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Practice-Based research Synthesis A practice-based research synthesis specifcally focuses on which characteristics of a program or practice are most important in terms of explaining the benefcial outcomes in different studies of the same or similar programs or practices gastritis diet �� buy genuine renagel on line. The main goal of a practice-based research synthesis is to sort out which aspects of a program or practice are the active ingredients so that those can be emphasized when the program or practice is adopted by others gastritis differential diagnosis renagel 800 mg low price. An analysis of this type of systematic review will generally include statements about the evidence-based characteristics of the programs or practices gastritis pepto bismol purchase renagel 400mg. A synthesis of the same program or practice that yields similar results in different studies would be the kind of results necessary to say the program or practice is evidence-based gastritis ginger ale buy renagel cheap. The hallmark of this type of study is random assignment of participants to groups (group design studies) or the random assignment of the timing of when individual study participants experience an intervention (single participant design studies) gastritis symptoms acute order renagel once a day. A randomized controlled design study is generally conducted with large numbers of participants where the differences between the intervention and nonintervention groups at the end of the intervention need to be large enough to conclude that the intervention was effective gastritis diet �� buy renagel with paypal. An explicit attempt is made to ensure that the groups are more similar than different on important characteristics. Single Participant design Studies Single participant design studies frst observe the study participants prior to the intervention (called the baseline) and then observe or assess the participants after the intervention is started at different times for the different participants. The replication of the effects across participants is how effectiveness of the intervention is demonstrated. This is accomplished by showing that changes occur only after the intervention is introduced to the frst participant, then the second participant and so on until all participants have experienced the intervention. Quasi-Experimental Studies Quasi-experimental design studies try to mirror experimental design except that study participants are not randomly assigned to intervention or nonintervention groups. Rather, an intervention is used with one group where another group that is similar to the intervention group is used as a comparison group. These types of studies typically include the collection of information about the characteristics of the participants to see if the two groups are more similar than different. Quasi-experimental studies use sophisticated statistical methods such as propensity score analysis, fxed effects, and difference in difference models among others to control for the differences between the treatment and comparison groups. At a minimum, they should include pretests on the outcome measures of interest to see if their performance is similar enough to say that any differences in outcomes after an intervention were the result of the intervention. The more the effects of the program or practice are replicated by different scientifc research studies, the stronger the support for the claim that it is evidence-based. Therefore, multiple studies using at least one of the three types of research (systematic reviews, experimental studies, quasi-experimental studies) are necessary for a program or practice to be considered evidence-based. Appendix B-2 provides a fowchart (How to Determine Whether a Program or Practice is Evidence-Based) of the process to determine whether or not the level of research available regarding a program or practice is suffcient to meet evidence-based criteria. This fowchart provides a step-by step procedure for determining the level of evidence available for a program or practice. If there is research evidence available for a program or practice at any level, then it is considered an evidence-based practice. Starting at the top of the checklist, the frst question asks, ?Has a meta-analysis of the program or practice been conducted? If the research evidence is compared to each of the eight levels and the answer at each level is ?no, the program or practice is not evidence-based. However, a program or practice could still be approved for funding if it is established as an evidence-informed practice. In their book describing the multiple Incredible Years Programs, Webster Stratton and Mihalic (2001) cite research on the programs effectiveness. In a Cochrane Collaboration review of group-based parent training programs, two of the intervention studies used Incredible Years. In these studies, there were small to moderate decreases in child conduct problems. Definition of Terms the following defnitions of terms provide necessary information that should be helpful in determining whether or not a program or practice meets the criteria for being evidence-informed. An evidence-informed program should be based on child development theory, practitioner wisdom and research fndings. This model or framework includes a description of the experiences and opportunities that are used to infuence participants behavior and the expected or anticipated benefts of the program or practice. Many child development theories inform parents and practitioners about best practices when caring for and educating young children. When working with parents, program staff members encourage parents to interact in a sensitive and responsive way with their children in an effort to increase the likelihood that children will form strong attachments and be able to replicate this ability in other contexts. Cognitive theories by Jean 92 Piaget [13] and Lev Vygotsky [14] provide important insight about how children think and learn. For example, Vygotsky argued that the tendency of young children to speak out loud when they are thinking, called private speech, serves an important purpose. Private speech guides children in planning activities and behavior, such as the steps to build a tower with blocks. This speech is an important precursor to planning how to solve problems that children will use as a strategy when they get older. Caregivers may apply this theory and encourage young children to talk to themselves out loud about what they are doing. Practitioner wisdom refers to the accumulated experience gleaned from using a program or practice and the informed understanding of when, how and why the program or practice is likely to produce expected or anticipated benefts. Qualitative and basic research refers to evidence (qualitative or quantitative or both) that is used to inform which aspects of a program or practice are expected to have anticipated benefts. There should be several studies reporting research fndings that suggest there would be a relationship between the intervention or practice and the desired outcome. For example, research shows that the more children are read to using certain characteristics, the more likely children will be strong readers later in school. Therefore, it would make sense to develop an intervention where parents were encouraged to read to their children frequently using certain techniques as they read. What the Evidence-Informed Program or Practice Should Have to Support Implementation In addition to being based on child development theory, practitioner wisdom, and basic research, the evidence-informed program or practice should also have a strong logic model, implementation guidelines, and a history of positive results. A strong logic model is a graphic or table that includes a description of why there is a need for a program or practice, with whom the program or practice will be used, what the key elements of the program or practice are, how much and how well the program or practice activities are delivered as intended, what the outcome for the program or practice recipients was, and how the outcome will achieve long term goals. A history of demonstrated positive results means data collected on an ongoing basis by the implementers of a program or practice that shows that the program or practice is associated with expected or anticipated benefts. The Resource Guide provides a review of the evidence of positive results available for commonly funded Smart Start activities. The local partnership will need to provide its own history of results for those initiatives that are not covered in the research literature. The fgure below shows one way that the criteria for an evidence-informed program or practice are related. Both theory and a strong logic model are used to describe or specify a theory-of-change. The theory-of-change is informed by an evidence-base that justifes why the theory-of-change should explain why a program or practice ?ought to work. There must be a child development theory, a strong logic model, either qualitative or basic research fnding positive effects, practitioner evidence about when, how, and why to implement the program or practice, implementation guidelines, and a history of the program or practice demonstrating positive results. The program or practice is considered evidence-informed if each of the criteria is answered ?yes. The evidence for Child Care Health Consultation is organized using the elements of an evidence-informed practice as defned in the Defnition of Terms section above and includes the following sections: child development theory, logic model, quantitative or qualitative data, practitioner wisdom, implementation guidelines, and demonstration of positive results. They also provide guidance to early educators on healthy and safe environments which reduce the spread of infectious diseases, prevent injuries, and reduce exposure to toxins. On the pre/post test analysis there were statistically signifcant differences on 9 of the 10 policies. Kotch and his colleagues matched child care centers in three states and randomly assigned them to intervention and nonintervention groups. In the article entitled Health Consultation in Early Childhood Setting, a health care consultant describes how she works with early child care programs to develop plans to improve the quality of care for all children and to provide training for program staff. These guidelines describe the fve priority practices included in the roles and responsibilities for a generalist and the seven priority practices included in the roles and responsibilities of a child care health consultant. An important aspect of the implementation of any program is the training of the providers. The Child Care Health Consultation program includes a training course that is designed in four parts (foundations of child care health consultation, principles and practices of child care health consultation the child care environment, and demonstration of child care health consultation skills). Three of the parts contain modules that are completed by the individual and the fourth part contains a fnal project which includes a child care site visit and a report that demonstrates an understanding of the material covered in the course. A blank checklist is also included for your use when assessing other programs or practices. Conclusion this document explains the process that has been developed and used to assess the programs funded by Smart Start. It provides the defnitions of evidence-based and evidence-informed practices approved by the North Carolina Partnership for Children, Inc. It also provides examples of how to make a determination of evidence-based or evidence informed programs and practices along with fow charts and checklists for both levels of evidence. These examples will help local partnerships make the determination of the level of evidence for programs and practices that are not assessed in the Smart Start Resource Guide of Evidence-Based and Evidence Informed Programs and Practices: A Summary of Evidence. Parsons, Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3 year old children. Van Ijzendoorn, Sensitivity and attachment: A meta-analysis on parental antecendents of infant attachment. Websites that Rate Research Evidence of Programs or Practices in Early Childhood Appendix B-2. Evidence-Informed Checklist 96 Appendix B-1 Websites that Rate Research Evidence of Programs or Practces in Early Childhood Organizaton Website the Campbell Collaboraton htp:// The control may be a standard practice, a placebo ("sugar pill"), or no intervention at all. Systematic Review?A systematic review is a literature review focused on a research question that tries to identify, appraise, select, and synthesize all high quality research evidence relevant to that question. Meta-Analysis?A meta-analysis is a quantitative approach in which individual study fndings addressing a common problem are statistically integrated and analyzed to determine the effectiveness of interventions. Research Synthesis?A research synthesis is similar to a meta-analysis because it looks at many different studies of the same or similar programs or practices but may not use effect sizes for determining effectiveness or effciency. Control Group?A control group is a group of people or classrooms that closely resembling the people or classrooms in the treatment group in many demographic variables but not receiving the intervention under study and thereby serving as a comparison group when treatment results are evaluated. Any changes in this group are used to estimate what would have happened if the intervention had not been carried out. In experimental studies, the comparison group is generally referred to as the control group. An effect size is the estimated of the magnitude of a relationship without making any statement about whether the apparent relationship in the data refects a true relationship in the general population. The effect sizes from a meta-analysis of multiple studies must be large enough for a researcher to conclude that the program or practice was effective or effcient. Pre-Test/Post-Test?In a single group research study, the same parents or practitioners are measured before the intervention (pre-test) and then re-measured after the intervention (post-test). Theory of Change: the types of services, resources, and supports that are offered or provided to families participating in parent and family resource programs include parenting classes, parent-child groups, parent support groups, parenting materials, information and referral, child development advice, mutual parent supports, adult education, and drop-in child care. Some but not all family and parent resource programs provide nutritional services, child health care, employment services, and recreation activities. Family resource and community-based parent resource programs are premised on the belief that when needed services, resources, and supports are made available to families, and particularly parents, parents are more likely to have the physical and psychological time and energy to devote to child rearing responsibilities. These programs are also premised on the belief that the parenting services, resources, and supports available to parents will promote and develop their parenting knowledge and skills which in turn are used to promote and enhance child learning and development. Program Features: the core features of family resource and community-based parent resource programs include. Use of family support principles for guiding the ways in which program staff treat and involve families. Target Audience: Pregnant women and families of children birth to age of entry into kindergarten, although there are now many family resource programs that serve older children and adolescents and their families Research Evidence: Two research syntheses and two research reviews include analyses of different types of family resource program models and practices and their relationships to different parent, child, and family outcomes [1-4]. Both the Goodson [3] and Trivette and Dunst [4] reviews included analyses of fndings from studies of different kinds of family resource and parent resource programs including those in the Dunst et al. The table summarizes the fndings from the two syntheses and two reviews in terms of the different parent and child outcomes that were the focus of analysis. Evidence for changes and improvements were reported in all four sources for parenting knowledge, parenting skills, child social development, and other kinds of child development outcomes. Changes and improvements in parent well-being, parent self-effcacy beliefs, and family well-being were reported in two research reports. In the two meta analyses [1, 2], the positive effects for participation in family resource programs or provision of supports in a family-centered manner were found for most but not all studies in the research syntheses. A particular pattern of results were reported by nearly all the reviewers of the studies included in their reports. The strongest effects for family resource program participation were found for improvements in parenting knowledge, parenting skills, and parent self-effcacy beliefs, and the smallest effects were found for outcomes that were not direct targets of the family resource program interventions. This was not surprising since the theory of change for these programs are premised on the fact that some effects would be expected to be indirect mediated by other variables. These types of indirect effects were the focus of two meta-analyses of the provision of supports in a family-centered manner [5, 6]. In both research syntheses, staff treatment of families in a manner consistent with the core principles of family resource programs were indirectly related to parent and family well-being mediated by self-effcacy beliefs. Similarly, the infuences of how staff treated families were indirectly related to parent-child interactions mediated by parenting competence and confdence beliefs. These types of indirect relationships were reported in both meta-analyses for the infuence of treating families in a family-centered manner and a number of different child outcomes. The extent to which one-stop-shopping family resource centers or programs where different services, resources, and supports available from the same program or organization were co-located in the same center had added benefts was a special focus of the search for studies of the effectiveness of family resource programs. Results showed that providing different services 111 to children and families in the same location was associated with better outcomes compared to programs where services were provided in different locations to the same children and families. The particular combination of services that were provided at the same center or location however could not be determined from the ways in which the fndings were reported by Layzer et al. Research Evidence for Parent and Family Resource Programs Parent/family outcomes Child outcomes Parent Parent Parent Family Parent Child social Child Research evidence knowledge skills well-being well-being e?

However gastritis diet �� generic renagel 400mg mastercard, although it will soon be two decades since and female participants in signifcant numbers gastritis symptoms back buy renagel on line amex. Further studies mary prevention were derived from fve large trials that are required to provide evidence that aspirin at equivalent enrolled mostly men gastritis diet gastritis symptoms generic renagel 800mg with mastercard. This Pharmacists in all practice setings can become involved is a generally favorable risk-to-beneft ratio gastritis diet 4 your blood buy renagel 800mg on-line. The pharma aspirin therapy is unacceptably high to be routinely recom cist should make a concerted efort to counsel women from mended gastritis weight gain order renagel 400mg with amex. Aspirin therapy must be individualized and based underserved communities because these women have the on the relative benefts and risks of the specifc patient gastritis xantomatosa order discount renagel line. Pharmacists can be involved in research ary prevention trials that did not explore the risk/beneft of interventions that determine the most efective approach to aspirin therapy in a sex-specifc fashion. Few women were educating women about signs and symptoms of cardiovas enrolled in these trials, but subgroup analyses pointed to cular events, as well as strategies to avoid delay in seeking similar benefts derived between the sexes. Other Drugs in Women Willingness to participate in clinical trials has been Although the Seventh Report of the Joint National examined in randomized prospective fashion, demonstrat Commitee on Prevention, Detection, Evaluation, and ing that women are less likely to participate because of a Treatment of High Blood Pressure does not suggest a sex lower trust of researchers and a greater perceived risk from based approach to hypertension, the presence of certain research participation. Pharmacists who conduct clinical conditions in women may infuence the selection of anti trials should use awareness of these sex-based diferences hypertensive therapy. For example, certain antihypertensive in perceived risks and benefts to improve the participation agents can cause developmental abnormalities and fetal of women. Pharmacists can promote the use of primary and second Finally, numerous clinical trials have established the car ary prevention guidelines to improve drug use and improve diovascular risk associated with estrogen therapy. Conclusion Cardiovascular disease remains the leading cause of mor tality in women; it is responsible for almost as many deaths Role of the Pharmacist in the United States as the next fve leading causes of death While we await further research on how sex may infu combined. Women seemed to beneft more than men from As the awareness of true disparities and sex-related difer the protective efects of exercise and alcohol. These fndings should be hypothesis gen Greater recruitment and enrollment of women in clinical erating for future research on lifestyle modifcation (diet, trials is essential to providing sex-specifc results. Sex-related exercise, and alcohol) and its infuence on sex-specifc mor considerations in administering drugs may maximize the tality reduction. This review focuses on sex-specifc factors that contribute to hypertension in women. Evidence-based guidelines for cardiovascu of lef ventricular hypertrophy, heart failure with preserved lar disease prevention in women: 2007 update. Data literature specifc to women, as well as a comprehensive outlining risk factors specifc to women for the development review of primary prevention strategies known to be efec of hypertension are explored, including hormone therapy, tive in both sexes. With few exceptions, recommendations oral contraceptive use, alcohol, and other nutritional factors. Clinicians treating patients with mendations for avoiding certain drugs in pregnancy. The hypertension will fnd this review useful with respect to sex guideline acknowledges that almost all women are at risk specifc infuences on this disease. A science advisory from the because many prevention strategies have not been studied American Heart Association Prevention Commitee of the extensively in women, but also because it is not comprehen Council on Cardiovascular Nursing, Council on Clinical sive in this respect. Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes 2. Participants were screen everyone with coronary heart disease for depression observed for 4 years. Although data suggest depression afects sity were similar for men and women, but sex-specifc risk women more than men, this guideline is limited because it factors were also observed. Population-atributable risks does not review depression or the need to treat depression from psychosocial factors were higher in women than men in a sex-specifc fashion. Interviews are included, which can introduce recall bias because they are retrospective. The Reynolds risk score and were treated less ofen with statin and aspirin therapy. Research is artery disease by angiography, women were more likely to under way to determine the validity of this risk tool in these have angina at follow-up (57% vs. Symptom presentation of women with Secondary prevention therapies with antiplatelet and lipid acute coronary syndromes. One limitation of this study is that it is based goal of determining whether sex-related diferences in pre in European cardiology practices; as such, it may not be rep sentation are signifcant enough to warrant separate public resentative of other populations. Women with chest pain are more likely to have the assessment of myocardial ischemia in the absence of nonobstructive coronary disease. This supplement contains only a few of the most ing potential gender biases and sex-specifc observations. Angina with ?nor nosis of women with nonobstructive coronary disease are mal coronary arteries. Reviews from the inception of the database to 2004; they also provide evidence from cohort, registry, and trial 9. Percutaneous coronary intervention patients exhibiting chest pain without obstructive coronary and adjunctive pharmacotherapy in women. A statement fndings, although no randomized trial data are available to for healthcare professionals from the American Heart compare these therapies with cardiovascular event reduc Association. This review provides the clinician with the view available safety and efcacy data of interventional therapies point that nonobstructive coronary disease, found more in women and ofers a thorough review of adjunctive phar ofen in women, is not benign. College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Commitee to 10. Four class I recommendations are made Implementation of the American College of Cardiology/ specifcally for women; these include the same drug therapy American Heart Association Guidelines) National Quality as men for both hospitalization and secondary prevention, Improvement Initiative. Women were older, had more comorbid conditions, at high risk may beneft from invasive strategies to the and had a 25% greater adjusted risk of mortality than did same extent as men. A criticism of these fndings is that minor, and combined major and minor bleeding were all a greater percentage of preexisting comorbid conditions in signifcantly increased in women assigned to the enoxapa women could have infuenced complications afer the pro rin treatment group. The fndings of no signifcant beneft and potential older than 75, and the dosage of enoxaparin was reduced by 25% because most older patients had diminished kid for harm from angiography in women with low-risk features ney function. A criticism of this trial was that enoxa for a biomarker-specifc treatment approach in women. The bleed minutes apart) or a combination of abciximab (standard ing risk atributable to excessive dosages was much higher dose of a 0. Bleeding was signifcantly lower for for comorbidities, female sex was independently associated both women and men who received proper dosage adjust with death (9. A higher risk of death between 30 days and 1 speculated that one-fourth of the diference in bleeding risk year was noted in women (3. A randomized trial of low dose aspirin in the primary prevention of cardiovascular disease in women. This large, randomized, placebo-controlled study is important because it is the frst primary prevention study of aspirin conducted solely in women. Randomized tri als have previously shown cardiovascular beneft for men with aspirin use, with litle protection from ischemic stroke. Fatal stroke rates were not diferent between placebo and treatment groups; however, the aspirin group had a 19% decreased risk of nonfatal stroke (p=0. In addition, estimated harms from aspirin ther apy are calculated on the basis of sex and age. It represents the work of a primary and sec charge de la cardiopathie ischemique stable. Elle represente le travail ondary panel of participants from across Canada who achieved d?un panel principal et d?un panel secondaire de participants de l?en consensus on behalf of the Canadian Cardiovascular Society. The semble du Canada qui ont atteint un consensus au nom de la Societe suggestions and recommendations are intended to be of relevance to canadienne de cardiologie. Les suggestions et les recommandations primary care and specialist physicians with an emphasis on rational doivent avoir rapport avec les soins primaires et les medecins Received for publication May 15, 2014. These recommendations are aimed to provide a reasonable Corresponding author: Dr G. John Mancini, University of British and practical approach to care for specialists and allied health professionals Columbia, Diamond Centre, Room 9111, 2775 Laurel St, Vancouver, British obliged with the duty of bestowing optimal care to patients and families, and can be subject to change as scienti? Adherence to these recommendations will not necessarily produce successful outcomes in every case. Of these, 54% were due to ischemic heart priateness of diagnostic and treatment choices. We recommend that a focused history and physical have since occurred and guidelines from other societies examination be obtained to elucidate symptoms, car 3,4 updated. We suggest that initial assessment be supplemented by tion considered bias, consistency, and precision of study re routine testing that includes hemoglobin, full choles sults but with a major emphasis on readily available methods terol panel, fasting glucose, hemoglobin A1c, renal in community practices. Clas sically, angina is described as a dull retrosternal discomfort/ ache/heaviness that might or might not radiate to the jaw, neck, shoulders or arms, is provoked by exertion or emotional stress, and is relieved within 5 minutes of rest or nitroglycerine 2 use. However, nonclassical symptoms are common, partic ularly among diabetic patients, and even response to nitro 17-19 glycerine might be misleading. Accordingly, the context is important and all risk factors should also be considered (Table 1). Routine laboratory tests should be obtained to determine the presence and severity of factors that might in? Literal adherence to the pretest probabilities as shown for tomography are rapid and exciting but not generally available 22,29 example in Figure 2 is not appropriate. Therefore, although Figure 2 would imply that only men 50 years of age with commonly available tests are emphasized, local expertise and typical angina can be con? Testing access to specialized tests should be considered when making in this group will identify high-risk features affecting man these choices. The diagnostic accuracy of noninvasive tests agement decisions and dictating the pace at which the next varies (Table 4). It is also of greatest relevance to patient perception of Finally, the intermediate risk group is an extremely broad disease. A symptom or sign-limited test should anginal criteria should undergo testing for diagnostic be performed, ideally without the in? We suggest that men 40 and women 60 years of logical testing with vasodilator perfusion imaging or dobut age with 1 of 3 anginal features should undergo amine echocardiography should be considered. Alternative diagnoses to angina for patients with chest pain Cardiovascular Pulmonary Gatrointestinal Chest wall Neurological Psychiatric Aortic dissection Pulmonary embolism Esophagitis Costochondritis Cervical disease Anxiety disorders Congestive heart failure Pneumothorax Esophageal spasm Fibrositis Herpes zoster Hyperventilation Pericarditis Pleuritis Biliary colic: Fibromyalgia Panic disorder Syndrome X Primary pulmonary Cholecystitis Rib fracture Affective disorders (eg, depression) (microvascular disease) hypertension Choledocholithiasis Sternoclavicular Somatiform disorders Cholangitis arthritis Thought disorders (ie,? Patients with very high risk features tricular ejection fraction generally providing the strongest 36-40 requiring de? In this case, a second test can be chosen that as life threatening arrhythmias, or who have survived sudden sesses one of the 3 elements on which diagnosis and prognosis 35 cardiac arrest. However, it should not be offered to patients can be based that has not yet been assessed (eg, follow a who do not wish to consider revascularization, or who are not nondiagnostic functional test with an anatomical test). This is determined by the considered a complement or alternative to the more routine fundamental triad of ischemic burden, anatomical burden of testing already described. Accordingly, in Figure 4, reasonable options for an initial noninvasive test in routine practice are described. Conditions that provoke or exacerbate ischemia important to keep in mind the relative radiation dosages and to ensure that the laboratory is using appropriate radiation Increased oxygen demand Decreased oxygen supply 45 reduction methods. Noncardiac Hyper/hypothermia Anemia Hyperthyroidism Hypoxemia/high altitude Sympathomimetic toxicity Pneumonia (eg, cocaine use) Hypertension Asthma Anxiety Chronic obstructive pulmonary disease High cardiac output states Pulmonary hypertension (eg, arteriovenous? We suggest that exercise testing, if possible, is preferred because it is more strongly perceived by patients as relevant to their activities than pharmacologic testing and provides assessment of functional capacity (Con ditional Recommendation, Low-Quality Evidence). We recommend that a noninvasive assessment of rest progression, and neurohumoural activation. We suggest that patients with initially equivocal or non symptoms might be modulated throughout the course of diagnostic test results or a strong discrepancy between follow-up and can often be diminished or eliminated over clinical impression and testresults beconsidered for further time. Exercise testing is also contraindicated in patients with acute myocardial infarction (within 2 days), unstable angina pectoris, uncontrolled arrhythmias causing symptoms of hemodynamic compromise, un controlled symptomatic heart failure, active endocarditis or acute myocarditis or pericarditis, suspected aortic dissection, suspected acute pul monary or systemic embolism, and noncardiac disorders that might be aggravated with exercise. Concomitant use of atropine with dobutamine stress is contraindicated in patients with glaucoma. Dobutamine should not be used in patients with ventricular arrhythmias, recent myocardial infarction, unstable angina, signi? Caution is warranted when In the absence of these, angina can be treated with either a b combining a b-blocker with nondihydropyridine calcium blocker or calcium channel blocker depending on symptom channel blockers (eg, verapamil or diltiazem) because of the relief and tolerability. In cases of suboptimal symptom relief, potential development of severe bradycardia, atrioventricular consideration should be given to switching to the other block, or excessive fatigue. In patients who might not tolerate therapy, combining b-blockers with preferably a long-acting even cardioselective b-blockers or who have contraindications calcium channel blocker (preferably a dihydropyridine), or to b-blockade (eg, asthma, severe Raynaud phenomenon), calcium channel blockers and long-acting nitrates become the recommended initial options for angina relief. Sublingual nitroglycerin can be used intermittently for exertional angina or prophylactically when certain activities are known to elicit angina. It should be noted that other antianginal medications not yet available in Canada might warrant modi? Finally, some methods for improving angina or exercise tolerance remain controversial and are not recommended at this time (eg, chelation therapy, allopurinol, magnesium sup plementation, coenzyme Q10, suxiao jiuxin wan and shenshao 3 tablets, testosterone). Failure to achieve elimination or an acceptable level of symptoms and/or an acceptable quality of life after optimal implementation of recommended Figure 5. Fundamental prognostic factors for assessing stable medications warrants consideration of revascularization rather ischemic heart disease. Based on access to care criteria within Recommendation, Moderate-Quality Evidence). This period of roughly 12-16 weeks should be adequate to aggressively institute and titrate all initial treatment with a b-blocker and/or a long-acting indicated medications, determine adequacy of symptom relief calcium channel blocker is not tolerated or contra and quality of life, and identify patients who might warrant indicated or does not lead to adequate symptom control consideration of revascularization. Many patients treated in (Conditional Recommendation, Moderate-Quality this fashion will achieve quality of life and symptom resolu Evidence).

The extra ?blow is slightly increased inhalation-exhalation in relation to the vowel sounds (?Hees) gastritis diet �� renagel 400mg low cost. Patterned paced breathing requires increased attention-focusing by the laboring woman with either a set number of ?Hees to the ?blow gastritis diet �� purchase 800 mg renagel with visa, or a random number of ?Hees to the ?blow gastritis diet 2 go discount renagel 400 mg overnight delivery. Some sample Patterned-Paced Breathing can be as follows: 3:1 the contraction begins with a cleansing breath gastritis kronik adalah renagel 400 mg on line. The woman then does 3 ?Hees and a ?blow gastritis hypertrophic buy cheap renagel 800mg on-line, 3 ?Hees and a ?blow diffuse gastritis definition order 400 mg renagel overnight delivery, and so on until the contraction ends with another cleansing breath 5:3:1. The woman does 5 ?Hees and a ?blow, 3 ?Hees and a ?blow, then 1 ?Hee and a ?blow, then 5 ?Hees and a ?blow, 3 ?Hees and a ?blow, then 1 ?Hee and a ?blow, and so on until the contraction ends with another cleansing breath. Hand Signals: With this variation, the coach hold up 2 fingers indicating that the woman is to do 2 ?Hees before the ?blow. The coach then changes to any umber of fingers to indicate how many patterned-paced breaths the woman is to take before the ?blow each time (the coach is restricted to one hand so may choose any umber between 1-5 only). With each ?blow the number of fingers changes indicating the change in number of ?Hees to be done. Hand signals are intended to be a random pattern as opposed to the above preset patterns. The most common reasons to resist the urge to push include when her cervix is not yet fully dilated or when the doctor has not yet arrived for the delivery. If a woman is directed to resist the urge to push, she will be instructed to blow through the contractions in a rapid and forceful manner. This forceful, rapid and constant inhalation and exhalation of air prevents the woman from bearing down with the contractions. Although the woman does not add her expulsive effort to the contractions when she is doing rapid ?Hee-blow breathing, her uterus continues to contract and push down on the baby. The woman must remember to take in a breath for every sound or exhalation she makes. She must also maintain a fairly rapid cycle of inhalations and exhalations as a slower cycle may allow her to hold her breath and bear down which is what she is trying to avoid doing with this technique. It can be difficult for a woman to trust in herself when she perceives conflicting messages or information coming from ?experts. Following is a list of factors which have been identified as possibly having a beneficial or a detrimental effect on the progress of labor: Beneficial Effect on Labor Detrimental Effect on Labor 1. The labor the upright positions the most recumbent position is especially advantageous for the progress of labor associated with the prolongation of labor 6. Persons surrounding the laboring behave as participants woman behave as observers (decreases her sense of privacy). If the woman becomes very and is coping well, leave her alone internalized, interrupting that internalization by forcing the woman to respond to the coach or staff. A Birth Plan usually assumes a normal and uncomplicated birth, but will also contain options should a non-conforming labor occur. Below are listed numerous options from which a customized Birth Plan may be devised. It is understood that only a few of the many presented possibilities will be important to any one person or couple. Admission and Labor Procedures Routine enema (Fleet or bucket enema) upon admission to the hospital. It is understood that some procedures may best be done during a contraction such as late labor pelvic exams, episiotomy, amniotomy, etc Artificial pain relief decisions made with laboring woman/couple, not just by the staff. Delivery and Birth Primips allowed to push in labor room until bulging of the perineum, then moved into delivery room for the last few pushed and delivery of the baby. Delivery of Placenta Manual removal of placenta soon after birth of the baby. Cesarean Birth Cesarean delivery decisions due to antepartum (pregnancy) or intrapartum (labor complication. When baby is placed in the warmer for evaluation and care, the warmer is placed within sight of the mother. It is also understood that many new babies are not enormously hungry immediately after birth. What to Take to the Hospital Your bags should be packed 3 to 4 weeks before your due date, or earlier if your doctor gives you any indication that you may deliver early. Prodromal Signs of Labor Pre-Labor Signs Lightening, Engagement, or ?the baby dropped Due to relaxation of the pelvic ligaments, softening of the lower uterine segment, and somewhat to a reduction in amniotic fluid volume, the fetus moved deeper into the pelvis. This typically occurs 10 days to four weeks prior to the onset of labor in primips, and just prior to or in labor for multips. Shortness of breath and heartburn are improved while urinary urgency is increased. Loss of Mucous Plug this is the extrusion of the plug of mucous that was filling the cervical canal during pregnancy (acting somewhat like a cork in a bottle). A few drops of blood may escape with the plug but this is not to be confused with the true bloody show of active labor. It is oftentimes manifested by rearranging of the nursery, checking and rechecking that everything is just right. Spurt of Energy Many women experience extra energy within approximately 24 hours prior to the onset of labor. Once identified, this energy should be saved for labor and not expended on cleaning the house or other chores. Flu-like Symptoms and Frequent Soft Bowel Movements Many women experience frequent soft bowel movements which are hormonally induced to clear the lower intestinal tract. Usually an irregular pattern (but can be regular and will dissipate with hydration. When the length of the cervix is reduced by one half it is referred to as 50% effaced; when it has thinned out as completely as the adjacent lower uterine segment, it is referred to as 100% effaced. Admission and Hospital Labor Procedures Urinalysis Description: Upon admission to the labor unit, the woman is requested to use the bathroom and to obtain a clean catch urine sample for laboratory analysis. Considerations: Lying flat on the back during labor compresses the inferior vena cava (a major blood vessel) reducing blood flow and oxygen to the placenta and, therefore, to the fetus. Studies show that frequent position changes and/or being upright during labor (walking, standing, etc. When studied, most women reported that once they acclimated to the upright position, they tolerated their labors as well as or better than when in the recumbent position. The vaginal exam is also repeated at infrequent intervals to access the progress of labor, to determine the appropriateness of administration of medications, and to confirm the diagnosis when symptoms change. Withholding vaginal exams with these patients reduces the risk of either introducing infection, of artificially rupturing the membranes, or of stimulating a preterm labor. Considerations: the emptying activity of the stomach and intestines slows down dramatically during active labor so that oral nourishment is not digested well. Clear liquids do not require active digestion so may be ingested in small quantities during labor in the form of ice chips or small sips of water. Ice chips, sucking on a wet wash cloth, and lip balm may afford symptomatic relief. There is a rare possibility that a patient could vomit and aspirate her stomach contents with the administration of a general anesthetic. Due to this possibility, most physicians prefer their laboring patients to keep their stomachs empty in case of an emergency Cesarean delivery. Most Cesarean deliveries are accomplished with regional anesthesia, however, and not general anesthesia. Considerations: the enema is administered to empty the lower rectum which provides more space for the fetal descent (for the baby to move down). The enema may stimulate the labor by the increased release of prostaglandins upon evacuation of the bowels. The enema reduces or eliminates the possibility of expelling feces during second stage labor when the woman is actively pushing. The enema may be unnecessary if the woman has had diarrhea or numerous bowel movements prior to the onset of labor. Once the catheter is in place, the needle is removed and a bag of fluid is connected to the in-dwelling venous catheter by way of a tubing between the bag of fluid and the catheter. Prep Description: Shaving of the pubic hair of the perineum (area between the vaginal opening and rectum) and/or around the labia. Considerations: the prep was thought to eliminate a possible source of bacterial contamination. Possible knicks or scrapes of the skin occurring during the shaving procedure, however, have been found to actually increase the likelihood of infection. It was thought that a prep was necessary to provide a clear area for suturing an episiotomy or perineal tear. In the majority of women, however, there is little or no pubic hair growing in the area of the episiotomy (perineum,). If there is significant hair growth in the perineum, clipping the pubic hair just prior to delivery is usually sufficient to remove enough hair for later suturing of episiotomy repair. The perineum can be uncomfortable and itchy while the pubic hair brows back and the episiotomy heals. Amniotomy Description: the artificial rupture of the amniotic sac by the physician. A hooked instrument, called an amnihook, is inserted through the vagina and a tear is made in the amniotic membranes. The actual tearing of the membranes is painless but the procedure may be uncomfortable due to the accompanying vaginal exam. Without artificial amniotomy, the membranes usually do not rupture spontaneously in the majority of labors until late first stage labor. Considerations: Contractions become more intense as the cushion of amniotic fluid in front of the fetal presenting part is removed allowing more direct pressure against the cervix with each contraction. An amniotomy must be performed in order to attach the internal scalp electrode of the electronic fetal monitor to directly assess the fetal heart rate. Amniotomy may be performed to check for signs of meconium in the fluid, a possible sign of fetal distress. Once the amniotic sac is ruptured, the commitment is made to achieve active labor and delivery within 24 hours to reduce the chance of fetal infection. Stages of Labor First Stage of Labor That stage when uterine contractions of sufficient frequency, intensity and duration cause the cervix to dilate from 1 to 10 centimeters, or to sufficient dilation to allow passage of the fetal head down into 3 phases of labor: early, active, and transition. Second Stage of Labor Begins when dilation of the cervix is complete and ends with delivery of the infant. Third Stage of Labor Begins with delivery of the infant and ends with delivery of the placenta and fetal membranes. Fourth Stage of Labor Begins with delivery of the placenta and lasts for an hour or so after delivery during which time uterine ?after contractions act to control bleeding from the placental implantation site. Menstrual cramps, gas pains, indigestion, abdominal tightening Descent Station of presenting part 2 or -1 Bloody Show Color. May also be felt as back pain with ?back labor Descent Station of presenting part -2, -1 or 0 Bloody Show Color. Speak to mother or give her instructions using simple, positive and direct statements between contractions. Time & record contractions Use trigger words from previous practices such as ?Relax, ?Let go, ?Release tension, ?Concentrate, ?You are wonderful, ?You can do this, ?I love you, and so on. May also be felt as back pain with ?back labor Descent Station of presenting part -1 to +1 Bloody Show Color. Moderate to copious Emotional and Behavioral Changes in the Woman Irritable Anxious Feeling of panic Susceptible to suggestions, vulnerable, dependent Mood change. Have her urinate at the onset of transition Encourage position changes 1-2 times per hour Decisions with mother and health team Actively support her relaxation as much as possible, and breathe with her as necessary. Use appropriate breathing to prevent urge to push when it occurs, until pushing is allowed. Pressure on tailbone, rectum and pelvic floor with rectal bulging, flattening of the perineum and heavy bloody show. In multips, the uterus often contracts vigorously at intervals giving rise to painful sensations known as ?after contractions. Detachment of placenta typically occurs within 5-30 minutes after birth of infant. This is done to assist the uterus to contract efficiently to reduce the amount of vaginal bleeding thereby minimizing the possibility of postpartum hemorrhage. Lochia (vaginal discharge of blood and tissue) begins after delivery of the placenta and, initially, is bright red in color and large in quantity. Episiotomy and/or any vaginal or perineal tears are repaired Woman experiences generalized body trembling (?shakes) due to circulatory changes which can be misinterpreted as chills or as being cold Woman is typically alert, euphoric, tired, emotional, laughing, and/or crying She seeks reassurance that the infant is normal. After th th e 10 day, the lochia assumes a yellowish-white color as is scant in amount. Lochia tends to disappear in 3-4 weeks after delivery but can persist for up to 6 weeks with early resumption of activities) Fundus is massaged every 15 minutes for first hour after delivery to assess uterine firmness and amount of lochia flow the bladder postpartum has an increased volume capacity and a relative insensitivity to increased fluid pressure. Overdistention of the bladder can dislocate the uterus causing hypotonus leading to excessive bleeding. Incomplete urine emptying and excessive urine retention can lead to bladder infections. Retells own account of labor May feel relief, elation, excitement or exhaustion May be hungry due to missed meals while participating in the labor. Pushing for Birth the primary consideration in choosing an expulsive position is its ability to promote the optimal progress of labor. The position of the mother, the position of the baby, and whether the mother is anesthetized or not can affect the efficiency of the maternal bearing down effort during second stage labor. This, in turn, can effect the length of time spent, and the amount of effort expended in second stage labor or expulsion of the baby. Good access to the perineum for control of delivery and/or use of interventions such as episiotomy, anesthesia, for ceps, etc. Takes pressure off of hemorrhoids May not be convenient for birth No weight on inferior vena cava attendant.

Together gastritis symptoms temperature buy renagel overnight delivery, these 3 vari fibers gastritis diet what to eat discount 400 mg renagel with mastercard, the stroke volume increases gastritis symptoms back pain renagel 800 mg lowest price, up to its maximum capacity gastritis from not eating order discount renagel line. If stroke volume cannot be main tained gastritis diet 7 up generic 800mg renagel visa, then heart rate must increase to maintain cardiac which elevates left-atrial pressure and pulmonary venous output gastritis diet menu purchase renagel from india. Initially, this response will suffice, but pro Based on autonomic input, the heart will respond to the longed activation results in loss of myocytes and maladap same preload with different stroke volumes, depending on tive changes in the surviving myocytes and the extracel inherent characteristics of the heart. The stressed myocardium undergoes remodeling and dilation in response to the insult. Remodeling also results in additional cardiac decompensation from complications, including mitral re gurgitation from valvular annulus stretching, and cardiac arrhythmias from atrial remodeling. Patients presen tation can greatly differ, depending on the chronicity of the disease. For instance, most patients experience dyspnea when pulmonary-artery occlusion pressure exceeds 25 mm Hg. This series of Frank-Starling curves demonstrates that at any given preload (end-diastolic volume), increases in contractility capillaries are recruited and increase capacitance to deal with the added volume. At this point, by action of pressure gradients, fluid will form in the interlobular septae and the perihilar region. As noted above, chronic heart failure is associated with increased venous capacitance and lymphatic drainage of the lung. As a result, crackles are often absent, even in the setting of elevated pulmonary capillary pressure. Con tinued sodium retention preferentially results in peripheral edema and, ultimately, in the development of pleural ef fusions. The long-term response to elevated pulmonary venous pressure includes interstitial fibrosis with thicken ing of the alveolar membrane. Evaluation of the Patient With Congestive Heart Failure patients with dyspnea, a chest radiograph is a useful first test for differentiating patients with heart failure from pa the approach to the patient with suspected heart failure tients with primary pulmonary disease (Fig. Radio includes a history and physical examination, chest radio graphic findings suggestive of heart failure include car graph, and a series of diagnostic tests to assess both the diomegaly (cardiac-to-thoracic ratio above 50%), acuity and severity. History alone is insufficient to make cephalization of blood vessels, increased interstitial mark the diagnosis of heart failure, but often provides clues to ings, and pleural effusions. Patients with previous evi failure can be related to either the reduction of cardiac dence of heart disease, diabetes mellitus, hypertension, or output (fatigue, weakness) or to excess fluid retention (dys documented coronary-artery disease are at increased risk pnea, orthopnea, and ?cardiac wheezing). Fluid retention also ments of cardiac contractility, there were no laboratory results in peripheral edema and occasionally in increasing tests to assist in the diagnosis of heart failure. Absence of dyspnea triuretic peptide is one of a family of neurohormones that on exertion essentially rules out heart failure due to left is produced by the ventricles in response to increased pres ventricular dysfunction. It works to counteract the effect of crackles and wheezing) is predominant in acute or sub the renin-angiotensin system by providing vasodilation, acute disease. A 45), which correlates with elevated pulmonary-artery oc cut-off value of 100 pg/mL diagnoses heart failure with clusion pressure 80% of the time. Pleural effusion blockers protect the heart from the harmful effects of Tachycardia (120 beats/min) norepinephrine and epinephrine. Intolerance to blockers is uncommon and is usually due to bradycardia or dizziness. Diuretics are essential in the relief of dyspnea and signs Therapy for Congestive Heart Failure of sodium and water retention (peripheral edema or pleural effusion). They are best used in the minimum dose needed Understanding the pathophysiology of heart failure al to maintain the ?dry weight in patients with symptomatic lows one to achieve the goals of treatment, which are to heart failure. Much litera ventricular synchronization, in the hope of improving car ture and research has been published on medical manage diac output. The basic theories include termination of the brillators reduce the risk of death in patients who have renin-angiotensin system to prevent the long-term compli moderate-to-severe symptomatic heart failure and a re cations of the cascade. Treatment often focuses on a com duced ejection fraction despite maximum medical thera bination of afterload-reduction with angiotensin-convert py. Although clinical trials have shown signifi they experience in performing certain activities (Table cantly lower mortality with multiple interventions, the over 2). A recent randomized controlled trial by apneic event, exacerbating the underlying cardiac dysfunc Mansfield et al45 attempted to show clinical benefit from tion. This allows randomizing patients to treat pulmonary edema, which leads to initial hyperventilation. Hanly et al, in a one-night study, decreased compliance, increased airway-closing pressure, discovered that nocturnal oxygen improved oxygenation increased work of breathing, and greater oxygen consump and sleep architecture and decreased sleep-disordered tion. The patients Acute pulmonary edema with respiratory distress is a were predominantly older, white, and male, and had isch common presentation to the hospital. Consistent with pulmonary edema is that positive pressure may limit the previous trials, early analysis showed an improvement in decrease in functional residual capacity, improve respira the occurrence of central apnea, increases in mean oxygen tory mechanics and oxygenation, and decrease left-ven saturation, improved ejection fraction, and suppression of tricular preload and afterload. However, the primary out improve hypercarbia, with a greater decrease in work of comes (death and cardiac transplantation) did not differ breathing. Furthermore, are probably those presenting to the emergency room and no difference was observed in morbidity measured by qual who have a narrow time-window for intervention. Pang et al performed the first meta-analysis concerning Only one prior study reported a mortality benefit with the the use of positive-pressure airway support. Positive pressure ventilation pressure to the maximum tolerated, and expiratory pres in the management of acute and chronic cardiac failure: a systematic sure to a rise in oxygen saturation (initial settings 10/5 cm review and meta-analysis. Do patients with proved the respiratory rate, dyspnea score, and ratio of suspected heart failure and preserved left ventricular systolic func PaO to fraction of inspired oxygen; however, there was no 2 tion suffer from ?diastolic heart failure or from misdiagnosis? A significant reduction in hospital mortality or need for in prospective descriptive study. Disorders of the heart: normal and abnormal myo cal therapy, and significantly reduced the intubation rate. Pulmonary factors limiting exercise capacity in pa the airway, inability to clear secretions, high risk for as tients with heart failure. Coronary artery disease cally the most critical factor is setting an end point for the in patients with heart failure and preserved systolic function. Am J determination of the need for invasive ventilation, thereby Cardiol 2002;89(6):719?722. Medical therapy can improve the biolog ical properties of the chronically failing heart: a new era in the Summary treatment of heart failure. J Appl in the differential diagnosis in all adult patients who present Physiol 1964;19:713?724. Pulmonary circulation and nosis is established by a careful history and physical ex regulation of fluid balance. Ultrastructural appearances of pulmonary capillaries at high trans giogram may be required if the diagnosis of pulmonary mural pressures. The limited reliability of physical signs directed toward normalizing the underlying physiologic for estimating hemodynamics in chronic heart failure. Brain natriuretic peptide in the management of heart failure: the versatile neurohormone. Chest hypertension) may halt or slow the progression of the dis 2004;125(2):652?668. B-type natriuretic peptide measurements in diagnosing nary disease, cigarette abuse, or diabetes) is essential in congestive heart failure in the dyspneic emergency department pa optimizing patient outcome and improving quality of life. Sleep-related breathing dis development of heart failure in asymptomatic patients with reduced orders and cardiovascular disease. Cardiac resynchronization in chronic heart fail women with congestive heart failure. Daytime sleepiness, snoring, and obstructive sleep ap tum in: N Engl J Med 2005;352(20):2146. Controlled trial of continuous positive airway pres statement for healthcare professionals from the Cardiovascular Nurs sure in obstructive sleep apnea and heart failure. Arch Intern Med syndrome in patients with chronic heart disease: a critical review of 1995;155(12):1297?1302. Plasma norepinephrine as a guide to prognosis in patients with Sleep 1999;22(5):667?689. Influence of negative intrathoracic pressure on right atrial and systemic venous dynamics. Ventilatory and hemodynamic effects of continuous positive air heart failure and central sleep apnea. Ventilatory and diffusion abnormalities in potential tients with heart failure and obstructive sleep apnea. Lung membrane diffusing capacity, heart failure, and heart Obstructive sleep apnoea in patients with dilated cardiomyopathy: transplantation. Anesth Analg 1997; pressure airway support on mortality and the need for intubation in 84(5):1091?1096. Crit Care Non-invasive pressure support ventilation versus conventional oxy Med 1997;25(4):620?628. Noninvasive ventilation in cardiogenic pulmonary edema: a namic effects of bilevel nasal positive airway pressure ventilation in multicenter randomized trial. For these reasons, updated training material for new and experienced triage nurses is required. The design is conducive to computerization and can offer nurses decision support at the point of care. This tool can be posted on a computer at triage for nurses to refer to to assist in their decision making and assigning of a triage score. Posters and desk reference tools are also available to purchase for education and support at triage. It is a process by which patients are prioritized and classified according to the type and urgency of their conditions. Sorting of patients for the purpose of determining treatment priorities originated on W orld W ar I battlefields. The military intent was to provide care to the casualties who could be salvaged for a rapid return to the war front. Combat triage was guided by the maxim ?The best for the most with the least by the fewest (Simoneau, 1985). In contrast, the medical intent of triage in hospitals is to assign resources as quickly as possible to those with the highest acuity. The process of triage was introduced to hospitals in the early 1960s to address the increasing number of emergency visits following the introduction of Medicare and to deal with patients with non-urgent conditions. Initially a variety of triage methods were used with three-level triage (emergent, urgent, non-urgent/deferrable) the most common. The effect of a series of triage decisions is to identify those that need to be seen first and create a priority list by acuity level (or risk) of those patients waiting for treatment. Those with more acute conditions are seen first, in order to reduce the risk that their condition may deteriorate. Ensures that the critically ill or injured receive attention before the less ill or injured patients 2. A timely approach alleviates the anxieties of the patient and/or their caregiver(s) knowing that they are in the system and can improve lines of communication. It becomes even more critical to identify the sickest and those patients at greatest risk for a bad outcome and to prioritize them to be seen. This needs to be clear to patients, colleagues, administrators and government officials alike. At best it offers the failing system an imperfect safety net to minimize waiting room morbidity and mortality. One of the goals of this process is to shorten the time from arrival to assessment by an Emergency physician by ensuring patients not requiring stretcher care have alternate treatment spaces to wait in. The triage process should not become a block, or significant delay, but rather a way of ?streaming patients to the most appropriate care area. The goal for all parts of the health care continuum is ?right patient, right place, right time, with right care giver. The safety of the person incorrectly assigned to a lower level may be compromised. Patients arrive experiencing symptoms, not a diagnosis and the full range of their health issues is not known the conditions seen may combine medical, surgical, mental health or social emergencies the patients encompass all ages, cultures, and ethnicities requiring the triage nurse to have knowledge of the impact of these factors on presentations and patient and family expectations An number of patients have to access emergency departments for primary health care due to lack of community health resources Notes: 5 1. Communicating with the Public the triage nurse is usually the public face of the emergency department, and often the entire hospital. The triage nurse is usually the only health professional in contact with patients in the waiting room. Their attitude and behavior is on public display and requires great tact and patience. Communicating with Health Professionals the triage nurse collaborates with various members of the health care team the charge nurse or primary nurses, emergency physicians, paramedics, nurse practitioners, physician consultants, security staff, registration clerks and others?to facilitate the movement of patients into treatment. Triage requires coordination between the charge nurse and emergency physicians in order to make efficient use of treatment resources. Initiating treatment protocols/first aid measures Individual facilities may have medical directives/treatment protocols for the triage nurse to provide symptom relief or initiate limited investigations. Monitoring and Reassessing It is the responsibility of the triage nurse to monitor and reassess the waiting room patients to identify changing conditions. Participating in patient flow the triage nurse collaborates with the primary care team to coordinate patient flow. Documenting the Triage Nurse documents all relevant findings in accordance with hospital or provincial regulations. Documentation requirements must never delay treatment in critically ill or injured patients.

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