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Travelers with colostomies are not at increased risk during air travel arrhythmia dance company buy genuine nifedipine on line, although intestinal distention may increase fecal output blood pressure 9060 20mg nifedipine mastercard. Mechanical considerations may play a role in the travel of neurosurgical patients arteria epigastrica superficial generic 20 mg nifedipine. Gas trapped within the skull will cause increased intracranial pressure when it expands at altitude primary pulmonary hypertension xray cheap nifedipine 30mg with visa. If such information is not available, it is advisable to wait at least 7 d before traveling. Likewise, a person with a cerebrospinal fluid leak from any cause should not fly because of the possibility of backflow and microbial contamination due to the pressure changes within the cabin (52). Neuropsychiatry Neurological and psychiatric disorders of particular concern for airline passengers are those that might be suddenly incapacitating, acutely progressive or dementing, or that might involve dangerous or disruptive behavioral manifestations. Physicians who must decide whether patients with such disorders should travel by air should recall their personal experiences with air travel, considering not only flights that went well, but also those that did not. Patients with some neurological or psychiatric disorders become very upset by changes to familiar routines, confusion over procedures, enforced crowding with strangers, or lack of privacy (41). What will be the effect upon a patient of such irritants as parking, luggage transport, long lines, security checks that may involve physical searches, confusing announcements, gate changes, cancelled flights, cramped seating, taxiway delays, turbulence, airsickness, inconvenient or delayed access to toilet facilities, lost luggage, disruption of schedules by weather, aircraft delays or missed connections, and other realities of air travel? Concerning medication, one axiom to remember is, "Never prescribe a medication for inflight use unless the patient has used it before, is familiar with its primary effects, and has had no undue side effects. Keeping these principles in mind, physicians should consider the following specific elements when patients with neurological or psychiatric conditions wish to fly. However, patients with uncontrolled, frequent seizures should be cautioned about air travel including the attendant risk of limited medical care capability inflight. Individuals with seizures sufficiently frequent to cause immediate concern should consider traveling with a companion. Patients with epilepsy should be made aware of the potential seizure threshold-lowering effects of fatigue, delayed meals, hypoxia, and disturbed circadian rhythm if passing through multiple time zones (41,53). In addition, patients with epilepsy need to be cautious about consuming alcohol before or during air travel and should be reminded of the importance of complying with their treatment regimen. Compliance with medication dosage and time schedules should be emphasized and anticonvulsant medication should be readily available in carry-on bags (not only in checked luggage). Patients who have had a recent cerebral infarction (stroke) or other acute neurological event should be observed until sufficient time has passed to assure stability of the neurological condition. Clearly, the risk of post-event complications, the physical and mental disability, and the decreased capacity to withstand the stresses of flight are cogent reasons not to fly. Once the acute phase of recovery is over and the patient is stable, travel may be reconsidered. Psychiatric Persons with psychiatric disorders whose behavior is unpredictable, aggressive, disorganized, disruptive or unsafe should not travel by air. Patients with psychotic disorders who are stabilized on medication and are accompanied by a knowledgeable companion may be able to fly. Physicians should be alert for tendencies toward claustrophobia and phobias about air travel or interpersonal crowding. An anxiolytic medication may be indicated if the patient has used it before with good results and without undue side effects. Anxiety may also be allayed by a calm and clear explanation of its nature, by use of previously learned relaxation techniques, and-in acute stages of hyperventilation- by using an airsick bag as a rebreathing device. Fully detoxify patients diagnosed with drug or alcohol abuse before they travel, in order to avoid inflight withdrawal reactions. Carefully consider the social factors involved when such patients travel alone in an environment where alcohol is easily available, and counsel accordingly. Remember that some patients who function reasonably well during daylight hours in familiar settings.
Partial audits may be performed remotely or through on-site review; sometimes they use surveys and questionnaires pulse pressure of 65 purchase nifedipine. Internal and external audits normally have different interests and scopes arrhythmia with normal ekg nifedipine 30 mg free shipping, and they can complement each other heart attack 85 blockage order 30mg nifedipine mastercard. For example hypertension nursing teaching nifedipine 20 mg generic, an internal audit may be used as preparation for an external audit or to monitor the implementation of the external audit recommendations. Also, the internal audit rather than the external audit, especially in the international context, would be more suitable for reviewing radiotherapy outcomes in the audited centre. This is mostly because the current clinical outcome data reflect the treatment of patients at the audited centre a few years earlier, not at the time of the audit. The infrastructure and processes may have changed over the years, and the current practices at the time of the audit will be reflected in future outcomes. The relationship between the current outcomes and past practices may be difficult to assess by external auditors and they may not be able to formulate useful recommendations. Therefore, the external audit, in particular that by the international auditing body, should be considered an assessment or a snapshot of practices at the time of the audit. Consequently, such an audit would typically focus on infrastructure, including equipment, facilities and human resources, radiotherapy processes, and possibly research and training activities. An internal audit is usually carried out by an audit team from within the centre, but outside the radiotherapy department, and typically reviews compliance with hospital procedures and protocols. For example, internal audits may systematically review different topical areas through a series of partial audits as per the internal audit programme, and the external audit may assess the complete clinical pathway in a comprehensive manner. Appropriate data collection forms can be developed for a specific part of the practice in order to collect data for analysis over a defined period of time. Using such data, the audit can then assess the effectiveness of the practice, draw conclusions and outline recommendations for improvement, where appropriate. Normally, internal audits are carried out on a regular basis, with a typical frequency of 12 months or less. External audits are generally independent and are carried out by organizations external to the audited centre. A programme of routine internal audits complemented by less frequent external audits is considered a practical and effective tool for quality improvement. A reactive audit can be associated with incident monitoring, which consists of reporting and analysing 312 clinical cases where there is concern regarding an adverse event or possibly adverse outcomes. Specifying the objectives of the audit is important for the audit preparation, the auditing process, its outcome and acceptance; therefore, the audit objectives have to be clearly defined. The time frame and programme of the quality audit also have an impact and must be carefully planned by the institution organizing an audit. As the audit is a collaborative process involving the staff of the audited centre and the audit team, both groups have their roles and responsibilities assigned. A local team should be identified to interact with the auditors, representing appropriate professional groups, who will prepare the documentation necessary for the audit, inform relevant staff of the upcoming audit and arrange for practical aspects of the audit. Staff in the audited area should be aware of the audit, its objectives, its programme and the expected level of their engagement. Staff should feel comfortable with the audit process in order to fully engage with it. The quality audit should be an open and collaborative review of the radiotherapy practice, including any difficulties involved, with the intention of recognizing, understanding and addressing them. The local team should make available records and findings of previous external and internal audits, as appropriate, for the audit team to review. It may be necessary to collect some additional data sets or prepare statistics for review by the auditors, depending on the audit requirements. In addition, a broader perspective, wisdom and good judgement would help to properly address issues that may arise in the audit and to carry out the audit activities in a tactful and sensitive manner. The audit team should communicate the audit rules to the local team and should follow the pre-agreed programme of the audit. Typically, the audit starts with the entry briefing to introduce to the staff of the audited centre the auditors and the audit objectives, programme and logistics. For example, a comprehensive clinical audit will review the overall performance of the radiotherapy centre following the patient pathway.
Sometimes broad-spectrum antibiotic therapy heart attack exo xoxo buy nifedipine 20 mg mastercard, mucolytic agents heart attack mayo clinic order nifedipine 20mg visa, oral decongestants blood pressure chart per age buy generic nifedipine 20mg on-line, steroids prehypertension birth control pills order discount nifedipine on-line, and temporary use of nasal decongestant spray such as oxymetazoline may shrink the nasal mucosa adequately to provide temporary sinus ventilation and drainage. Nasal saline spray also helps with nasal drying and epistaxis due to low humidity. After landing, any patient with persistent sinus block that has not resolved with decongestant therapy or spray, or whose symptoms worsen within 24-48 h, should see a physician. This is best prevented by preflight treatment with antihistamines, topical nasal steroids and, in some cases, immunotherapy. Throat Patients who have longstanding tracheotomy, laryngectomy, vocal cord paralysis or other laryngeal dysfunction may need extra moisturization and possibly removal of thickened secretions due to lower humidity inflight. To avoid this problem, extra oral hydration, moisture generator, and suctioning may be considered by the physician. Following tonsillectomy and adenoidectomy, palatoplasty, or nasal or facial fracture repair, patients can fly once postoperative bleeding risk has passed, after about 2 wk in most cases, and after clearance by an otolaryngologist. Patients who have undergone facial plastic surgical procedures such as facelift, blepharoplasty, otoplasty, peels, rhinoplasty, implants, or dermabrasion can fly once drains are removed and they are cleared by their surgeon (usually within 1-2 wk). Surgical Conditions the safety of air travel following a surgical procedure is becoming an important issue with the increasing frequency of ambulatory surgery. It is not uncommon for a patient to travel by air, have an outpatient surgical procedure performed, and then return to home by plane soon after. Consideration must be given to the optimal timing of a postoperative flight, the assessment of patient stability, and special medical needs, such as pain management and precaution awareness. General anesthesia, frequently used for ambulatory surgery, is not a contraindication to flying because the cardiac depressant effects and the changes in vascular resistance of anesthetic agents are rapidly reversible following emergence. In addition, the anesthetic gases do not predispose to decompression symptoms because of their low concentration, rapid equilibration, or both. Nitrous oxide at 70% concentration has poor tissue solubility and a short equilibration time (15 min). Halothane, ethrane, and isoflurane are used in low concentrations (1-4%) and rapidly equilibrate, making decompression effects unlikely. However, severe postspinal headache precipitated by airline travel has been reported 7 d after a spinal anesthetic, possibly because of ambient cabin pressure changes inducing a dural leak (75). It should be kept in mind, however, that postoperative patients are in a state of increased oxygen consumption due to the trauma of surgery, the possible presence of sepsis, and the increased adrenergic outflow. Concurrently, O2 delivery may be decreased or fixed in patients who are elderly, volume depleted, anemic, or who have cardiopulmonary disease. Consequently, for such patients it may be wise to delay air travel for several days or provide medical O2 during the flight. It must also be remembered that because of the decreased use of blood transfusions, many postoperaA12 tive patients today are far more anemic than in the past. A potentially dangerous situation is the postoperative elderly patient who is anemic and who has underlying coronary artery disease. This patient is in a physiological state of increased O2 consumption and has a diminished and possibly fixed state of O2 delivery. With coronary artery disease and limited vasodilational ability, limited coronary reserve would put this patient at risk (42). Patients who have had a recent pneumonectomy or a pulmonary lobectomy have minimal pulmonary reserve. A ground level SaO2 of greater than 90% (or a PaO2 70 mm Hg) usually does not require medical O2 during flight. It is important to remember that intestinal gas will expand 25% by volume at a cabin altitude of 8000 ft (2438 m). Post-abdominal surgery patients have a relative ileus for several days, thereby putting them at risk for tearing of suture lines, bleeding, and perforation. In addition, stretching gastric or intestinal mucosa may result in hemorrhage from ulcer or suture sites. A patient with an asymptomatic partial small or large bowel obstruction may also be unable to accommodate the gastrointestinal gas expansion during a flight, and should be advised not to travel by air.
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