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Adams and col- leagues found similar types and distributions of injuries among the adoles- cent complainants (14–19 years) they examined (132) buy viagra plus 400mg online. In this population viagra plus 400 mg sale, tears of the posterior fourchette or fossa navicularis were the most common find- ings (40%) buy discount viagra plus 400 mg on line. The studies of macroscopic findings among complainants of sexual assault have also found that most of the injuries detected are located on the external genitalia (133 400 mg viagra plus with amex,134). Healing of lacerations of the posterior fourchette is predominantly by first intention, with no residual scarring being detected at follow-up assess- ments (90). Nonetheless, scarring may occur occasionally in these areas, but it is important not to mistake a linear vestibularis, a congenital white line iden- tified in the fossa navicularis (present in 25% of neonates), for a scar (135). Accidental injuries of the external genitalia of female children are well documented in the literature. The site and nature of the injury will depend on the type of trauma and the conformation of any object involved (136,137). Hymen The hymen must be examined in detail after an allegation of a nonconsensual penetrative act. When the hymen is fimbriated, this assess- ment may be facilitated by the gentle use of a moistened swab to visualize the hymenal edges. When the hymenal opening cannot be seen at all, application of a few drops of warm sterile water or saline onto the hymen will often reveal the hymenal edges. Foley catheters are also a useful tool to aid hymenal visu- alization in postpubertal females (138). A small catheter is inserted through the hymenal opening, the balloon is then inflated with 10–20 mL of air, and the catheter is gently withdrawn so that the inflated balloon abuts the hymen. Obviously, in the acute setting, none of these maneuvers should be attempted until the relevant forensic samples have been retrieved. There is little specific information available regarding the type and fre- quency of acute hymenal injuries after consensual sexual acts, particularly regarding the first act of sexual intercourse. They found lac- erations (tears) with associated bruising at the 3-o’clock and 9-o’clock posi- tions on the hymen of a 14-year-old and bruises at the 6-o’clock and 7-o’clock Sexual Assualt Examination 95 positions on the hymens of two other females (aged 13 and 33 years). Unfortunately, no details regarding pre- vious sexual experience are recorded on their pro forma. In the same article, the hymen was noted to be one of the four most commonly injured genital sites among 311 postpubertal complainants of nonconsensual sexual acts. The hymenal injuries detected colposcopically were bruises (n = 28), lacerations (n = 22), abrasions (n = 13), swelling (n = 10), and redness (n = 4). The hymenal lacerations were either single (n = 12), nine of which were at the 6-o’clock position, or paired around the 6-o’clock position (n = 10). The authors found that hymenal lacerations were four times more common in the younger age groups. Bowyer and Dalton (133) described three women with hymenal lacerations (detected with the naked eye) among 83 complainants of rape who were examined within 11 days of the incident; two of the three women had not previously experienced sexual intercourse. One retrospective survey of the acute injuries noted among adolescent com- plainants of sexual assault (aged 14–19 years) found that hymenal tears were uncommon, even among the subgroup that denied previous sexual activity (132). Bruises, abrasions, reddening, and swelling completely disappear within a few days or weeks of the trauma (90,139). Conversely, complete hymenal lacerations do not reunite and thus will always remain apparent as partial or complete transections (123), although they may be partially concealed by the effects of estrogenization (140). However, lacerations that do not extend through both mucosal surfaces may heal completely (2). There is one case report of a 5-year-old who was subjected to penile penetration and acquired an imperforate hymen resulting from obliterative scarring (141). On the basis of the current literature, complete transections in the lower margin of the hymen are considered to provide confirmatory evidence of pre- vious penetration of the hymen. However, it is not possible to determine whether it was a penis, finger, or other object that caused the injury, and there is an urgent need for comprehensive research to determine whether sporting activi- ties or tampon use can affect hymenal configuration. Although partial or com- plete transections of the upper hymen may represent healed partial or complete lacerations beyond the acute stage, there is no method of distinguishing them from naturally occurring anatomical variations. Goodyear and Laidlaw (142) conclude that, “it is unlikely that a normal- looking hymen that is less than 10 mm in diameter, even in the case of an elastic hymen, has previously accommodated full penetration of an adult fin- ger, let alone a penis. On the other hand, it is now generally accepted that postpubertal females can experience penile vaginal penetration without sustaining any hymenal deficits; this is attributed to hymenal elasticity (142,143).

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Higgins and Moore (2000) continue exam- structions about the nature and goals of nursing order 400 mg viagra plus otc. Theories developed at the middle range include specific concepts and are less abstract than grand theories 400mg viagra plus otc. A phi- and levels of abstraction of nursing theories order 400mg viagra plus otc, they losophy comprises statements of enduring values are also sometimes described by the content or and beliefs held by members of the discipline buy viagra plus 400mg overnight delivery. Types of Nursing Theory Philosophical statements are practical guides for examining issues and clarifying priorities of the Nursing theories have been organized into cate- discipline. George (2001) sets forth cate- to examine compatibility among personal, profes- gories of theories according to the orientation of sional, organizational, and societal beliefs and the theorist: nursing problems, interactions, gen- values. Conceptual models are sets of general concepts and Meleis (1997) describes types of nursing theory propositions that provide perspectives on the based on their levels of abstraction and goal orien- major concepts of the metaparadigm, such as per- tation. Barnum (1998) divides theories into those son, health and well-being, and the environment. Types of nursing theories generally in- beliefs, as in philosophical statements and prefer- clude grand theory, middle-range theory, and ences for practice and research approaches. Conceptual models are less abstract Grand theories have the broadest scope and present than the metaparadigm and more abstract than general concepts and propositions. Theories at this theories, offering guidance (not distinct direction) level may both reflect and provide insights useful to nursing endeavors. Conceptual models may also for practice but are not designed for empirical test- be called “conceptual frameworks” or “systems. This limits the use of grand theories for direct- ing, explaining, and predicting nursing in particular situations. In general, nursing theory describes and explains Development of grand theories resulted from the phenomena of interest to nursing in a system- the deliberate effort of committed scholars who atic way in order to provide understanding for use have engaged in thoughtful reflection on nursing in nursing practice and research. Although there is debate about which nursing theories are grand in scope, the fol- Nursing practice theory has the most limited scope lowing are usually considered to be at this level: and level of abstraction and is developed for use Leininger’s Theory of Culture Care Diversity and within a specific range of nursing situations. Universality, Newman’s Theory of Health as Theories developed at this level have a more direct Expanding Consciousness, Rogers’ Science of impact on nursing practice than do theories that Unitary Human Beings, Orem’s Self-Care Deficit are more abstract. Nursing practice theories pro- Nursing Theory, and Parse’s Theory of Human vide frameworks for nursing interventions and pre- Becoming. These theories are presented in the third dict outcomes and the impact of nursing practice. At the same time, nursing questions, actions, and procedures may be described or developed as nurs- ing practice theories. Practice theories theories that are both broad enough to be useful in should also reflect concepts and propositions of complex situations and appropriate for empirical more abstract levels of nursing theory. Nursing scholars proposed using this level veloped at this level is also termed prescriptive the- of theory because of the difficulty in testing grand ory (Dickoff, James, & Wiedenbach, 1968; Crowley, theory (Jacox, 1974). Middle-range theories are 1968), situation-specific theory (Meleis, 1997), and more narrow in scope than grand theories and offer micro theory (Chinn & Kramer, 2004). The depth and sitions at a lower level of abstraction and hold great complexity of nursing practice may be fully appre- promise for increasing theory-based research and ciated as nursing phenomena and relations among nursing practice strategies. Benner (1984) demon- ports of nurses’ experiences of developing and using middle-range theory. A wide range of nursing The day-to-day experience of nurses is a practice situations and nursing issues are being ad- major source of nursing practice theory. The methods used for developing middle-range theories are many and represent some of the most exciting work being strated that dialogue with expert nurses in practice published in nursing today. Many of these new the- is fruitful for discovery and development of prac- ories are built on content from related disciplines tice theory. Research findings on various nursing and are brought into nursing practice and research problems offer data to develop nursing practice (Lenz, Suppe, Gift, Pugh, & Milligan, 1995; Polk, theories as nursing engages in research-based de- 1997; Eakes, Burke, & Hainsworth, 1998).

Upper Respiratory Tract Disorders Respiratory disorders are divided into two groups: upper respiratory tract disorders and lower respiratory tract disorders buy viagra plus 400mg with amex. These include the common cold discount 400mg viagra plus overnight delivery, acute rhinitis (not the same as allergic rhinitis) effective viagra plus 400mg, sinusitis buy viagra plus 400mg mastercard, acute tonsillitis, and acute laryngitis. The rhinovirus is frequently accompanied by acute inflammation of the mucous membranes of the nose and increased nasal secretions. The rhinovirus is seasonable: 50% of the infections occur in the winter and 25% dur- ing the summer. Although no one has directly died from the common cold, it does create both physical and mental discomfort for the person and leads to a loss of work and school. During this time, the rhinovirus can be transmitted by touching contaminated surfaces and from contact with droplets from an infected patient who sneezes and coughs. After the incubation period, the patient experiences a watery nasal discharge called rhinorrhea, nasal congestion, cough, and an increasing amount of mucosal secretions. Many patients try home remedies to battle the rhinovirus, however these don’t affect the virus. Home remedies include rest, vitamin C, mega doses of other vitamins, and, of course, chicken soup. Vitamin C and mega doses of other vitamins have not been proven effective against the common cold. When home remedies fail, patients turn to both prescription and over-the- counter medication. Charts throughout these pages provide information about specific drugs in each group. Antihistamines (H blocker) 1 Many cold symptoms are caused by the body’s overproduction of histamines. Histamines are potent vasodilators that react to a foreign substance in the body such as the rhinovirus. H2 receptors cause an increase in gastric secretions and are not involved in this response. This is referred to as nasal con- gestion and is caused when the nasal mucous membranes swell in response to the rhinovirus. A decongestant is a drug that stimulates the alpha-adrenergic receptors to tell the brain to constrict the capillaries within the nasal mucosa. The result is that the nasal mucous membranes shrink, reducing the amount of fluid that is secreted from the nose. Decongestants are available in nasal spray, drops, tablets, capsules, or in liq- uid form. These are nasal decongestants that provide quick relief to the patient; systemic decongestants that provide a longer lasting relief from congestion; and intranasal glucocorticoids that are used to treat seasonal and perennial rhinitis. Cough Preparations A cough is a common symptom of a cold brought about by the body’s effort to remove nasal mucous that might drain into the respiratory tract. Antitussives are the ingredients used in cough medicine to suppress the cough center in the medulla. Although the cough reflex is useful to clear the air passages, suppres- sion of the cough reflex can provide some rest for the patient. Expectorants When an individual has a cold or other respiratory infection, it is common to have rather thick mucous that is difficult to expectorate. Expectorants are med- ications that loosen the secretions making it easier for the patient to cough up and expel the mucous. They work by increasing the fluid output of the respira- tory tract and decrease the adhesiveness and surface tension to promote removal of viscous mucus. A list of drugs utilized in the treatment of upper respiratory tract disorders is provided in the Appendix. Patients may take systemic or nasal decongestants to reduce the congestion that frequently accompanies sinusitis. Patients are told to drink plenty of fluids, to rest, and to take acetaminophen (Tylenol) or ibupro- fen for discomfort. In some cases, antibiotics are prescribed if the condition is severe or long lasting and an infection is suspected. Pharyngitis is caused by a virus (viral pharyngitis) or by bacteria (bacteria pharyngitis) such as the beta-hemolytic streptococci.

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