By Z. Anktos. Lewis-Clark State College.

Fertilization causing regression of the corpus luteum penegra 50mg mens health 7 tests of true strength, termination of does not occur in the uterus discount penegra 100mg without a prescription mens health uk, especially not after the the luteal phase, and return to the next cycle; they do first meiotic division when the chromosome number is not prolong the cycle or postpone it. In fact, pregnancy tends Graafian follicles do not enter the oviduct and are not to preserve oocytes, as ovulation ceases during preg- fertilized. Plasma progesterone levels are high during and the oocyte does not implant. The blastocyst will pregnancy as a result of activation of the corpus luteum implant in the uterus. In addition, extrusion of the po- and placental production of progesterone. Elevated lar body is associated with fertilization, but this event progesterone blocks follicular development and the occurs within the oviduct. Fertilization by more than one sperm tase is associated with increasing the most potent an- is prevented by the cortical reaction. Cortical granules drogen, dihydrotestosterone, and reducing LH containing proteolytic enzymes fuse just beneath the secretion. Estrogens are associated with female sec- entire surface of the oolemma. The proteolytic en- ondary sex characteristics, although some androgens zymes are released to the perivitelline space, destroy regulate pubic hair development. En- Chapter 39 zyme reaction is a nonspecific term with little meaning for polyspermy. The decidual reaction is ronal components, but the hormonal component is ef- an inflammatory-like reaction that occurs simultane- ferent and the neuronal component is afferent. When ously with implantation of the blastocyst into the uter- the baby suckles, neural signals from the nipple travel ine endometrium. Oral steroidal contraceptives gener- ent component), which triggers the release of oxytocin ally contain progesterone and estrogen-like molecules, from the supraoptic nuclei (efferent component). Oxy- which feed back negatively on the hypothalamic-pitu- tocin enters the circulation, enters the breasts, and itary axis and reduce the secretion of LH and FSH; this causes contraction of the myoepithelial cells. Placental is the primary mechanism of action in preventing preg- lactogen is no longer present after parturition; it is a nancy. Dopamine release is decreased by although oral contraceptives do alter the uterine envi- suckling, and as a result, PRL secretion is increased. If ovulation were not blocked, the other pa- uterus must be primed with both progesterone and es- rameters would not be effective in blocking pregnancy. Implantation oc- Oral contraceptives block the LH surge; they do not curs on day 7 after fertilization. The LH receptors, signaling them to produce progesterone, developing embryo enters the uterus on day 3 or 4, it which is necessary for the maintenance of pregnancy. The acrosome reaction causes a fusion lactogen is not produced until after pregnancy is well of the plasma membrane and the acrosomal membrane established. Progesterone is a common hormone asso- of the sperm, with subsequent release of proteolytic ciated with the menstrual cycle and pregnancy. The zona mans, the inflammatory reaction at implantation does 736 APPENDICES not signal the mother that she is pregnant and it fol- of insulin resistance. The female phenotype can develop from progestin precursors because it lacks 17 -hy- in an XY male if the biological action of testosterone is droxylase. This absence can be due to a lack of testos- converted to 16OH-DHEAS by the fetal liver and terone secretion caused by enzyme deficiencies or a then to estriol by the placenta; this reaction is substan- lack of the testosterone (DHT) receptor. In this tial and is an indicator of fetal stress (estriol low) or process, called testicular feminization, a phenotypic well-being (estriol high). The mother’s adrenal can female develops in the presence of an XY karyotype. Androgens cannot be pro- terone to estrogen), with inguinal or abdominal testes, duced from cholesterol in the placenta; the placenta no uterus (because AMH is secreted), underdeveloped lacks 17 -hydroxylase. Estradiol is generally not con- male accessory ducts (lack of testosterone action), and verted to estriol. Insulin resistance is associated with insufficiency (low cortisol and androgens from the reduced utilization of glucose by the mother and this adrenals) have any effect on inducing female pheno- glucose is spared for the fetus. Inhibin would reduce FSH secretion lower but higher with insulin resistance. Insulin moves and ultimately reduce adult testis size, but in the fetus glucose into cells.

Whereas some individuals react Most chronic illnesses or disabling con- mildly to a condition that may devastate ditions require ongoing treatment cheap 100mg penegra free shipping prostate 24 price, med- another discount penegra 100mg on line prostate test, others display considerable emo- ical supervision, or restrictions on activity tional and physical discomfort with con- to control the condition or to prevent ditions that most people consider minor. However, many individu- Obviously, various psychosocial factors als with chronic illness or disability fail to determine individuals’ reactions to illness follow the recommendations prescribed, and, consequently, their reactions to the imperiling their own well-being (Dunbar- recommendations and advice given. Chronic illness or disability disrupts the Neglecting to take medications as pre- way individuals view themselves and the scribed, resisting restriction of activities, or world, and it can produce distortions in engaging in behaviors that are likely to thinking. Most individuals initially expe- cause complications can significantly rience a feeling of vulnerability and a shat- influence individuals’ medical prognosis tering of the magical belief that they are and functional capacity (Dolder, Lacro, immune from illness, injury, or even Leckband, & Jeste, 2003; Schmaling, Afari, death. With this realization, they may lose & Blume, 2000; Vergouwen, Bakker, their sense of security and cohesiveness. Katon, Verheij, & Koerselman, 2003; Life may seem a maze of inconveniences, Zygmunt, Olfson, Boyer, & Mechanic, hazards, and restrictions. The best rehabilitation plan is of lit- to recommendations may be an attempt tle value if individuals do not follow the to exert self-determination, to regain a treatments designed to control their sense of autonomy and control, and to symptoms or disease or to prevent com- claim some mastery over their individual plications or progression of the disease destiny. In other instances, resistance to (Kovac, Patel, Peterson, & Kimmel, 2002; treatment recommendations may be a Loghman-Adham, 2003). Although individuals who purposely Nonadherence can also be a reflection behave in a way that makes their condi- of an individual’s feelings about his or her tion worse seem irrational, there are a life circumstances. For some individuals, number of explanations for nonadherent having a chronic illness or disability is not 18 CHAPTER 1 PSYCHOSOCIAL AND FUNCTIONAL ASPECTS OF CHRONIC ILLNESS AND DISABILITY a positive role; for others, it may be far decrease income. The economic conse- preferable to the social role they held pre- quences of chronic illness or disability viously. If an wish to be independent and the wish to individual is receiving disability benefits remain dependent. Chronic illness or dis- and has little opportunity for satisfactory ability can be a means of legitimizing employment, he or she may not follow dependency, as well as a means of in- recommendations that would increase his creasing the amount of attention re- or her capacity to return to work and ceived. Motivation to retain the sick life is a relative concept, uniquely defined role is at times greater than the motivation by each individual. As a result, ulti- mendations result in pain, discomfort, or mate rehabilitation is hampered. If health scribed recommendations may not be per- and well-being are perceived as rewards for ceived as worth the psychological, social, a life well lived, illness or disability may or physical cost. Treatment can some- be viewed as punishment for real or imag- times, but not always, be adjusted to make ined actions of the past. Adherence to adhering to recommendations more palat- medical advice may be perceived as inter- able. Individuals’ right to self-determina- ference with a punishment believed to be tion must be carefully balanced with the deserved. In other instances, individuals assurance that the choice of nonadher- may feel guilty because they believe that ence is based on information and full the illness or disability is a direct result of understanding of the consequences. Some individuals readily adjust to the Guilt or shame at being different may also challenges, limitations, and associated be- hinder adherence to treatment recom- havioral changes necessitated by chronic mendations. Many individuals, attempt to hide their condition from oth- however, actively sabotage treatment and ers and, thus, fail to follow recommenda- recommendations, to their own detri- tions that they fear may call attention to ment. Many occupations offer lack of motivation, or failure to follow rec- fringe benefits, such as paid sick days or ommendations, it is important to identi- even time off with pay in which to seek fy the barriers that prohibit adherence and medical care, but other occupations pro- to recognize that such reactions may indi- vide no such benefits. In the latter in- cate difficulty in accepting the condition stances, days taken off from work because or adapting recommendations to their of illness or medical appointments can own unique way of life. Stages of Adaptation and Adjustment 19 PATIENT (CLIENT AND FAMILY) ticipate in some previously performed EDUCATION activity. Regardless of the nature of the loss, a variety of reactions may take place Although medical care, support, and while individuals attempt to make neces- auxiliary services are important aspects of sary adaptations and changes. The shock of diagnosis and its chronic disease or disability requires con- consequent implications may have a siderable individual and family effort. As the reality of the situation be- ed to carry out treatments in their home comes clear, they may experience a sense rather than depend on medical personnel of hopelessness and despair, mourning for in health care settings.

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Education about multiple sclerosis and personalized information about his wife d cheap penegra 50 mg visa man health question. Encouragement to continue to cope with the current situation 110 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM 4 order 50 mg penegra with amex prostate cancer 8 scale. What nursing interventions might improve the patient’s sympto- matic problems? All of the above Case Study 10 Gerald is a forty-two-year-old man with a ten-year history of multiple sclerosis. He served in the Navy prior to his marriage and then became a security guard at a local company. He has brainstem symptoms (tremor, atax- ia, nystagmus) and is no longer able to work. He has been hospitalized three times during the past five years for paranoid behaviors. Following his most recent hospitaliza- tion, he promised that he would remove the guns from his home. He has been tested for cognitive impairment (memory, judgment, and learning have been affected) and has been counseled by a neuropsy- chologist until his insurance ceased covering for care. He has become increasingly abusive to his wife and family as his condition has progressed. He threatens his wife and children with both physical abuse and with his guns. He is intermittently depressed and exhibits paranoid behaviors (his wife is having an affair, his daughter should have been an abortion). Recently, his wife has been participating in coun- seling; the patient refuses to do so. She has returned to work since finances are a problem in light of the needs of the growing children. The children are having problems in school; they are responsible for the patient’s care when they return home in the afternoons. Should the patient agree to hospitalization, what discharge planning would be helpful for this family? What other nursing interventions would be helpful upon the patient’s discharge? Advising the family to consider long-term placement if this situation continues to worsen c. Ensuring that the home environment is safe for the patient and family d. All of the above 112 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM Answers to Case Study Questions Case Study 1 Case Study 7 1. Which of the following statements about the possible cause(s) of MS is incorrect? Abnormal autoimmune response to myelin develops after exposure to some environmental agent in genetically predisposed individuals b. Combined effects of the autoimmune response cause the demyelination, axonal damage, and scarring seen in patients with MS 2. How many exacerbations, with neurologic symptoms referable to lesions in the white matter of the CNS, must a patient experience before a definite diagnosis of MS can be made? On onset, MS follows a relapsing-remitting pattern in approximately what percentage of patients? Continuing care needs of a patient with relapsing-remitting MS do not include: a. Ensuring adequate access to medications and adaptive equipment 113 114 NURSING PRACTICE IN MULTIPLE SCLEROSIS: A CORE CURRICULUM b. Sustaining care for patients with advanced MS may include all except which of the following? Recommending installation of adaptive hand controls on the patient’s automobile d. Agents that may help reduce symptoms of fatigue include all of the following except: a.

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Organic sol- related to drug abuse result from nonster- vents such as airplane glue can produce ile injections or from adulterants buy cheap penegra 100mg online man health 1240, rather cardiac arrhythmia generic penegra 100mg mastercard androgen hormone jacksonville, bone marrow depression, than from the drug itself. Abscess Prolonged use of nitrites is thought to suppress the immune system, increasing the Bacterial infection may cause pus to col- individual’s susceptibility to infection. In Nitrites are frequently used to enhance association with drug use, improper sexual pleasure; consequently, individuals cleansing of the skin before injection or the who use nitrites in this way and are also use of a nonsterile needle may lead to an exposed to human immunodeficiency abscess. Skin at the site becomes warm, red, virus (HIV) may be at greater risk for devel- swollen, and painful with a purulent (pus) oping HIV infection because of their sup- discharge. Skin around the area frequent- pressed immune system and subsequent ly becomes necrotic (dies). Treat- senses, driving during intoxication is haz- ment of an abscess consists of draining the ardous. Even though the effects of purulent material and debriding (remov- inhalants are brief, their use can result in ing) the area of dead tissue. No specific medical treat- usually prescribed, especially if individu- ment is usually indicated for inhalant als demonstrate systemic symptoms. An acute inflammation of the tissues without necrosis (tissue death) is called cellulitis. When associated with intra- MEDICAL CONSEQUENCES OF venous drug abuse, cellulitis is caused by ABUSE OF OTHER DRUGS AND the invasion of a variety of organisms or SUBSTANCES by irritation of the tissues from the drug itself. The tissue becomes red and tender, Substance abuse leads to psychological, and there may be adenopathy (swelling social, and vocational impairments and of- of lymph nodes). Treatment of cellulitis 220 CHAPTER 7 CONDITIONS RELATED TO SUBSTANCE USE depends on the cause. If the fibrous changes are extensive, they affect the oxygen-exchanging abili- Injections with nonsterile needles or in- ty of the lungs. Symptoms similar to those jections of drugs that have been contam- of emphysema may develop. Changes in inated by adulterants may leave needle lung elasticity can eventually result in pul- track scars. Injections cause a mild inflam- monary hypertension and subsequent heart matory reaction and, with subsequent failure. Injection of a drug into an artery ter 11 for a discussion of pulmonary hyper- instead of a vein can cause an extreme tension and heart failure. If not treated occur if organisms localize in the lung after properly, gangrene may develop, necessitat- the nonsterile injection of a substance. Aspiration pneumonia, an inflammation of the lung, may result from the inhalation Cardiovascular Complications of foreign substances or chemical irritants. Aspiration of gastric contents is also a Other than direct effects on the heart common cause of aspiration pneumonia. Rather than being a direct can lead to potentially serious conse- result of drug use, tuberculosis is more quences (see Chapter 11). In some instances, inflam- poor hygiene, and overcrowding all con- mation of the veins with clot formation tribute to development of the disease. In (thrombophlebitis) may occur because of addition, because some drugs have an im- the toxic effects of the drug. An Respiratory Complications overdose of narcotics or sedative/hypno- tics can severely depress the respiratory The intravenous injection of drugs to center, causing cessation of breathing and which adulterants such as talc, starch, or consequent death. Overdoses of narcotics baking soda have been added may result have also been associated with develop- in pulmonary complications. Because ment of severe pulmonary edema (collec- these substances do not dissolve, they cir- tion of fluid in the lungs), which, without culate in the blood and may become treatment, can also result in death. Diagnostic Procedures 221 Gastrointestinal Complications Other Complications Because the liver acts as the detoxifica- The chronic use of some drugs may tion center for the body, individuals who result in nystagmus (involuntary eye chronically abuse drugs may damage movement). Chronic, excessive abuse of sol- renal failure, which can progress to per- vents, for example, can cause liver necro- manent kidney damage (see Chapter 13).

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