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The Legislature, in codifying the discovery rule

The Legislature, in codifying the discovery rule, has also required plaintiffs to pursue their claims diligently by making accrual of a cause of action contingent on when a party discovered or should have discovered that his or her injury had a wrongful cause. (E.g., Code Civ. Proc., �� 340.1, subd. (a) [""within three years of the date the plaintiff discovers or reasonably should have discovered""], 340.15, subd. (a)(2) [""[w]ithin three years from the date the plaintiff discovers or reasonably should have discovered""], 340.2, subd. (a)(2) [""[w]ithin one year after the date the plaintiff either knew, or through the exercise of reasonable diligence should have known""], 340.5 [""one year after the plaintiff discovers, or through the use of reasonable diligence should have discovered""].) This policy of charging plaintiffs with presumptive knowledge of the wrongful cause of an injury is consistent with our general policy encouraging plaintiffs to pursue their claims diligently. (Norgart, supra, 21 Cal.4th at p. 395, 87 Cal.Rptr.2d 453, 981 P.2d 79.)

Question 1

Is there any rationale for giving either propranolol, valproate or

buspirone to patients with cerebellar ataxia?

Question 2

Is there a laboratory marker for cerebral dominant arteriopathy with

subcortical infarcts and leucoencephalopathy (CADASIL)? Is serum lactic

acid elevated?

Question3

Primary brain tumours rarely metastasize outside the brain but

malignancies outside the brain frequently metastasize to the brain. Why?

Question 4

In a case of brain tumour, can papilloedema occur without a headache?

Question 5

What are the pathological diagnostic features of glioblastoma

multiforme?

Question 6

Is acetazolamide effective in cases of normal pressure hydrocephalus?

How effective is low-dose digoxin?

Question 7

If dementia and incontinence are present, but gait apraxia is not, can

normal pressure hydrocephalus be diagnosed?

Question 8

Is a normal CT (plain and with contrast) in patients with headache,

bilateral papilloedema and a clear conscious level sufficient to diagnose

benign intracranial hypertension?

Question 9

What is the value above which cerebrospinal fluid (CSF) pressure is said

to be raised?

Question 10

Could benign intracranial hypertension be diagnosed without headache

as a complaint?160"

Is there any reason to administer either of these drugs: propranolol, valproate, or buspirone to patients with cerebellar ataxia?

Propranolol: May be of some use in reducing tremors which are a feature of the cerebellar ataxia but its use is restricted and not always successful.

Valproate: Not given for cerebellar ataxia; more often given for epilepsy.

Buspirone: Primarily employed in the management of anxiety disorders and its use in cereral ataxia is contraindicated.

Is there a laboratory marker for cerebral dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)? Is serum lactic acid increased

CADASIL: There are no special laboratory findings, however genetic test for mutations of the NOTCH3 gene is considered to be pathognomic for the disorder.

Serum Lactic Acid: Usually, not increased in CADASIL.

The primary brain tumour does not commonly spread to other parts of the body but the extra cranial tumors commonly spread to the brain. Why?

Primary Brain Tumors: They tend to have a high propensity of invading local regions but they have low potential of spreading to distant sites because of the blood-brain barrier.

Malignancies Outside the Brain: The brain is a preferred site for metastasis and is relatively privileged from lymphatic drainage, and therefore is frequently implicated in metastatic disease.

It is very rare but possible for papilloedema to appear in a patient with a brain tumor without having a headache.

Papilloedema does not always present with a headache, although headache is one of the most frequent symptoms. Other features of raised intracranial pressure may also be seen.

What are the pathological hall marks of Glioblastoma multiforme?

Diagnostic Features: Characterised by high cellularity, necrosis and vascular proliferation. Microscopic study shows that the tumour cells are pleomorphic and there are numerous mitotic figures.

Can it then be said that acetazolamide is useful in normal pressure hydrocephalus? What can be said about the efficacy of low-dose digoxin?

Acetazolamide: Usually not useful in the management of normal pressure hydrocephalus. It is more often employed for conditions that are associated with high intracranial pressure.

Low-Dose Digoxin: Does not form part of the management of normal pressure hydrocephalus. Its use in this condition has not been well substantiated.

Even if dementia and incontinence are demonstrated, but gait apraxia is not, is it possible to make a diagnosis of normal pressure hydrocephalus?

Gait apraxia is not a feature of normal pressure hydrocephalus, so the patient does not have this condition. Diagnosis generally requires all three classic symptoms: Alzheimer’s disease, problem with walking, and inability to control urination.

Are a normal CT (plain and with contrast) in patients with headache, bilateral papilloedema and a clear conscious level sufficient for the diagnosis of benign intracranial hypertension?

BCS, also known as pseudotumor cerebri, often involves a high CSF pressure on lumbar puncture, and may not be apparent on CT scans alone.

At what level is the cerebrospinal fluid pressure considered to be raised?

Elevated CSF Pressure: Usually considered raised if it is more than 20-25 cm of water (or about 15-20 mmHg).

Is benign intracranial hypertension possible to be diagnosed without headache as a chief complaint?

No, headache is a frequent and one of the major manifestations of benign intracranial hypertension. A diagnosis is usually made in the course of a headache, papilloedema, or increased cerebrospinal fluid pressure.

Likewise, in Norgart, the daughter of the plaintiffs had committed suicide in her 673

Likewise, in Norgart, the daughter of the plaintiffs had committed suicide in her

673

673 home by intentionally taking an overdose of prescription drugs, including Halcion. (Norgart, supra, 21 Cal.4th at p. 390, 87 Cal.Rptr.2d 453, 981 P.2d 79.) We upheld the superior court's grant of summary judgment against the plaintiffs, reversing the Court of Appeal, and finding that the plaintiffs had reason soon after their daughter's death to discover their causes of action for wrongful death against Upjohn for manufacturing and distributing Halcion. (Id. at p. 407, 87 Cal.Rptr.2d 453, 981 P.2d 79.) More specifically, in Norgart we found that there was no triable issue of material fact and that Upjohn was entitled to judgment on the statute of limitations defense because the plaintiffs had reason to discover their cause of action against Upjohn soon after their daughter's death when they learned at that time of her depression and suicide by taking an overdose of prescription drugs, including Halcion. (Ibid.) The plaintiffs also learned of a possible connection between Halcion and the suicide, because such connection was disclosed during the plaintiffs' investigation on the drug's package insert, which warned of a possible suicide risk. (Ibid.)

Question 1

How often does migraine headache present unilaterally?

Question 2

Are ergotamine-containing preparations contraindicated in the

treatment of resistant migraine in hypertensive patients? Can I give it,

under close supervision of the blood pressure, in the emergency room?

Question 3

Should ergotamine be given to abort a migrainous attack in a pregnant

female? If not, what is the recommended alternative?

Question 4

What is the frequency of migrainous attacks above which prophylactic

therapy should be commenced? If commenced, for how long should

the treatment be continued and what should be done if frequent attacks

recur after discontinuation of the prophylactic treatment?

Question 5

Is verapamil more effective in migraine prophylaxis than flunarizine?

Question 6

Are imipramine and fluoxetine effective as a prophylactic treatment

against migraine? Are they as effective as amitriptyline?

Question 7

1. Is sodium valproate more effective than valproic acid with regard to

migraine prophylaxis and anti-epileptic activity?

2. Is carbamazepine effective as a prophylaxis against migraine?

Question 8

Can flunarizine, diltiazem and nifedipine be used in the treatment of a

cluster headache and do they have the same efficacy as verapamil?

Question 9

If cluster headache migraine is confidently diagnosed in general practice,

is it worth trying lithium prophylaxis or should this commence at

secondary care level? Which other treatment is recommended?180

Question 10

Is ergotamine effective in preventing an attack of cluster headache?"

Migraine and Cluster headache Management – Questions and answers.

1. Migraine headache is mostly present unilaterally; how often does it show this pattern of occurrence?

Unilateral Presentation: Migraine headaches affect one side of the head in most of the cases, with a frequency of 60 to 70%. But it is to be noted that migraines can also be bilateral – meaning they can occur on both sides of the head.

2. Are ergotamine-containing preparations safe in the use for resistant migraine in hypertensive patients? Is it safe to administer it, under close monitoring of the blood pressure, in the emergency room?

Ergotamine and Hypertension: Preparations containing ergotamine are usually not recommended for patients with hypertension because they increase the tone of blood vessels which in turn will increase the blood pressure. But in a controlled environment such as the ER, in as much as possible, they may be given with very strict monitoring of the blood pressure and frequent checks and interventions as required.

3. Should ergotamine be used to put an end to a migrainous attack in a pregnant woman? What then should one do if this is not possible?

Ergotamine and Pregnancy: Ergotamine is usually not recommended for use in pregnant women because of possible harm to the unborn baby. The preferred discipline for abortive management of migraines in pregnant women is paracetamol or some NSAIDs, depending on gestational period and patient’s condition. It is recommended to always seek the opinion of an obstetrician before instituting any treatment.

4. At what frequency of migrainous attacks should one start prophylactic treatment? If started, how long should the course of the treatment be and what should be done if the attacks occur soon after cessation of prophylactic treatment?

Frequency for Prophylaxis: Members of the prophylactic therapy are usually prescribed to patients who have from 2 to 4 migraines per month or if the attacks are so severe that they limit the patient’s ability to function. Treatment period is usually 3-6 months and the progress should be assessed from time to time. If the attack continues to appear after the cessation of prophylactic treatment, then the treatment may be continued or another drug may be chosen or the dosage may be changed.

5. Is verapamil better than flunarizine in the prevention of migraine?

Verapamil vs. Flunarizine: Verapamil and flunarizine are both employed for the prevention of migraine but the benefits of their use may not always be the same. Verapamil is a CCB while flunarizine is a CCB with other properties. Flunarizine is effective for the prophylaxis of migraine, but the evidence indicates that verapamil may be less effective than flunarizine in preventing migraines.

6. Is imipramine and fluoxetine useful as preventive therapy in migraine? Are they as useful as amitriptyline?

Imipramine and Fluoxetine: Imipramine and fluoxetine, both of which belong to the class of antidepressant drugs, are employed in the prophylactic management of migraine with more or less efficacy. Among the antidepressants, amitriptyline, a tricyclic antidepressant, is reputed to be more useful in migraine prevention than imipramine or fluoxetine. Amitriptyline is often used because it has a better empirical support and there are clinical data which support use of this drug in reducing number of migraines.

7. 1. Is the sodium valproate better than the valproic acid in averting migraine and in the treatment of epilepsy? 2. Does carbamazepine prevent migraine in patients with high risk of developing migraine?

Sodium Valproate vs. Valproic Acid: Sodium valproate and valproic acid are in fact the same in terms of effectiveness in migraine prevention since sodium valproate is the salt form of valproic acid. Both are equally efficient, though sodium valproate is employed more frequently owing to the patient’s compliance and dosing schedule.

Carbamazepine: Carbamazepine one of the anticonvulsant medications is not usually recommended for migraine prevention. It is mainly used in the treatment of epilepsy and some forms of neuropathic pain and has no indication for migraine prevention.

8. Are flunarizine, diltiazem and nifedipine effective for the treatment of a cluster headache and are they as effective as verapamil?

Flunarizine, Diltiazem, and Nifedipine: Flunarizine and verapamil are extensively used in the prevention of cluster headache; verapamil is reportedly highly effective. Diltiazem and nifedipine that belong to calcium channel blockers are less often used and their efficacy is considered to be lower than that of verapamil for cluster headache prevention.

9. Should the diagnosis of cluster headache be made with confidence in general practice, it may be useful to attempt lithium prophylaxis, or should this be done in secondary care? What other management do you advise?

Lithium Prophylaxis: Lithium is considered as a treatment for cluster headaches and it can be used if the diagnosis of cluster headache is rather confident. However, because of the possible complications and side effects of lithium this may be better initiated at secondary care level. Some other medications that are used for the treatment of cluster headaches are verapamil, corticosteroids and oxygen therapy in some occasions.

10. Does ergotamine work for the prevention of an attack of cluster headache?

Ergotamine and Cluster Headache: Ergotamine is not usually employed in the prophylaxis of cluster headaches. It is normally prescribed for the management of acute migraines. Preventive therapy for cluster headache is best done using verapamil while ergotamine is not useful in the prevention of the condition.

Euthanasia and suicide need to take a perspective that is different.

Euthanasia and suicide need to take a perspective that is different. What could have been done to help or save the person? Is society reliable in taking care of those who are suffering terribly? Does a person have the right to make certain decisions to avoid an uncertain future?

It is for this reason that euthanasia and suicide are issues that are both ethically and legally as well as socially relevant. Here’s a perspective on these topics:The following are the views on these issues:

Help and Prevention:

Medical and Psychological Support: Mental health care and palliative care services for the same reason that they help to improve the quality of life in patients with severe pain or mental health illness. It can be prevented, prevented and counselling and therapy can be of help.

Support Systems: Having a support system which can be in the form of family, friends, and support groups is a way of getting emotional and other forms of support.

Pain Management: In the case of those patients with terminal illnesses, it is quite possible to alleviate the pain and contain the symptoms with a view to reducing suffering and improving the quality of life.

Societal Responsibility:

Healthcare Access: The government and other sectors of societies should ensure that every individual should be given an opportunity to access quality health care service, mental health and palliative care. This involves patient’s empowerment and coming through for the people who require quality health care services.

Social Support Systems: There is therefore the need for governments and other organizations to strengthen social protection interventions such as cash transfer, social services and other community based programmes to support vulnerable populations.

Autonomy and Decision-Making:

Right to Self-Determination: Those are rights that people have a right to choose on how they want to live and how they want to die as long as it is legal. This entails the right of allowing the animal to die or to clam for euthanasia where this is legally permissible.

Ethical Considerations: Nevertheless, the following should be considered when coming up with such decisions as ethical issues include coercion, mental capacity and the impact on the relatives.

Uncertain Future:

Exploring Alternatives: It is therefore worthwhile at least once before taking irreversible actions, to try and look for the best profesional advice.

Legal and Ethical Frameworks: In the countries that allow euthanasia or assisted suicide, there are normally a number of legal and well-coordinated procedures that must be followed for the sake of making the decision appropriately and with precautions.

Why do nurse educators solicit feedback from faculty and students for curricular quality improvement?

How does the teaching style of faculty members influence student retention and satisfaction?

How does student engagement influence the teaching style of faculty members?

What is the difference between traditional and innovative curriculum?"

The Current Work in Curricular Quality Improvement and the Feedback Role.

1. Why do nurse educators want feedback from faculty and students for curricular change?

The academic and clinical faculty and the students are sensitized by the nurse educators to examine and improve the content of the curriculum to make it comparable to other educational systems and clinical practice. The main reasons for soliciting feedback include:Some of the general reasons that explain why people turn to feedback include:

Enhancing Relevance: It will help to expose the weaknesses of the syllabus and ensure that the content used in teaching is still applicable in the modern nursing, technology and health care.

Improving Effectiveness: With such perception of the faculty and the students, then it will be easier for the educators to bring about change on the teaching and learning processes, material and assessments.

Increasing Engagement: Feedback mechanisms assist institutions in the involvement of the stake holders in the educational process, team work and ensuring that all parties have a say in the process.

Ensuring Quality: The cost of the education and the frequent evaluation and feedback lead to rigorous learning and high educational standards hence improved learning outcomes and readiness of the graduates in nursing.

2. How does the teaching styles of the faculty members help in increasing the retention and satisfaction of the students?

The teaching style of faculty members has a significant impact on student retention and satisfaction in several ways:The following are the ways through which the teaching style of faculty members affects student retention and satisfaction:

Engagement: Spiced up lessons such as group activities and real life examples make the students more receptive and concentrated and there is a high possibility that they may retain more information.

Support: The teachers who are competent to teach the concepts, provide feedback within the stipulated time and are approachable improve on the learning environment thus increasing the satisfaction of the students.

Relevance: Such teaching strategies that link the classroom theory to practical application make the students know the real application of the course they are undertaking hence making them to be satisfied with the program.

Flexibility: It has been proposed that the effective application of teaching styles that different from those favoured by the students may lead to enhanced satisfaction rates and reduced dropout among students who are at risk of dropping out.

3. To what extent does the level of students’ participation influence the manner in which the faculty teaches?

Student engagement influences teaching style in several ways:Learning process is therefore a critical factor that determines the way teachers teach in the following ways:

Feedback Adaptation: Therefore, when the students are fully engaged, the teachers will have no option but to change the ways they teach so as to address the feedback given and the learning needs of the students, through the use of more learning experiences.

Innovative Approaches: The students who are motivated are likely to have a positive feedback on the new methods and will tend to look for more new methods of teaching therefore calling on the faculty to develop new technologies and strategies of teaching.

Continuous Improvement: The faculty members that fall under the high level of engagement may be motivated to enhance their teaching skills in order to maintain or even increase the level of participation and achievement of the student.

Dynamic Interaction: The engaged students can make the class more chaotic and make one have to adjust the class to enable the students to discuss, analyze and learn in groups.

4. What, therefore, is the difference between a conventional curriculum and a revolutionary curriculum?

Traditional Curriculum:

Structure: It is usually linear and systematic, where the lessons followed are organized in a curriculum and the way of teaching is also clear.

Teaching Methods: Lectures and Textbooks: The methods of learning are more on the class lectures, textbooks and exams, thus the focus is more on the theoretical learning.

Assessment: In the course, 90% of the content is assessed through tests and quizzes in order to check the level of student learning.

Flexibility: In fact, it is rather rigid and does not welcome new tendencies and changes in the special field.

Innovative Curriculum:

Structure: They are more nuanced and are likely to be more flexible, and can be interdisciplinary and up to date.

Teaching Methods: Methods of teaching such as case, simulation, group projects, and the use of technology in the teaching learning process.

Assessment: It also tests the student, has the student critique other students and relate concepts to real life situations for effectiveness.

Flexibility: Alterations with the trends and the recommendations given by the students for the development of a better learning atmosphere.

Differential diagnosis for Ankle sprain.

What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

Can somebody help with this"

Differential Diagnosis for Ankle Sprain:Possible diagnosis for Ankle Sprain include:

Fracture:

Plan for Diagnostics: Request Lateral view X-ray of the ankle to rule out bone fracture. However, a negative first set of radiographs should not deter the clinician especially if there is a high clinical suspicion of a fracture as a CT or MRI scan should be requested.

Plan for Treatment and Management: In case of a fracture, the patient may require to be put in a cast or splint, the affected limb should not be used, the limb should be elevated and in severe cases surgery depending on the type of fracture. The results of imaging should be confirmed by repeated examination in the case of rehabilitation.

Tendinitis:

Plan for Diagnostics: A routine physical examination should be done and special emphasis should be paid to the tendons around the ankle most especially the Achilles tendon. Inflammation, or tears in the tendon are well captured by an ultrasound or a Magnetic Resonance Imaging (MRI).

Plan for Treatment and Management: It also entails the R. I. C. E protocol; which include the use of rest on the affected area, application of ice on it, administration of non steroidal anti inflammatory drugs to reduce pain and inflammation and physical exercise in form of stretching and building up the muscles. Among the other forms of treatment that may be employed are the ultrasound therapy or the shock wave therapy. The doctor examines the patient and enquires on the symptoms in order to assess the condition of the patient.

Ligament Tear (e. g. , Anterior Talofibular Ligament Tear):Tear of a Ligament (e. g. , Anterior Talofibular Ligament Tear):

Plan for Diagnostics: The examination may also reveal instability or paradoxical motion that is, the joint may appear to be loose or shift abnormally. Besides this, an MRI can be done or at times plain X-ray with stress views will be done to assess for ligament ruptures.

Plan for Treatment and Management: The first treatment comprises of R. I. C. E which is an acronym for rest, ice, compression as well as elevation and NSAIDs. It is imperative to do physical therapy for the range of motion and for the strengthening of muscles. At the extreme, it may be necessary to operate. The follow up entails assessment of the stability of ligaments with regard to their ability to function.

Plan for Ankle Sprain Diagnosis and Management:Proposal for the Diagnosis and Management of Ankle Sprain:

Diagnostics:

Initial Assessment: Conduct a complete history and physical examination to determine the degree and nature of the damage.

Imaging: X-ray, as a minimum, to rule out bone injuries and if soft tissue injury is suspected then MRI or sonography can be utilized.

Primary Diagnosis:

Ankle Sprain: If there is no evidence of fractures on the imaging and there is a suspicion of the ligament problem on the clinical examination then.

Treatment and Management:

Pharmacologic Treatments:

NSAIDs: For pain and inflammation, for instance, there are ibuprofen and naproxen.

Acetaminophen: For analgesia in patients in whom NSAIDs are contraindicated or not suitable to be given.

Nonpharmacologic Treatments:

R. I. C. E. : RICE technique; in order to cure the swelling and the pain one needs to avoid the use of the affected part, use an ice pack, use a bandage or a compression wrap and try to keep the affected part raised.

Physical Therapy: To improve and reconstruct or strengthen the muscles of the ankle joint.

Supportive Devices: An orthopedic shoe or an ankle brace or splint to support the joint that is involved in the case.

Alternative Therapies:

Heat Therapy: Heat is also a known mediatory of inflammation; after the inflammation has been reduced heat is applied for the muscle relaxation.

Acupuncture: May have an effect on pain and the process of recovery.

Follow-Up Parameters:

Re-evaluation: To assess the patient’s condition and to recommend subsequent course of action and treatment in case there are no improvements or deterioration of the patient’s condition, as well as to check for side effects or occurrence of other diseases.

Functional Assessment: Evaluation: Perform ROM and check the patient’s muscle strength, and mark their preparedness for the next round of activities.

Rationale:

Diagnostics: It assist in the right management to be made and or to avoid or reduce on complications that may arise in the course of the disease. It is a means of differentiating the three from other related conditions.

Treatment and Management: Pharmacological and Non pharmacological measures: Pain, inflammation and recovery of the function is the aim of both drug and non drug therapies. There is a possibility of the two forms of treatment to be regarded as additional to the conventional treatment. It is used in establishing whether there is any improvement and if there is the need to make adjustments in the plan of treatment.

Create a plan for reality offentation session

Create a plan for reality offentation session, Detall what skills it aims to develop and who needs to be involved, as

well as materials required."

To create a plan for a reality orientation session, follow these guidelines:To design reality orientation session plan, consider the following:

Reality oriented session proposal

Objective:

To increase participants’ understanding of time, place and identity and thus their orientation and cognition, the following activities will be used:To increase participants’ understanding of time, place and identity and thus their orientation and cognition, the following activities will be used:

Skills Aimed to Develop:

Time Awareness: The capability to determine the particular hour of the day, day of the week, month and the year.

Place Awareness: The capacity to indicate and recognise present location, setting and environment and to have the ability to recall them.

Identity Awareness: Knowing and explaining who one is and that way one fits into the group or any given environment.

Memory and Cognitive Function: Preserving and even in some ways improving short term memory and the cognitive processes related to tasks in daily life.

Participants:

Primary Participants: Those who require reality orientation, for instance, patients suffering from a disordered state of mind, the elderly suffering from Alzheimer’s disease.

Facilitators: Some of them are for instance; Nurses, Occupational therapists, or even trained caregivers.

Support Staff: Others, who can assist with activities and other matters and problems that the child may encounter.

Materials Required:

Calendars: Several large wall calendars with the current date and day and month in large letters and bold fonts.

Clocks: A wall clock or a digital watch so as to know the time at any point of time in a very convenient manner.

Environmental Cues: Posters or signs indicating different parts of the facility to be occupied (for instance dining area, activity area, washroom etc).

Personalized Memory Boards: Photos with the names and other details on cards and/or boards or in books for the purpose of SELF awareness.

Activity Sheets: The tools which are employed to enable participants to talk about time, place and identity: materials for use or exercises for the participants.

Interactive Tools: Auditory and group work: Whiteboards or flip charts.

Visual Aids: Others are; pictures or maps to help in the identification of the facility.

Session Structure:

Introduction (10 minutes):

Greetings to the participants and objectives of the session.

Please, spend a few minutes and review the time table for the session below.

Time Awareness Activity (15 minutes):Time Awareness Activity: (15 minutes):

To confirm the date, day and time of the day one has to use calendars and clocks.

Have someone come up with a debate or a trivia that is in some way related to the date or an event.

Place Awareness Activity (15 minutes):Geographical orientation Activity (15 minutes):

Let the participants understand various areas in the facility through the use of signs and maps.

Hold a “search” in which people are required to find and identify different areas.

Identity Awareness Activity (15 minutes):GROUP ACTIVITY: Identity Awareness Activity (15 minutes):

To help participants know their names, roles and experiences use the following aids; names and roles on flip charts or any board.

Get the participant to talk about him or herself or tell a story.

Memory and Cognitive Function Activity (15 minutes):Memory and Cognitive Function Activity (Intervention): (15 minutes):

Some of the activities that can be done include simple games such as the memory games or even puzzles that have a time and place element.

Use tools that can assist learners to participate in group activities and also to ensure that learners are informed on the lesson to be covered.

Review and Wrap-Up (10 minutes):Review and Wrap-Up (10 minutes):

Explain the points that were made in the session.

Make positive statements and in case there is something that the patient may wish to know or is concerned about address it.

Follow-Up:

Block time for revisit to revisit some concepts or skills or just to check on the student.

Make alterations on the learning activities and learning resources as the participants’ response and their learning accomplishment.

What Is the most common cause of sudden cardiac death in young people?

Myocardial infarction

hypertrophic cardiomyopathy

Supraventricular tachycardia

Arrhythmogenic right ventricular dysplasia; aka arrhythmogenic right ventricular cardiomyopathy (ARVC)"

The most frequent reason for SCD in young individuals is hypertrophic cardiomyopathy.

Explanation:

Hypertrophic Cardiomyopathy (HCM): This is a genetic disorder that causes the muscular walls of the heart to become too thick making the heart to block the blood flow and cause irregular heartbeat. It is the commonest cause of sudden cardiac death in athletes and people with no previous signs of the disease.

Other Options:

Myocardial Infarction: Although it can lead to sudden cardiac death, it is not seen in young individuals to the extent that it is seen in elderly individuals or in those with co morbidities.

Supraventricular Tachycardia (SVT): It is not usually lethal by itself in young persons, but it may result in certain manifestations and, rarely, may play a part in the development of cardiac complications.

Arrhythmogenic Right Ventricular Dysplasia (ARVD/ARVC): This is a more rare form of the condition in which the right ventricle of the heart is replaced by fibrous or fatty tissue which may cause arrhythmias. It is a cause of sudden cardiac death but is less frequent than HCM in the young population.

Reference: Osterholm, M. (2005). Preparing for the next pandemic. The New England Journal of Medicine, 352(18), 1839-1842.

PLEASE READ THE ARTICLE FIRST.

ABSTRACT

FULL TEXT

Annual influenza epidemics are like Minnesota winters -- all are challenges, but some are worse than others. No matter how well we prepare, some blizzards take quite a toll. Each year, despite our efforts to increase the rates of influenza vaccination in our most vulnerable populations, unpredictable factors largely determine the burden of influenza disease and related deaths. During a typical year in the United States, 30,000 to 50,000 persons die as a result of influenza virus infection, and the global death toll is about 20 to 30 times as high as the toll in this country. We usually accept this outcome as part of the cycle of life. Only when a vaccine shortage occurs, or young children die suddenly does the public demand that someone step forward to change the course of the epidemic. Unfortunately, the fragile and limited production capacity of our 1950s egg-based technology for producing influenza vaccine and the lack of a national commitment to universal annual influenza vaccination mean that influenza epidemics will continue to present a substantial public health challenge for the foreseeable future.

An influenza pandemic has always been a great global infectious-disease threat. There have been 10 pandemics of influenza A in the past 300 years. A recent analysis showed that the pandemic of 1918 and 1919 killed 50 million to 100 million people,1 and although its severity is often considered anomalous, the pandemic of 1830 through 1832 was similarly severe -- it simply occurred when the world's population was smaller. Today, with a world population of 6.5 billion -- more than three times that in 1918 -- even a relatively ""mild"" pandemic could kill many millions of people.

Influenza experts recognize the inevitability of another pandemic. When will it begin? Will it be caused by H5N1, the avian influenza virus strain currently circulating in Asia? Will its effect rival that of 1918 or be more muted, as was the case in the pandemics of 1957 and 1968? Nobody knows.

So how can we prepare? One key step is to rapidly ramp up research related to the production of an effective vaccine, as the Department of Health and Human Services is doing. In addition to clinical research on the immunogenicity of influenza vaccines, urgent needs include basic research on the ecology and biology of influenza viruses, studies of the epidemiologic role of various animal and bird species, and work on early interventions and risk assessment.2 Equally urgent is the development of cell-culture technology for production of vaccine that can replace our egg-based manufacturing process. Today, making the 300 million doses of influenza vaccine needed annually worldwide requires more than 350 million chicken eggs and six or more months; a cell-culture approach may produce much higher antigen yields and be faster. After such a process was developed, we would also need assured industrial capacity to produce sufficient vaccine for the world's population during the earliest days of an emerging pandemic.

Beyond research and development, we need a public health approach that includes far more than drafting of general plans, as several countries and states have done. We need a detailed operational blueprint of the best way to get through 12 to 24 months of a pandemic.

What if the next pandemic were to start tonight? If it were determined that several cities in Vietnam had major outbreaks of H5N1 infection associated with high mortality, there would be a scramble to stop the virus from entering other countries by greatly reducing or even prohibiting foreign travel and trade. The global economy would come to a halt, and since we could not expect appropriate vaccines to be available for many months and we have very limited stockpiles of antiviral drugs, we would be facing a 1918-like scenario.

Production of a vaccine would take a minimum of six months after isolation of the circulating strain and given the capacity of all the current international vaccine manufacturers, supplies during those next six months would be limited to fewer than a billion monovalent doses. Since two doses may be required for protection, we could vaccinate fewer than 500 million people -- approximately 14 percent of the world's population. And owing to our global ""just-in-time delivery"" economy, we would have no surge capacity for health care, food supplies, and many other products and services. For example, in the United States today, we have only 105,000 mechanical ventilators, 75,000 to 80,000 of which are in use at any given time for everyday medical care; during a garden-variety influenza season, more than 100,000 are required. In a pandemic, most patients with influenza who needed ventilation would not have access to it.

We have no detailed plans for staffing the temporary hospitals that would have to be set up in high-school gymnasiums and community centers -- and that might need to remain in operation for one or two years. Health care workers would become ill and die at rates similar to, or even higher than, those in the general public. Judging by our experience with the severe acute respiratory syndrome (SARS), some health care workers would not show up for duty. How would communities train and use volunteers? If the pandemic wave were spreading slowly enough, could immune survivors of an early wave, particularly health care workers, become the primary response corps?

Health care delivery systems and managed-care organizations have done little planning for such a scenario. Who, for instance, would receive the extremely limited antiviral agents that will be available? We need to develop a national, and even an international, consensus on the priorities for the use of antiviral drugs well before the pandemic begins. In addition, we have no way of urgently increasing production of critical items such as antiviral drugs, masks for respiratory protection, or antibiotics for the treatment of secondary bacterial infections. Even under today's relatively stable operating conditions, eight different anti-infective agents are in short supply because of manufacturing problems. Nor do we have detailed plans for handling the massive number of dead bodies that would soon exceed our ability to cope with them.

What if an H5N1 influenza pandemic began not now but a year from now? We would still need to plan with fervor for local nonmedical as well as medical preparedness. Planning for a pandemic must be on the agenda of every public health agency, school board, manufacturing plant, investment firm, mortuary, state legislature, and food distributor. Health professionals must become much more proficient in ""risk communication,"" so that they can effectively provide the facts -- and acknowledge the unknowns -- to a frightened population.3

With another year of lead time, vaccine might have a more central role in our response. Although the manufacturing capacity would still be limited, strategies such as developing antigen-sparing formulations -- that is, intradermal formulations that take advantage of copious numbers of dendritic cells for antigen processing or formulations including adjuvants to boost the immune response -- might extend the vaccine supply. Urgent planning efforts are required to ensure that we have the syringes and other essential equipment, as well as the workforce, for effective delivery. Finally, a detailed plan for vaccine allocation will be needed -- before the crisis, not during it.

What if the pandemic were 10 years away and we embarked today on a worldwide influenza Manhattan Project aimed at producing and delivering a pandemic vaccine for everyone in the world soon after the onset of sustained human-to-human transmission? In this scenario, we just might make a real difference.

The current system of producing and distributing influenza vaccine is broken, both technically and financially. The belief that we can greatly advance manufacturing technology and expand capacity in the normal course of increasing our annual vaccination coverage is flawed. At our current pace, it will take generations for meaningful advances to be made. Our goal should be to develop a new cell-culture-based vaccine that includes antigens that are present in all subtypes of influenza virus, that do not change from year to year, and that can be made available to the entire world population. We need an international approach to public funding that will pay for the excess production capacity required during a pandemic.

Today, public health experts and infectious-disease scientists do not know whether H5N1 avian influenza virus threatens an imminent pandemic. Most indications, however, suggest that it is just a matter of time: witness the increasing number of H5N1 infections in humans and animals, the documentation of additional small clusters of cases suggestive of near misses with respect to sustained human-to-human transmission, the ongoing genetic changes in the H5N1 Z genotype that have increased its pathogenicity, and the existence in Asia of a genetic-reassortment laboratory -- the mix of an unprecedented number of people, pigs, and poultry.

It is sobering to realize that in 1968, when the most recent influenza pandemic occurred, the virus emerged in a China that had a human population of 790 million, a pig population of 5.2 million, and a poultry population of 12.3 million; today, these populations number 1.3 billion, 508 million, and 13 billion, respectively. Similar changes have occurred in the human and animal populations of other Asian countries, creating an incredible mixing vessel for viruses. Given this reality, as well as the exponential growth in foreign travel during the past 50 years, we must accept that a pandemic is coming -- although whether it will be caused by H5N1 or by another novel strain remains to be seen.

Should H5N1 become the next pandemic strain, the resultant morbidity and mortality could rival those of 1918, when more than half the deaths occurred among largely healthy people between 18 and 40 years of age and were caused by a virus-induced cytokine storm (see diagram ) that led to the acute respiratory distress syndrome (ARDS).4 The ARDS-related morbidity and mortality in the pandemic of 1918 was on a different scale from those of 1957 and 1968 -- a fact that highlights the importance of the virulence of the virus subtype or genotype. Clinical, epidemiologic, and laboratory evidence suggests that a pandemic caused by the current H5N1 strain would be more likely to mimic the 1918 pandemic than those that occurred more recently.5 If we translate the rate of death associated with the 1918 influenza virus to that in the current population, there could be 1.7 million deaths in the United States and 180 million to 360 million deaths globally. We have an extremely limited armamentarium with which to handle millions of cases of ARDS -- one not much different from that available to the front-line medical corps in 1918.

Is there anything we can do to avoid this course? The answer is a qualified yes that depends on how everyone, from world leaders to local elected officials, decides to respond. We need bold and timely leadership at the highest levels of the governments in the developed world; these governments must recognize the economic, security, and health threats posed by the next influenza pandemic and invest accordingly. The resources needed must be considered in the light of the eventual costs of failing to invest in such an effort. The loss of human life even in a mild pandemic will be devastating, and the cost of a world economy in shambles for several years can only be imagined.

An interview with Dr. Osterholm can be heard at www.nejm.org.

References

1. Johnson NP, Mueller J Updating the account lobal mortality of the 1918-1920 ""Spanish"" influenza pandemic. Bull Hist Med 2002;76:105-115

2. Stohr K Avian influenza and pandemics--research needs and opportunities. N Engl J Med 2005;352:405-407

3. Sandman PM, Lanard J. Pandemic influenza risk communication:the teachable moment. 2005. (Accessed April 14, 2005, at http://www.psandman.com/col/pandemic.htm.)

4. Kobasa D, Takada A, Shinya K, Enhanced virulence of influenza A viruses with haemagglutinin of the 1918 pandemic virus. Nature 2004;431:703-707

5. Peiris JS, Yu WC, Leung CW, Re-emergence of fatal human influenza A subtype H5N1 disease. Lancet 2004;363:617-619

In the article by Osterholm, the author presents a possibility of another pandemic. Consider your leadership perspective during a pandemic influenza outbreak in the United States

As the Director of FEMA, how would you respond during this outbreak?

Use a systems approach to work with Director, CDC, Governor of an afflicted state, Incident Response Commander, Response Leader, American Red Cross (or other non-governmental organization) to establish immediate response in preventing another pandemic.

Based on the leadership role as Director, FEMA, include the following:

A summary of the leadership challenges this leader would face in assuring the system changes necessary to be prepared for the next pandemic.

An explanation of how your leadership challenges as Director, FEMA relate to challenges of the other leaders listed above.

An explanation of how transformational and transactional leaders might influence outcomes within this case

A summary of how poor leadership might affect the outcome of the case"

The following is the FEMA Director’s Action Plan in Response to a Pandemic Influenza Outbreak:

Summary of Leadership Challenges

As the Director of FEMA, responding to a pandemic influenza outbreak involves several key challenges:When it comes to dealing with the outbreak of a pandemic influenza as the Director of FEMA the following key challenges can be identified.

Coordinating with Multiple Agencies: Ensuring that the CDC, state governors, Incident Response Commanders and NGOs such as the America Red Cross is in sync. This requires the well stated channels of communication and also the cooperation agreements on the division of labor.

Resource Allocation: Functioning in the management of limited resources such as vaccines and antiviral drugs formulations and other related medical products. These are issues such as those that pertain to enhancing the production and distribution Spurs in the shortest time possible.

Public Communication: To enlighten the public and reduce their fear by telling them the right information and also to encourage them to follow the health standards. It also entails discrediting myths and myths and pacifying communities.

Planning and Preparedness: The measures include; developing and implementing formal plans to combat the pandemic, setting up of thora hospitals, training of more personnel in the health sector as well as ensuring that health facilities have the capacity to handle more patients.

Political and Public Pressure: When it comes to meeting the demands of the political class and the society which is increasingly impatient and demanding.

The relationship between Leadership Challenges and Other Leaders

Director, CDC: There is no intersection between CDC’s core objectives that are research, vaccines, and epidemiology and FEMA’s core tasks of logistics and coordination. It is essential for both the leaders to make sure that their strategies are not contradictory and the resources are optimally used.

Governor of an Afflicted State: He has to do with matters to do with the state policy and co-ordination of the state’s power. To this end, helping in the coordination with FEMA and other federal agencies for the state level implementation of the strategies is crucial.

Incident Response Commander: This leader is in charge of probably the on ground response and the emergency operations. Some of the functions are to put into practice the plans that FEMA and other entities develop, coordination of the local activities, and improvement of the overall systems.

Response Leader: It is often from an NGO and may encompass community mobilisation and support services. They are intended to address current requirements and provide support in the activities of FEMA and other organizations.

The Impact of Transformational and Transactional Leadership

Transformational Leadership:

Vision and Inspiration: The transformational leaders would make sure that the teams are motivated, to this end, they would describe what the response entails and encourage creativity.

Change Management: It would give the leadership to effect the system change necessary for the management of the pandemic, for instance, to set new processes or to acquire new technologies for vaccine delivery.

Empowerment: This type of leadership foster cooperation and enable all the employees at all the level hence enhancing their performance during the management of the outbreak.

Transactional Leadership:

Task and Process Focus: Transactional leadership would be appropriate in the case of the following, for instance, supplying of materials or following the laid down health measures.

Efficiency: This is useful in ensuring that the needs of the moment are served and that the responses given are within the normal scheme of things which is quite handy in managing a crisis.

Performance Monitoring: They would be very watchful over the performance and would ensure that the goals that have been set are met, any deviation from the plan being corrected immediately.

Impact of Poor Leadership

Poor leadership could severely impact the outcome of the pandemic response in the following ways:If poor leadership is entertained, the following may happen in the course of handling the pandemic:

Ineffective Coordination: It has been realized that non-effective communication and co-ordination leads to delayed action, repetition of action, overlap and/or void in action.

Resource Mismanagement: It means that if resources are not properly used in the system, then what may transpire is that the scarce resource will be absent where it is most needed and hence the situation will be compounded.

Public Mistrust: This would mean that there would be no trust, non-adherence to the set measures and cross infections.

Operational Failures: Failure to plan for management and lack of flexibility to changes means that the response interventions may not be effective and lead to more morbidity and mortality.

AKI. A 67-year-old woman presented to the ER with c/o oliguria, nausea/vomiting, & generalized edema.

AKI. A 67-year-old woman presented to the ER with c/o oliguria, nausea/vomiting, & generalized edema. BUN = 27, creatinine = 3.0, UA shows casts & protein. History: She has been on Amphotericin B for meningitis, DMII, HTN.

QUESTION: What nursing diagnosis are appropriate for the patient? Include AEB and R/T."

For a 67-year-old woman presenting with symptoms and laboratory findings suggestive of acute kidney injury (AKI), the following nursing diagnoses are appropriate:The following are nursing diagnoses that can be made for a 67-year-old woman who has features of acute kidney injury (AKI):

1. Impaired Renal Function

AEB: Enlargement of the kidneys, BUN 27 mg/dL, Creatinine 3 mg/dL. These include anuria, serum creatinine of less than 0 mg/dL, oliguria and urinary albumin and casts.

R/T: Nephrotoxicity from Amphotericin B, DMII and HTN.

2. Fluid Volume Excess

AEB: In this case there will be generalised oedema of the body and decreased production of urine.

R/T: Decreased kidney function in regard to the capability to excrete fluids because of the AKI.

3. Risk for Electrolyte Imbalance

AEB: A past history of AKI which can also cause the alteration of electrolytes.

R/T: Reduced kidney function which lead to electrolyte imbalance and side effect of Amphotericin B and a history of DMII.

4. Nausea and Vomiting

AEB: Symptoms: Nausea and vomiting by the patient.

R/T: High BUN and creaine which leads to uremic symptoms and side effects of the drugs used.

5. Risk for Infection

AEB: On amphotericin B treatment which increases their susceptibility to being infected.

R/T: Potential drug side effects including the kidney dysfunction which is a risk factor of getting an infection.

6. Altered Nutrition: Under the category of Body Needs, the following can be found:

AEB: Nausea and vomiting, and the patient may not be able to take in food or only a small amount of it.

R/T: Some of the gastrointestinal symptoms that can affect the patient’s oral intake as well as the possible effects of AKI on the nutritional status of the patient.

Nursing Interventions:

Monitor Renal Function: The patient’s BUN, creatinine and electrolytes should be checked at least once a day.

Assess Fluid Status: Assess the patient’s dietary and fluid intake and output as well as the patient’s weight and presence of oedema.

Manage Nausea and Vomiting: The patient should only be given antiemetic drugs if required and the patient’s response should be closely monitored.

Educate on Medication: Provide details on the potential renal toxicity of Amphotericin B and emphasize on the importance of renal function assessment.

Promote Optimal Nutrition: A dietitian should be consulted to suggest modification in the present diet plan with respect to the present symptoms and nutritional needs.

In what ways does mental health need to be considered across the illness/injury continuum?"

Mental health needs to be considered across the illness/injury continuum in several key ways:

1. Prevention and Early Intervention

Screening and Assessment: Preventive care diagnostic examinations for people in need (e. g. , those with family history of mental disorders or other diseases).

Education: Mental health education and sensitization of patients, families and other members of the public on the issues affecting the mental health.

2. Diagnosis and Treatment

Integrated Care: Mental or emotional assessment for patients with acute or chronic medical/ surgical condition, should also be included in the assessment. Mental health conditions can affect the trajectory and the treatment of physical health conditions.

Holistic Approach: Including the psychological and the physical wellbeing of the patient in the treatment plans. For instance, a chronic disease such as diabetes may be accompanied by depression, which will in turn influence the management of the disease.

3. Management of Chronic Conditions

Co-Management: Engaging in the management of care between mental health practitioners, and other practitioners in the treatment of illnesses that have psychological dimensions such as chronic diseases or disabilities.

Support Services: Offering mental health care including counselling and therapy to enable patients deal with the emotional challenges of having a chronic illness or injury.

4. Recovery and Rehabilitation

Psychosocial Support: Provision of psychosocial support during the phase of recovery and rehabilitation in order to help the patient manage conditions such as anxiety, depression or adjustment disorders that may develop during this stage.

Patient Empowerment: Positive reinforcement in care planning as well as in rehabilitation to foster mental health and to empower and engage patients in their care.

5. End-of-Life Care

Emotional and Psychological Support: Offering a range of psychological services in meeting the needs of patients and families who are dealing with end-of-life concerns and bereavement, counseling and pain management support.

Advance Care Planning: Logically, some important topics are: Participation in conversations regarding preferences for care and preferences for dying, which may decrease fear and enhance the quality of life of patients and their families.

Involvement of Various Stakeholders

Multidisciplinary Teams: This give them access to mental health professionals, social workers and counselors in order to have a more complete medical team for the patient.

Family and Caregiver Support: Teaching and empowering the family members and caregivers for them to be in a position to take care of their own mental health as well as that of their loved ones.

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