cultured for the isolation of N. Depending on the stage of development; If the inclusion body is more mature, it will contain ---- red- mauve stiaing elementary particles. Using a sterile dry cotton wool swab, collect a sample of discharge from the infected tissue. If there is no discharge, use swabmoistened with sterile physiological saline to collect a specimen. If the specimen has been aspirated, transport the needle and syring in a sealed water proof container immediately to the laboratory. Laboratory examination of skin specimens 1) Culture the specimen Blood agar and MacConkey • Inoculate the specimen 0 • Incubate both plate aerobically at 35-37 C overnight. Additional: Sabourand agar if a fungal infection is suspected • Inoculate to agar plate • Send to a Mycology Reference laboratory. Ulcerans 0 • Incubate aerobically at 35-37 C for up to 48hours, examining the growth after overnight incubation. Blood agar and MacConkey agar at room temperature, if bubonic plague is suspected: • Inoculate the specimen • Incubate both pletes aerobically at room temperature far up to 48hours. Additional: Potassium hydroxide preparation, if ringworm or other superficial fungi infection is suspected. For detection of ringworm: Giemsa techniques or wayson`s techniques,if bubonic plague is suspected. Ziel-Neelsenstained smear if buruli ulcer is suspected examine for acid fast bacilli. Dark-field microscope to detect treponemes - look for motile treponeme if yaws or pinta is suspected Examine and report the culture Blood agar and MacConkey agar cultures Look for: S. Pyogenes • Ureaplasma urealyticum • Chlamydia trachomatis and • Occassionally Trichomonas vaginalis Cervical swabs from non-puerperal women: • N. Collection and transport of urogenital specimen • Amies medium is the most efficient medium for transporting urethral, cervical and vaginal swabs. The pathogen is, therefore, more likely to be isolated from a cervical swab than from a vaginal swab.

Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care purchase 162.5 mg avalide amex, 7th Edition purchase avalide with a visa. After sedating a patient buy avalide 162.5mg without a prescription, you assess that he is frequently drowsy and drifts off during con- c. What number on the sedation that sends additional pain stimuli to the scale would best describe your patient’s seda- central nervous system. Which of the following are accurate Multiple Response Questions descriptors of the gate control theory? Which of the following are characteristics of tatory pain stimuli away from the brain. Which of the following statements accurately be processed by the nervous system at any describe the nature of the pain experience? Patients are able to describe chronic pain through the nervous system, cells in the because it is generally localized. Pain that is resistant to therapy is referred person’s interpretation of the pain. Pain in people whose tissue injury is of a stimulus that causes the subject to rec- nonprogressive or healed is termed chronic ognize pain. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Pain that is resistant to therapy and per- sists despite a variety of interventions c. A patient who experiences acute pain following a noxious stimulus is experiencing 6. Pain that is diffuse or scattered and orig- inates in tendons, ligaments, bones, pain. Superficial pain that usually involves the localized following abdominal surgery is most skin or subcutaneous tissue likely experiencing pain. A person who experiences a “head rush” from eating ice cream too fast is experiencing originates in body organs, the thorax,. Pain that is perceived in an area distant arm following a myocardial infarction is from its point of origin experiencing pain. Somatic pain Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. A noninvasive alternative technique infarction that involves electrical stimulation of 13. Pain associated with a knee injury large-diameter fibers to inhibit the trans- mission of painful impulses carried over 14. Pain associated with a gash in the skin subconscious condition by means of suggestion 17. Pain associated with ulcers signal to help the patient learn by trial Match the term for nonpharmacologic pain and error to control the supposedly relief listed in Part A with its definition listed involuntary body mechanisms that may in Part B. Hypnosis iologic, and affective responses to pain that you might observe in these patients: g. Involves using one’s hands to consciously cesarean birth 2 days ago and is using her direct an energy exchange from the prac- call light to request something for her inci- titioner to the patient sional pain. Involves four elements: assuming a com- history of degenerative joint disease and fortable position with the body in good tells you this is a “bad morning” for his alignment, being in quiet surroundings, joints: “I think the weather must be repeating certain words, and adopting a affecting my arthritis. Requires the patient to focus attention on something other than the pain Situation C: 23. An example of mind–body interaction Situation D: used to decrease pain that involves one or all of the senses and focusing on a mental picture Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Give an example of how the following factors the threshold of pain has been reached and may influence a patient’s pain experience. List two experiences you have had with pain an example of each from your own experience management for patients. Which pain control measures were most effective, and what could you have done differently to b. Intractable pain: Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Describe how you would respond to a patient who tells you the following about his/her pain experience. How you could use to assess a patient for the has medication helped to control their pain? Quantity and intensity of pain: duration of the pain, coping measures, pain management, and the effect of pain on daily living. State your opinion of the use of placebos to about this patient, they tell you she is in end- satisfy a person’s demand for a drug. Is lying stage cancer and has received all the pain to the patient ever justifiable? Would you be an advocate for this patient and attempt to have more medication prescribed? How might who you are and your competence in pain management affect this woman’s last days? How would you modify your means of assess- ing for pain in the following patients? A patient with a cognitive impairment: Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Her blood pressure also shoots up periodic fatigue, anxiety, irritability, and mood when she is touched. The severity of her swings approximately 1 week before the start of illness has left her extremely weak and listless, her menses. She told the nurse practitioner that and her foster mother reports that she no her job as a computer programmer is stressful longer recognizes her child.

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Individuals with pernicious anemia may require B12 injec- tions from their doctor purchase 162.5 mg avalide otc. If deficient order avalide overnight delivery, supplement with iron avalide 162.5mg with amex, B12, and folate, along with a complete multivi- tamin and mineral complex. The excitement brought on by these situations is normal, and can actually help improve performance. This condition is among the most common psy- chiatric ailments, affecting 12 percent of Canadians. Feelings of anxiety trigger the body to release stress hormones that prepare you to react to a threat. The heart pumps stronger, breathing is increased, blood is shunted to the extremities to increase strength in the arms and legs, and digestion slows down so the body can reserve resources. Hun- dreds of years ago, this response was experienced occasionally and was vital to our survival. Today, however, stress and anxiety can be persistent and debilitating, with far-reaching consequences on health, leading to high blood pressure and cholesterol, insomnia, mood swings, depression, and other health problems. Some people experience extreme states of anxiety and worry, called panic attacks, which cause heart pounding, shortness of breath, chest pain, sweating, dizziness, and weakness. There are various lifestyle strategies and supplements that can be helpful in re- ducing anxiety and improving emotional well-being. Others include: Obsessive-compulsive disorder: Obsessions are persistent thoughts, ideas, impulses, or images that are intrusive and inappropriate and cause anxiety or distress. Compul- sions are repetitive behaviours (such as hand washing or checking things) or mental acts (such as counting or repeating words) that occur in response to an obsession or in a ritualistic way. Phobias: A phobia is a significant and persistent fear of objects or situations, such as flying. Post-traumatic stress disorder: Symptoms of post-traumatic stress disorder include flashbacks, persistent frightening thoughts and memories, anger or irritability in re- sponse to a terrifying experience in which physical harm occurred or was threatened (such as rape, child abuse, or war). Benzodiazepines are the main class of anti-anxiety drugs and include alprazolam (Xanax), clonazepam (Rivotril), diazepam (Valium), and lorazepam (Ativan). How- ever, they are addictive and have numerous side effects, including drowsiness, loss of coordination, dizziness, and impaired memory. Buspirone (Buspar) is a different type of anti-anxiety drug that is less addictive, but that still has side effects, including headache, nervousness, and insomnia. They work by altering the activity of neurotransmitters (chemical messengers) in the brain. Examples include fluoxetine (Prozac), paroxetine (Paxil), and ven- lafaxine (Effexor). These drugs may take four to six weeks to work, and are not effective for everyone (some experience worsened anxiety). Other side effects include 107 nervousness, headache, nausea, sexual dysfunction, sleep disturbance, and changes in appetite and weight. Professional counselling can help a person develop tools and coping skills to deal with stress and anxiety. One form of therapy that is highly effective for anxiety dis- A order is cognitive behaviour therapy. A therapist works with you to identify distorted thoughts and beliefs that trigger anxiety and you learn to replace negative thoughts and reactions with more positive ones, so that you view and cope with life’s events differently. Drink lots of water and decaffeinated beverages such as herbal teas (lemon balm, passion flower, and chamo- mile are known for their calming properties), or vegetable juices. Green tea is also helpful, as it contains theanine, an amino acid that has a calming effect. Foods to include: • Complex carbohydrates (whole grains such as brown rice, wheat bran, and oats) provide serotonin, a brain chemical that induces a calm feeling. Cut down on candy, baked goods, condiments (ketchup, salad dressings, and peanut butter), and snack foods. Walking, cycling, yoga, tai chi, and Pilates are great ways to reduce stress and anxiety. When feeling anxious, go to a quiet place where you can sit down and close your eyes. Take a slow, deep breath and hold it for four seconds, then exhale slowly for four seconds. Top Recommended Supplements B-vitamins: Essential for nervous system function; a deficiency can cause depression and anxiety. Some studies have found benefits with higher doses of a vitamin B3 derivative (niacinamide). Magnesium: Promotes calming and relaxation; levels may be depleted in those with stress and anxiety. Complementary Supplements Passion flower: An herb that promotes relaxation; studies support benefits for reducing anxiety and nervousness. Dosage: 4–8 mg of dried herb daily or 5–10 mL of tincture three to four times daily. Relora: A combination of magnolia and phellodendron that reduces stress without causing drowsiness. It causes drowsiness, so it can be helpful for those with insomnia due to anxiety. Get adequate rest and exercise regularly to reduce stress and anxiety and improve mood. To prevent and control anxiety attacks, try Suntheanine, passion flower, or Relora. The immune system produces antibodies that at- tack healthy joints, causing inflammation in the lining of the joints and pain. Chronic, uncontrolled inflammation leads to damage and destruction of the cartilage and joint tissues (bones, tendons, and ligaments) and the formation of scar tissue. It may start gradually or as a sudden, severe attack causing: • Flu-like symptoms (fatigue, weakness, and loss of appetite) • Joint pain, stiffness, and warmth • Swollen, red joints Some people have continuous symptoms and others go through periods of remission followed by flare-ups. Ironically, long- term use of these drugs can worsen joint health by accelerating the breakdown of cartilage. These drugs can cause serious side effects, such as nutrient deficiencies, blood disor- ders, and increased risk of infection. Contact your doctor if you have stomach pain or cramping or dark stools as these are signs of stomach bleeding. Foods to include: • Cold-water fish, olive oil, flaxseed, and hemp, which are rich in essential fatty acids, can help reduce inflammation.

Pelvic Cavity in the Male: Coronal Sections 345 Coronal section through pelvic cavity at the level of prostate and hip joint (anterior aspect) order avalide no prescription. Above = horizontal sections through the abdominal cavity avalide 162.5 mg free shipping, showing different contrast medium concentrations within the aorta and the aneurysm; below = 3-D reconstruction of the aneurysm; red = aorta; green = thrombotic areas; blue = vein (vena cava inferior cheap avalide 162.5 mg line, partly compressed). Pelvic Cavity in the Male: Vessels and Nerves of the Pelvic Organs 349 17 1 18 2 3 4 19 5 20 6 21 7 22 8 9 23 10 11 12 24 13 14 25 15 26 27 16 Vessels and nerves of the pelvic cavity in the male (medial aspect, midsagittal section). Urogenital and Pelvic Diaphragms in the Male 351 1 Right testis (reflected laterally and upward) 2 Bulbospongiosus muscle 3 Ischiocavernosus muscle 4 Adductor magnus muscle 5 Posterior scrotal nerves and superficial perineal arteries 6 Posterior scrotal artery and vein 7 Right artery of bulb of penis 8 Perineal body 9 Perineal branches of pudendal nerve 10 Pudendal nerve and internal pudendal artery 11 Inferior rectal arteries and nerves 12 Inferior cluneal nerve 13 Coccyx (location) 14 Penis 15 Left testis (reflected laterally) 16 Left posterior scrotal artery 17 Deep transverse perineal muscle 18 Left artery of bulb of penis 19 Posterior femoral cutaneous nerve 20 External anal sphincter muscle 21 Anus 22 Gluteus maximus muscle 23 Anococcygeal nerves 24 Acetabulum (femur removed) 25 Ligament of femoral head 26 Body of ischium (cut) 27 Sciatic nerve 28 Coccygeus muscle 29 Levator ani muscle a iliococcygeus muscle b pubococcygeus muscle c puborectalis muscle 30 Prostatic venous plexus 31 Body of pubis 32 Testis Urogenital diaphragm and external genital organs in the male with vessels and nerves (from below). The 21 right half of the pelvis including 20 14 the obturator internus muscle and femur have been removed to 32 display the right half of the levator ani muscle. The left crus penis has been isolated and reflected laterally together with the bulb of the penis. Urogenital and Pelvic Diaphragms in the Male 353 1 Right testis (reflected) 2 Corpus spongiosum of penis 3 Corpus cavernosum of penis 4 Perineal branch of posterior femoral cutaneous nerve 5 Posterior scrotal arteries and nerves 6 Deep artery of penis 7 Deep transverse perineal muscle 8 Right perineal nerves 9 Inferior rectal nerves 10 Inferior cluneal nerve 11 Anococcygeal nerves 12 Left spermatic cord 13 Left testis (cut surface) 14 Dorsal artery and nerve of penis 15 Deep dorsal vein of penis 16 Urethra (cut) 17 Artery of bulb of penis 18 Superficial transverse perineus muscle 19 Left artery of bulb of penis 20 Perineal branch of pudendal nerve 21 Anus 22 External anal sphincter muscle 23 Gluteus maximus muscle 24 Internal pudendal artery and pudendal nerve 25 Sacrotuberous ligament 26 Coccyx 27 Urogenital diaphragm (deep 22 transverse perineus muscle) 28 Tendinous center of perineum (perineal body) 29 Levator ani muscle 30 Anococcygeal ligament 31 Obturator internus muscle 32 Dorsal artery of penis Urogenital diaphragm and external genital organs in the male (from below). The urinary bladder 37 Infundibulum of uterine tube is empty, position and shape of the uterus are normal. Female Urogenital System 355 1 Muscular coat of urinary bladder 2 Folds of mucous membrane of urinary bladder 3 Right ureteric orifice 4 Interureteric fold 5 Internal urethral orifice 6 Vesico-uterine venous plexus 7 Urethra 8 Pubic bone (cut edge) 9 External urethral orifice 10 Vestibule of vagina 11 Left ureteric orifice 12 Trigone of bladder 13 Obturator internus muscle 14 Levator ani muscle 15 Bulb of the vestibule 16 Left labium minus 17 Psoas major muscle 18 Ampulla of rectum 19 Uterus 20 Urinary bladder 21 Promontory 22 Sigmoid colon 23 Uterine tube 24 Head of femur 25 Vagina Coronal section through the female urinary bladder and urethra (anterior aspect). During embryonal development, the 7 uterus and ovary remain within the 25 pelvic cavity where, after puberty, 16 the ovulation takes place. The anterior wall of the vagina has been opened to display the vaginal portion of the cervix. The fimbriae of the uterine tube have been reflected to show the abdominal ostium. Female Internal Genital Organs: Uterus and Related Organs 359 1 Ilio-inguinal nerve 2 Ureter 3 Psoas major muscle 4 Genitofemoral nerve 5 Common iliac vein 6 Common iliac artery 7 Ovary 8 Uterine tube 9 Peritoneum 10 Round ligament of uterus 11 Inferior vena cava 12 Abdominal aorta 13 Superior hypogastric plexus 14 Rectum 15 Recto-uterine pouch (of Douglas) 16 Uterus 17 Vesico-uterine pouch 18 Urinary bladder 19 Iliac crest 20 Pubic symphysis 21 Placenta 22 Amnion and chorion 23 Adnexa of uterus (uterine tube and ovaries) 24 Myometrium 25 Internal orifice of uterus 26 Cervix of uterus 27 Umbilical cord View of the female pelvis showing uterus and related organs (superior aspect). The anterior wall of the uterus has been removed to show the location of the placenta. Main drainage routes of lymph vessels of uterus and its adnexa (indicated by arrows). Female External Genital Organs 361 1 Glans of clitoris 2 Labium majus 3 Vestibule of vagina 4 Hymen 5 Posterior labial commissure 6 Body of clitoris 7 Labium minus 8 External orifice of urethra 9 Vaginal orifice 10 Ureter 11 Adnexa of uterus 12 Prepuce of clitoris 13 Crus of clitoris 14 Greater vestibular glands 15 Anus and internal anal sphincter muscle 16 Median umbilical ligament containing urachus 17 Urinary bladder 18 Infundibulum of uterine tube 19 Ovary 20 Ampulla of uterine tube 21 Suspensory ligament of the ovary 22 Bulbospongiosus muscle and bulb of vestibule 23 Central tendon of perineum (perineal body) 24 External anal sphincter muscle Female external genital organs (anterior aspect). Female external genital organs in relation to internal genital organs and urinary system, isolated (anterior aspect). Urogenital Diaphragm and External Genital Organs in the Female 365 1 Position of pubic symphysis 2 Body of clitoris 3 Prepuce of clitoris 4 Adductor longus and gracilis muscles 1 5 External orifice of vagina and labium minus 6 Posterior labial nerve 7 Perineal body 8 8 Deep artery of clitoris and dorsal nerve of clitoris 2 9 9 Adductor brevis muscle 10 Glans of clitoris 3 10 11 Crus of clitoris and 4 ischiocavernosus muscle 11 12 Bulb of vestibule and bulbospongiosus muscle 13 Anterior branch of obturator nerve 12 14 Labium minus 5 15 Vaginal orifice 16 Posterior labial nerves 13 17 Branches of pudendal nerve 6 18 External sphincter of anus 19 Anus 20 Bulb of vestibule (divided) 21 Dorsal artery of clitoris 22 Superficial transverse perineus muscle 7 23 Perineal branch of posterior femoral cutaneous nerve 24 Levator ani muscle External genital organs in the female (inferior aspect). The clitoris has been 25 Pudendal nerve and dissected and slightly reflected to the right. The prepuce of clitoris has been divided internal pudendal artery to display the glans. The bulb of vestibule has partly been removed; the left labium minus was cut away. The peritoneum at the left half of pelvic cavity has been 9 removed to display uterine tube, vessels, and nerves. Pelvic Cavity in the Female: Coronal and Horizontal Sections 367 1 Ilium 2 Rectum 3 Recto-uterine fold 4 Ovary 5 Uterine tube 6 Urinary bladder 7 Urethra 8 Labium minus 9 Recto-uterine pouch of Douglas 10 Uterus (uterovesical pouch) 11 Ligament of the head of the femur 12 Head of femur 13 Vestibule of vagina 14 Labium majus 15 Anal cleft 16 Coccyx 17 Rectum Coronal section through the pelvic cavity of the female (cf. Horizontal section through the pelvic cavity of the female at level of the urethral sphincter and vagina (from below). The two positions of the forearm essential to manual skills in the human, supination (right arm) and pronation (left arm), are shown. Skeleton of the Shoulder Girdle and Thorax 369 Vertebral column 1 Atlas 2 Axis 3 Third–seventh cervical vertebrae 4 First thoracic vertebra 5 Twelfth thoracic vertebra 6 First lumbar vertebra Ribs 7 First–third ribs True ribs 8 Fourth–seventh ribs 9 Eighth–tenth ribs False ribs 10 Eleventh and twelfth ribs (floating ribs) Clavicle 11 Sternal end 12 Articular facet for sternum 13 Acromial end 14 Articular facet for acromion 15 Impression for costoclavicular ligament 16 Conoid tubercle 17 Trapezoid line 18 Site of acromioclavicular joint 19 Site of sternoclavicular joint Scapula 20 Acromion 21 Coracoid process 22 Glenoid cavity 23 Costal surface Sternum 24 Manubrium 25 Body 26 Xiphoid process Skeleton of shoulder girdle and thorax (anterior aspect). Because of the human body’s upright posture, the upper limb has developed a high degree of mobility. The shoulder girdle is to a great extent movable in the thorax and is connected with the 16 trunk only by the sternoclavicular joint. Vertebral column Scapula 1 Atlas 12 Acromion 2 Axis 13 Spine of scapula 3 Third–sixth cervical vertebrae 14 Lateral angle 4 Seventh vertebra (vertebra prominens) 15 Posterior surface 5 First thoracic vertebra 16 Inferior angle 6 Sixth thoracic vertebra 17 Coracoid process 7 Twelfth thoracic vertebra 18 Supraglenoid tubercle 8 First lumbar vertebra 19 Glenoid cavity 20 Infraglenoid tubercle Clavicle 21 Lateral margin 9 Sternal end 10 Acromial end Thorax 11 Site of acromioclavicular joint 22 Body of sternum 23 Costal arch 24 Angle of ribs 25 Floating ribs Scapula 371 Right scapula (posterior aspect). Scapula A = superior border B = medial border C = lateral border D = superior angle E = inferior angle F = lateral angle 1 Acromion 2 Coracoid process 3 Scapular notch 4 Glenoid cavity 5 Infraglenoid tubercle 6 Supraspinous fossa 7 Spine 8 Infraspinous fossa 9 Articular facet for acromion 10 Neck 11 Supraglenoid tubercle 12 Costal (anterior) surface Right scapula (lateral aspect). Humerus 1 Greater tubercle 7 Deltoid tuberosity 13 Head 19 Trochlea 2 Lesser tubercle 8 Anterolateral surface 14 Anatomical neck 20 Posterior surface 3 Crest of lesser tubercle 9 Lateral supracondylar ridge 15 Anteromedial surface 21 Groove for ulnar nerve 4 Crest of greater tubercle 10 Radial fossa 16 Medial supracondylar ridge 22 Groove for radial nerve 5 Intertubercular sulcus 11 Lateral epicondyle 17 Coronoid fossa 23 Olecranon fossa 6 Surgical neck 12 Capitulum 18 Medial epicondyle 374 Skeleton of the Forearm Radius 1 Head 2 Articular circumference 3 Neck 4 Radial tuberosity 5 Shaft 6 Anterior surface 7 Styloid process 8 Articular surface 9 Posterior surface 10 Ulnar notch Ulna 11 Trochlear notch 12 Coronoid process 13 Radial notch 14 Ulnar tuberosity 15 Head 16 Articular circumference 17 Styloid process 18 Posterior surface 19 Olecranon Bones of right forearm, radius, and Bones of right forearm, radius, and ulna (anterior aspect). Articulations at the right elbow 20 Site of humero-ulnar joint 21 Site of humeroradial joint 22 Site of proximal radio-ulnar joint A = humerus B = radius C = ulna Bones of right elbow joint (lateral aspect). Skeleton of the Forearm and Hand 375 Skeleton of right forearm and hand in pronation. The human hand is one of the most admirable structures of appeared after the erect posture of the human body was the human body. An inevitable prerequisite for the development of a saddle joint, enjoys wide mobility so that the thumb can human cultures is not only the differentiation of the brain come into contact with all other fingers, thus enabling the but also the development of an organ capable of realizing hand to become an instrument for grasping and psychologic its ideas: the human hand. During evolution, these newly developed functions 378 Joints and Ligaments of the Shoulder 3 1 2 18 11 3 4 14 13 5 12 16 6 13 19 17 7 14 6 8 15 9 9 10 10 Right shoulder joint. The anterior part of the articular capsule has Coronal section of the right shoulder joint been removed and the head of the humerus has been slightly rotated (anterior aspect). Ligaments of the Elbow Joint 379 1 6 7 8 20 5 9 11 19 10 Elbow joint with collateral ligaments (medial aspect). Ligaments of the Hand and Wrist 381 1 Radius 2 Styloid process of radius 3 Palmar radiocarpal ligament 4 Tendon of flexor carpi radialis muscle (cut) 5 Radiating carpal ligament 6 Articular capsule of carpometacarpal joint of thumb 7 Articular capsule of metacarpophalangeal joint of thumb 8 Palmar ligaments and articular capsule of metacarpophalangeal joints 9 Palmar ligaments and articular capsule of interphalangeal joints 10 Articular capsule 11 Interosseous membrane 12 Ulna 13 Distal radio-ulnar joint 14 Styloid process of ulna 15 Palmar ulnocarpal ligament 16 Pisiform bone with tendon of flexor carpi ulnaris muscle 17 Pisometacarpal ligament 18 Pisohamate ligament 19 Metacarpal bone 20 Deep transverse metacarpal ligament 21 Tendons of extensor muscles and articular capsule 22 Collateral ligament of interphalangeal joint 23 Collateral ligaments of metacarpophalangeal joints 24 Second metacarpal bone Ligaments of right forearm, hand, and fingers (palmar aspect). The trapezius muscle has been cut near its origin at the vertebral column and reflected upward. Muscles of the Shoulder and Arm: Dorsal Muscles 383 1 Splenius capitis muscle 2 Sternocleidomastoid muscle 3 Trapezius muscle (reflected) 4 Lateral supraclavicular nerves 5 Clavicle 6 Levator scapulae muscle 7 Supraspinatus muscle 8 Spine of scapula 9 Deltoid muscle (reflected) 10 Rhomboid minor muscle 11 Rhomboid major muscle 12 Axillary nerve and posterior circumflex humeral artery 13 Infraspinatus muscle 14 Teres minor muscle 15 Long head of triceps brachii muscle 16 Teres major muscle 17 Inferior angle of scapula 18 Triceps brachii muscle 19 Latissimus dorsi muscle Muscles of shoulder and arm, deeper layer (right side, dorsal aspect). A Deep layer B Superficial layer 1 Flexor pollicis 3 Pronator teres muscle (red) longus muscle (blue) 4 Flexor carpi radialis 2 Flexor digitorum muscle (red) profundus muscle (red) 5 Flexor carpi ulnaris muscle (red) 6 Flexor digitorum superficialis muscle (blue) Flexor muscles of forearm and hand, middle layer (ventral aspect). The palmaris longus, flexor carpi radialis, and ulnaris muscles have been removed. Synovial sheaths of flexor tendons (palmar aspect of All flexors have been removed to display the pronator quadratus right hand, semischematic drawing). Muscles of the Forearm and Hand: Flexor Muscles 391 1 Humerus 2 Lateral epicondyle of humerus 3 Articular capsule 4 Position of capitulum of humerus 5 Deep branch of radial nerve 6 Supinator muscle 7 Entrance of deep branch of radial nerve to extensor muscles 8 Radius and insertion of pronator teres muscle 9 Interosseous membrane 10 Median nerve 11 Triceps brachii muscle 12 Trochlea of humerus 13 Tendon of biceps brachii muscle 14 Brachial artery 15 Pronator teres muscle 16 Tendon of pronator teres muscle 17 Ulna 18 Pronator quadratus muscle 19 Tendon of flexor carpi radialis muscle 20 Thenar muscles 21 Synovial sheath of tendon of flexor pollicis longus muscle 22 Fibrous sheath of flexor tendons 23 Digital synovial sheath of flexor tendons 24 Flexor digitorum superficialis muscle 25 Tendon of flexor carpi ulnaris muscle 26 Common synovial sheath of flexor tendons 27 Position of pisiform bone 28 Flexor retinaculum 29 Hypothenar muscles Right supinator and elbow joint (ventral aspect). A = axis of flexion and extension B = axis of rotation Arrows: S = supination P = pronation Synovial sheaths of flexor tendons Diagram illustrating the two axes of the elbow joint. Notice the six tunnels for the passage of the extensor tendons beneath the extensor retinaculum (schematic drawing).

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