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By observing the key movements in pended as ambulators shift their center of grav- Table 6–1 and extrapolating from Figure 6–3 proven 90mg dapoxetine erectile dysfunction in diabetes mellitus ppt, ity order dapoxetine 60mg with amex erectile dysfunction quality of life. For the stance and swing phases of the step the clinician can usually determine what a pa- cycle cheap generic dapoxetine uk young husband erectile dysfunction, these changes include: tient needs to practice and whether a brace is 1 buy dapoxetine american express erectile dysfunction low testosterone. Average temporal features of single-limb and double-limb support during a single gait cycle. Approximately 60% of the cycle is in stance during walking at the casual speed of 2. People with low Pelvis Lateral and horizontal shift to the back pain often experience pain at heel stance leg strike or as the swing phase is initiated, Hip Extension because these muscles contract. Knee Flexion upon loading Healthy elderly people walk more slowly and Extension at mid stance have a shorter stride length than young adults. Flexion at foot push off Table 6–2 shows the modest declines reported Ankle Dorsiflexion at heel contact, then for casual and maximum walking speeds as peo- plantarflexion with a propulsive ple age. Walking speed over a short distance rocker motion of the foot serves as an overall marker for the quality of Dorsiflexion as the lower leg moves the gait pattern. Table 6–3 provides a conver- over the foot sion table for the more frequently used meas- Plantarflexion for push off urement units of walking speed. Hemiplegia, paraplegia, disorders of the motor unit, ex- SWING PHASE trapyramidal disorders, the ataxias, and hydro- Pelvis Drops at toe off, then rotates forward cephalus all cause changes in the temporal and Hip Flexion to shorten the leg kinematic variables of the gait cycle. Knee Flexion to shorten the leg, then extension just before heel contact Ankle Dorsiflexion for heel strike NEUROLOGIC GAIT DEVIATIONS the Rancho Los Amigos charting system pro- vides one of several available systematic ob- 2. During the first part of stance, con- servational methods for gait analysis. The knee flexes approximately 30°–40° referring to the joint angle, muscle on and off near the end of stance. The pelvis is displaced toward the stance probably reliable only in the hands of experi- limb. Patients should be is in mid stance provide the most im- trained, however, with the template of Figure portant sensory inputs to the spinal cord 6–3 in mind so that optimal facilitation of gait for the stance to swing transition. In the swing phase, the pelvis rotates, so that the swinging hip moves forward faster than the hip that is in stance. The pelvis tilts down on the side of the swinging hip, under the control of the After an upper motoneuron injury, myriad opposite hip abductors. Average Walking Speeds for Short Distances in Healthy Men and Women Decade 20s 30s 40s 50s 60s 70s CASUAL (meters/minute) Men 84 88 88 84 82 80 Women 84 85 84 84 78 76 MAXIMUM (meters/minute) Men 152 147 148 124 116 125 Women 148 150 127 120 106 105 Source: Adapted from Bohannon, 199764 the gait pattern. The patient with hemiplegia may lose ness, impaired activation of muscles, coactiva- heel strike and the heel-to-forefoot rocker tion of muscle groups, hypertonicity, leg length action that increases the length of a step asymmetries of more than approximately 1 and adds forward propulsion. Instead, the inch, laxity of ligaments, joint and soft tissue patient may land flat-footed or on the fore- stiffness, contractures, and pain. Therapists foot, due to poor ankle dorsiflexion and make their adjustments to deviations that oc- knee extension. Poor dorsiflexion can arise cur during the six most easily separable events from a heel cord contracture, from sus- of the gait cycle. Initial contact with heel strike: Normally, by the tibialis anterior and toe extensor work at the knee flexors is mostly eccen- muscles, and by flexion of the knee, which tric during weight acceptance in stance. The tib- vent the vertical force at load acceptance ialis anterior contracts eccentrically the from rapidly building up at impact. The foot to the ground to touch, rather than to initial rocker action at the ankle and foot Table 6–3. Measurement Units to Quickly Convert the Range of Common Walking Speeds cm/second meters/minute feet/second km/hour mph 5 3 0. Stance Phase: Observational Analysis of Common Hemiparetic Gait Deviations Deviations Etiology Consequences Hip adduction Increased adductor activity Narrow base of support Inadequate strength of abductors Loss of balance Contralateral pelvic Weakness or inadequate control of hip Decreased stance stability drop abductors Inadequate hip Inadequate quadriceps Increased energy demand extension Hip flexion contracture Decreased forward progression Increased activity of hip flexors and velocity Excessive knee flexion posture Inadequate knee Inadequate quadriceps strength/control Increased energy demand extension Knee flexion contracture Decreased stance time Increased hamstring or gastrocnemius Decreased forward progression activity and velocity Inadequate hip extension or excessive dorsiflexion Knee extensor thrust Inadequate quadriceps control Loss of loading response at knee Increased quadriceps or plantarflexion Decreased forward progression activity and velocity Ankle instability Joint pain Plantar flexion contracture Excessive plantar flexion Increased plantar flexion activity Decreased forward progression Inadequate plantar flexion strength/ and velocity control Compensatory postures Plantar flexion contracture Increased energy demand Shortened stance time Excessive dorsiflexion Accommodation for knee flexion Stance instability contracture Decreased stance time Plantar flexion paresis Compensatory hip and knee flexion requiring increased energy Decreased forward progression/velocity No heel off Inadequate plantar flexion strength/ Decreased pre-swing knee flexion control Decreased forward progression/ Restricted ankle or metatarsal motion velocity Excess varus Increased invertor muscle activity Unstable base of support Decreased forward progression/ velocity Clawed toes Increased toe flexor muscle activity or Pain from skin pressure and weak intrinsic foot muscles weight bearing on toes Exaggerated compensation for poor Decreased forward progression/ balance velocity Toe flexion contracture also reduces this impact. In the hemi- and becomes an unstable weight-bearing plegic patient who immediately loads the surface. The quadriceps may give way so forefoot, the tibia is forced back and the the knee buckles or the knee may hyper- knee is thrust into extension, thereby im- extend and snap back. Midstance: At this point, the leg in swing may rotate in varus onto its lateral aspect passes the stance leg and the feet come 256 Common Practices Across Disorders Table 6–5. Swing Phase: Observational Analysis of Common Hemiparetic Gait Deviations Deviations Etiology Consequences Impaired hip flexion Increased extensor activity at knee Decreased forward progression and and ankle velocity Inadequate control of hip flexors Shortened step length Increased energy demand Impaired knee flexion Inadequate pre-swing knee flexion Toe drag at initial swing Increased knee extensor activity Contracture Hamstring paresis Inadequate knee Knee flexion contracture Shortened step length extension at end of Flexor synergy or withdrawal Decreased forward progression and swing prevents knee extension during velocity hip flexion Increased knee flexor activity Hip adduction Increased adductor activity Swing limb abuts stance limb or unsafely Excessive flexor or extensor narrows base of support synergy Decreased forward progression Excessive plantar Inadequate dorsiflexion strength Toe drag flexion at mid to Contracture Initial contact with foot flat or toes first end swing Increased plantar flexor activity or Loss of loading response at ankle extensor synergy next to each other. Terminal stance or heel off: This phase oc- ward velocity as it progresses over the curs just before heel contact by the op- stance leg. The trunk loses vertical height point, creating the potential energy of and the iliopsoas muscle contracts eccen- height, and is displaced to a maximum trically to resist the hip as the leg extends toward the stance leg. The knee peaks in its ex- the quadriceps muscles stop contracting tension and begins to flex and the gas- and the soleus contracts to slow the for- trocnemius joins the soleus contraction to ward motion of the tibia. In the patient with action force moves forward along the foot hemiplegia, contractures or spastic claw- as the ankle rotates from approximately ing of the toes may prevent weight from 15° of plantarflexion to 10° of dorsiflex- advancing to the forefoot. The gluteus muscles contract on the ing on flexed toes is also painful and in- opposite side to maintain pelvic align- creases hypertonicity. In the hemiplegic patient, the in- posite pelvis may drop from impaired hip ability to dorsiflex the ankle about 5° may abductor muscle activity. This deviation slows momentum swing begins at the end of the second and causes a shorter step by the opposite double-limb support phase. If the soleus contraction is inade- rectus femoris, and hip adductor muscles quate, the quadriceps muscles continue flex the hip. The rectus femoris also con- to fire to compensate for the dorsiflexed trols knee flexion by an eccentric con- ankle. Muscles that act across the an- sate, the patient must avoid early stance kle stabilize the foot as the triceps surae phase knee flexion and maintain the knee muscles contract. The ground reaction extension that was initiated during the force rapidly dissipates through the swing phase. Work at the ankle is Approaches for Walking 257 mostly concentric and is highest at push- WALKING SPEED off. The hemiplegic patient often misses Casual walking speed in hemiplegic gait is about this phase because of sustained knee ex- half of the walking speed of age-matched nor- tension from excessive quadriceps activ- mal subjects. Mean ranges for gait speed in sev- ity or as compensation for poor calf con- eral studies of recovery from hemiplegic stroke trol. Patients also compensate for toe drag 5 have been as low as 25 to 50 cm/second, com- by circumducting the leg or by vaulting pared to the 130 cm/second (2. A prospective observational study of 185 proximately 40% of the normal gait cycle. Swing has an dian of 45 cm/second on admission to 55 cm/sec- initial acceleration at the hip powered by 7 ond at discharge.
Snakeweed (Bistort). Dapoxetine.
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- Short limb dwarfism Al Gazali type
- Carpenter syndrome
- Gemss syndrome
- Arthrogryposis ectodermal dysplasia other anomalies
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A cytoprotective agent does not prevent or prostate-speciﬁc antigen (elevated levels may indicate treat all adverse effects of a particular cytotoxic agent and it prostatic cancer) generic 90mg dapoxetine with visa impotent rage random encounter. A CBC and white blood cell differential are done before Erythropoietin safe dapoxetine 60mg erectile dysfunction treatment testosterone, ﬁlgrastim buy 60 mg dapoxetine visa erectile dysfunction diabetes causes, oprelvekin buy on line dapoxetine erectile dysfunction treatment cincinnati, and sargramostim each cycle of chemotherapy to determine dosage and fre- are colony-stimulating factors (see Chap. Erythropoietin stim- function so fatal bone marrow depression does not occur, ulates production of red blood cells and is used for anemia; and to assist the nurse in planning care. For example, the oprelvekin stimulates production of platelets and is used to client is very susceptible to infection when the leukocyte prevent thrombocytopenia; ﬁlgrastim and sargramostim stim- count is low, and bleeding is likely when the platelet ulate production of white blood cells and are used to reduce count is low. Mesna is used with ifosfamide, tion, serum calcium, uric acid, and others, depending on which produces a metabolite that causes hemorrhagic cysti- the organs affected by the cancer or its treatment. Mesna combines with and inactivates the metabolite and thereby decreases cystitis. Dosages and routes of adminis- Nursing Diagnoses tration for these medications are listed in Drugs at a Glance: • Pain, nausea and vomiting, weakness, and activity intol- Cytoprotective Agents. Useful information includes the nausea, vomiting, and diarrhea type, grade, and stage of the tumor as well as the signs and • Risk for Injury: Infection related to drug-induced neu- symptoms of cancer. General manifestations include ane- tropenia; bleeding related to drug-induced thrombo- 920 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS cytopenia; stomatitis related to damage of GI mucosal • Physiologic care includes pain management, comfort cells measures, and assistance with nutrition, hygiene, ambu- • Deﬁcient Knowledge about cancer chemotherapy and lation, and other activities of daily living as needed. Most cancer treatment involves surgery, radiation, and chemo- • Promote weight control. Optimal regimens maximize effectiveness (eg, attempt development of several cancers, including breast and en- to eradicate tumor cells at primary, regional, and systemic dometrial cancer in women. Surgery is used to excise small, localized tumors, which • Strengthen host defenses by promoting a healthful may be curative; to remove tumors that have been reduced in lifestyle (eg, good nutrition, adequate rest and exercise, size by radiation therapy, chemotherapy, or both; and to treat stress management techniques, avoiding or minimizing complications of cancer, such as bowel obstruction. Passive smoking increases risk of lung cancer in spouses Radiation therapy is used to treat most types of cancer. It may be used with • Minimize exposure to sunlight, use sunscreens liber- surgery to reduce the need for radical surgery (eg, in breast ally, and wear protective clothing to prevent skin cancer. With soft tissue sarcomas of the symptomatic people, especially those at high risk, to detect limbs, wide excision plus radiation therapy can be used in- cancer before signs and symptoms occur. Radiation is also used to eliminate local clude regular examination of breasts, testicles, and skin and or regional malignant cells (eg, positive lymph nodes) that re- tests for colon cancer such as hemoccult tests on stool and main after surgery; with chemotherapy to cure or control sigmoidoscopy. Early recognition of risk factors, premalig- growth of tumors; and as a palliative treatment in metastatic nant tissue changes (dysplasia), biochemical tumor mark- disease, such as relieving symptoms in clients with bone or ers, and beginning malignancies may be lifesaving; early brain involvement. Once prevent or minimize the incidence and severity of adverse metastasized, solid tumors become systemic diseases and are reactions (Box 64-2). Main- Chronic lymphocytic leukemia, Bone marrow depression, hepato- tenance therapy, 0. Maintenance therapy, leukemias, cancer of breast, cystitis, hypersensitivity reac- PO 1–5 mg/kg daily lung or ovary, multiple tions, secondary leukemia or myeloma, neuroblastoma bladder cancer Ifosfamide (Ifex) IV 1. Re- Germ cell testicular cancer Bone marrow depression, hemor- peat every 3 wk or after white blood rhagic cystitis, nausea and vom- cell and platelet counts return to nor- iting, alopecia, CNS depression, mal after a dose. Extravasation may Cosmegen) testicular carcinoma, lead to tissue necrosis. Mitoxantrone (Novantrone) IV infusion 12 mg/m2 on days 1–3, for Acute nonlymphocytic Bone marrow depression, conges- induction of remission in leukemia leukemia, prostate cancer tive heart failure, nausea Pentostatin (Nipent) IV 4 mg/m2 every other week Hairy cell leukemia unrespon- Bone marrow depression, hepato- sive to alpha-interferon toxicity, nausea, vomiting Valrubicin (Valstar) Intravesically, 800 mg once weekly for Bladder cancer Dysuria, urgency, frequency, blad- 6 wk der spasms, hematuria Plant Alkaloids CAMPTOTHECINS Irinotecan (Camptosar) IV infusion, 125 mg/m2 once weekly Metastatic cancer of colon or Bone marrow depression, diarrhea for 4 wk, then a 2-wk rest period; rectum repeat regimen Topetecan (Hycamtin) IV infusion 1. Extravasa- Children, IV 2 mg/m2 weekly phomas, acute leukemia, tion may lead to tissue necrosis. Drugs at a Glance: Antineoplastic Hormones and Hormone Inhibitors Generic/Trade Names Routes and Dosage Ranges Clinical Uses Adverse Effects Antiestrogens Fulvestrant (Faslodex) IM 250 mg once monthly (one 5-mL Advanced breast cancer in GI upset, hot ﬂashes, injection site or two 2. They are usually treated Because the mouth and throat are anesthetized, swallowing and with antiemetics (see Chap. If systemic analgesics tonin receptor antagonist (eg, ondansetron) and a corticosteroid are used, they should be taken 30 to 60 minutes before eating. Other • In oral infections resulting from mucositis, local or systemic measures include a benzodiazepine (eg, lorazepam) for anticipa- antimicrobial drugs are used. Fungal infections with Candida tory nausea and vomiting and limiting oral intake for a few hours. Severe infections may require systemic antibiotics, foods the client is able and willing to eat, and nutritional supple- depending on the causative organism as identiﬁed by cultures ments, to increase intake of protein and calories, are helpful. An adequate diet and light to moderate exercise, • Help the client maintain a well-balanced diet. High- • Alopecia occurs with several drugs, including cyclophospha- protein, high-calorie foods and ﬂuids can be given between mide, doxorubicin, methotrexate, and vincristine. Nutritional supplements can be taken with or between loss can be psychologically devastating, especially for women. Provide ﬂuids with high nutritional value (eg, milk- Helpful measures include the following: shakes or nutritional supplements) if the client can tolerate • Counsel clients that hair loss is likely but that it is temporary them and has an adequate intake of water and other ﬂuids. In metabolites, antibiotics, and plant alkaloids and usually lasts 7 addition, the perineal area should be washed with soap and to 10 days. It may interfere with nutrition; lead to oral ulcera- water after each urination or defecation. Nurse or client • When venous access devices are used, take care to prevent interventions to minimize or treat mucositis include: them from becoming sources of infection. For implanted • Brush the teeth after meals and at bedtime with a soft tooth- catheters, inspect and cleanse around exit sites according brush and ﬂoss once daily with unwaxed ﬂoss. Use strict sterile technique and ﬂossing if the platelet count drops below 20,000/mm3 be- when changing dressings or flushing the catheters. Teeth may then be cleaned pheral venous lines, the same principles of care apply, with soft, sponge-tipped or cotton-tipped applicators. When they meals (to remove food particles that promote growth of micro- are necessary, cleanse the perineal area with soap and water organisms). One suggested solution is 1 tsp of table salt and at least once daily and provide sufﬁcient ﬂuids to ensure an 1 tsp of baking soda in 1 quart of water. Systemic dehydration and • If fever occurs, especially in a neutropenic client, possible local dryness of the oral mucosa contribute to the development sources of infection are usually cultured and antibiotics are and progression of mucositis. Fluids usually tolerated include tea, carbonated • Severe neutropenia can be prevented or its extent and dura- beverages, ices (eg, popsicles), and plain gelatin desserts. Fruit tion minimized by administering filgrastim or sargramostim juices may be diluted with water, ginger ale, Sprite, or 7-Up to to stimulate the bone marrow to produce leukocytes. Drinking tective environment may be needed to decrease exposure to ﬂuids through a straw may be more comfortable, because this pathogens. Precautions should be insti- Although individual tolerances vary, it is usually better to tuted if the platelet count drops to 50,000/mm3 or below. If using a central IV line, do not give the drug unless pa- • For platelet counts less than 20,000/mm3, stop brushing the tency is indicated by a blood return. Several drugs (called vesicants) cause severe • When extravasation occurs, the drug should be stopped im- inﬂammation, pain, ulceration, and tissue necrosis if they leak mediately.