Business Schools in Kenya

Following are the leading business schools in Kenya:

United States International University - Nairobi Campus
- The School of Business Administration offers a range of undergraduate programs, graduate programs, CEED certificate programs, Goldman Sachs Program.
- Undergraduate programs offered include: Bachelor of Science in International Business Administration; Bachelor of Science in Information

Wikipedia for Nurses

As a highly focused nurse, I am often researching medical topics as well as career opportunties. As I was researching nurse travel jobs, I ran into wikipedia where I surprsingly found a lot of information about the travel nursing topic.

I know that I have mentioned Aya healthcare before but I was surprised when I found that Aya healthcare nursing jobs had its own page aling top companies like State Farm Insurance and the Coca-Cola Company.

Going back to the topic at hand, I was a bit skeptical at first about using wikipedia as a source of information about medicine since we all know that wikipedia is setup so that anyone can add and edit text on the site.

However, as I browsed thru the site more, I learned that all content in wikipedia must have some kind of reference to be able to back up your content. This has definitively made a big impact on how I feel about the site now.

Serving those who serve

Dr. Carol Weingarten, in the Wounded Warrior Ministry Center, with cards made by members of the Villanova Chapter of the Student Nurses’ Association of Pennsylvania for which she is advisor.

Summer was a busy yet rewarding time for Carol Toussie Weingarten, PhD, RN, ANEF, associate professor in the College of Nursing. She and husband Michael S. Weingarten, MD, MBA, FACS, a VSB alumnus and professor of Surgery at Drexel University School of Medicine volunteered for their second consecutive summer working with the troops at Landstuhl Regional Medical Center (LRMC) in Germany. Inspired by their two-week mission last year, they did not hesitate to return in 2010 and are already slated to go back next July. “Courage, teamwork, superb care and kindness,” is how Dr. Weingarten summarizes the environment there, which was a good fit for her specialty area of health promotion and wellness.

LRMC is the largest American military hospital outside the United States, to which ill and wounded troops are taken from such places as Afghanistan and Iraq. Transition is a hallmark of LRMC, where the length of stay for inpatients can range from one to three days. Outpatients are housed for up to 14 days at the Medical Transient Detachment. Some patients are airlifted back to the U.S. for further care while others return downrange.

Through the Society for Vascular Surgery in cooperation with the American Red Cross, Dr. Michael Weingarten served as a volunteer vascular surgeon in the Combat Casualty Program where his skills were needed in the operating room and intensive care unit. Because there is no parallel nursing program, Dr. Carol Weingarten worked with outpatients as a civilian volunteer with the Chaplains' Wounded Warrior Ministry Center (WWMC) Projects. WWMC was created to provide comfort items like clothing and toiletries for wounded or ill service members but has expanded to provide further comfort. The WWMC incorporates several strategies to promote mental and spiritual health including combat support dinners, supervised trips for troops to areas of local interest and the Chaplains’ Closet –a “free” store with toiletries, adaptive clothing, handmade blankets, music, sweets and cards from well-wishers. The programs are supervised by pastoral care staff enhanced by volunteers, as appropriate, and contracted behavioral health specialists. Time itself can be a stressor as it stretches between tests and treatments. Dr. Weingarten explains, based on the time she spent supporting troops on the local trips and working with them at the Chaplain’s Closet, “I realized early in my experience as a WWMC civilian volunteer that (this was) a perfect placement for me. From a nursing perspective, the WWMC and its related projects are examples of health promotion.” Her work did not stop there.

“This year I undertook a nursing journalism project at LRMC. In 2009 I met and saw so many extraordinary nurses that I got permission from the Public Affairs Office and the Director of Nursing to interview nurses and staff in a variety of areas. I was welcomed everywhere,” notes Dr. Weingarten. Her work showcasing the efforts of the Army, Navy, Air Force and civilian nurses at LRMC will be published this October in The American Journal of Nursing and she targets a future publication in Pennsylvania Nurse. She is speaking this fall at the state Student Nurses’ Association of Pennsylvania (SNAP) convention about the couple’s experiences (she is the advisor for the Villanova Chapter of SNAP). In April, she and her husband are likely speaking together at the National Student Nurses’ Association convention. Her final thought? Dr. Weingarten reflects, “As I listened to each fascinating story, I realized that nursing becomes part of who you are, whether you are the interviewer or the person being interviewed.”

Supporters Join Forces to Save Terre Haute Midwives

by Melissa Garvey, ACNM Writer and EditorA group of midwives at Union Hospital in Terre Haute, Indiana, have been notified that their employment contracts will not be renewed this year. It’s a familiar situation—one that we saw play out in Wilmington, North Carolina, about this time last year.The midwives’ last scheduled day at the hospital is October 29, but a dedicated group of supporters is

Um. What does this tell you?

http://www.nursingtimes.net/whats-new-in-nursing/news-topics/health-workforce/dramatic-decline-in-nursing-posts-fuels-job-fears/5018755.article

The number of nursing vacancies has fallen by nearly 40 per cent in the last year, according to data gathered by Nursing Times.

The figures, together with new data from the NHS Information Centre, have fuelled fears that NHS trusts are freezing vacancies, are not replacing nurses and are converting posts to lower grades in order to tighten budgets.

Shock horror. Yawn.
and

http://www.nursingtimes.net/whats-new-in-nursing/news-topics/health-workforce/nurses-and-healthcare-assistants-forced-to-retire/5018724.article

Eleven nurses and 21 healthcare assistants have been forced to retire by an East Midlands primary care trust despite the government’s plans to scrap the default age for retirement from October next year.

and
 
http://www.nursingtimes.net/whats-new-in-nursing/students/new-nurses-struggling-to-find-jobs/5018525.article
 

RCN Scotland has said policies such as freezing posts and not replacing people who leave mean newly qualified nurses and midwives are struggling to find jobs in the NHS. The union has warned “unsustainable tactics” are being used by health chiefs struggling to cut costs, and called for more to be done to protect frontline services. It added the decisions could have “devastating consequences” for patient care in the future.

Remember this my dear reader: This has gone nationwide.  And it has been going on for a hell of a long time.My trust still hasn't hired any nurses.  But they have been advertising for management posts with stupid names and "champions" on salaries around £130,000 a year.

A Whole Different Ball Game

ON Saturday I stepped off the football treadmill and onto the rugby one, to cover one of the top matches in Premiership One of the Scottish club championship.

In terms of stature this league is Scottish Rugby's equivalent of the SPL - only an SPL without the Old Firm, who are playing in an international club league.

In terms of quality this match was probably the equivalent of an Irn-Bru First Division match, rather than an SPL encounter. Over the years I've done my share of First Division football (more than my share in fact), so it was interesting to make comparisons.

The club game is supposed to be amateur, except we all know some of the bigger clubs are paying players, particularly the "Kilted Kiwis" imported from New Zealand and Australia (there isn't a catchy term for Ozzies playing in Scotland, however); we also know that expenses to some Scottish players are generous, but the Scottish club league is NOT paying over-the-odds for mediocrities, unlike its football equivalents.

The commitment was total, the fitness levels way above anything you'll see in the SFL or even the SPL, but, it's a lot cheaper to get in. The ground facilities weren't quite up to the home team's football rival, but this was more than compensated for by among other things, the catering.

You can stick your pies and Bovril where the sun don't shine - pre-match I had a brilliant hot roast pork roll, with crackling and apple sauce, washed down by a generous cappacinno. Very nice, great value for money, but nothing compared to the roast beef lunch, washed down by a very nice Claret, the meal enhanced by stimulating conversation with the former Scotland and Lions legend lunching at the next table - and no, I wasn't in corporate hospitality - merely in the host club's club house prior to kick off.

But the big change is noticed after the match. In rugby, no hanging around outside dressing rooms or at tunnel mouths, waiting for the rival managers to deign to speak to us, their perception of the hacks from Hell. Within five minutes of the final whistle, we of the press pack were on the pitch, hearing first-hand the thoughts of the respective coaches. These were delivered with unfailing courtesy and understanding.

Later, the report for the Sunday paper filed, it was into the board room for a very pleasant chat with the committee-men from both clubs AND the referee, who was only-too-willing to explain a couple of controversial decisions.

Now, to be fair, one or two football referees will respond with civility and open-ness to requests for an explanation of how they dealt with a flash-point, but this is strictly on a "no names, no pack drill" basis - and not all are so approachable or accommodating.

If you want to speak to a player, no problem, they are all in the club bar, mingling with the members and supporters, while the majority of the fans do not head for the nearest boozer the minute the final whistle sounds - no need to the club bar is there, it's open and it's generally cheaper than the pub.

Usually, at a football match, I file on the whistle any reports which are scheduled for "on-the-whistle" sending; then it's down to get the quotes from managers and players and I am usually in the car and heading home by 5.30pm at the latest.

On Saturday, I was still enjoying the craic in the clubhouse at 6.30pm. It's a much more civilised game.

Football may be a game for gentlemen, played by hooligans and rugby a game for hooligans played by gentlemen - that description was borne out on Saturday.

Nursing Care Plan | NCP Testicular Cancer

The American Cancer Society estimated that approximately 8000 new cases of testicular cancer would be diagnosed in 2005 and 390 men would die from this disease. The cure rate exceeds 90% and the 5-year survival rate is 72%. The risk of developing this cancer is 1 in 300. Testicular cancer is a rare tumor that arises from the germinal cells (cells that produce sperm) of the embryonal tissues and causes less than 1% of all cancer deaths in men. Testicular tumors are classified as seminomas or nonseminomas. Seminomas are composed of uniform, undifferentiated cells that resemble primitive gonadal cells. This type of tumor represents 40% of all testicular cancer and is usually confined to the testes and retroperitoneal nodes. There are two types of seminomas: classical (occur between the late 30s and early 50s) and spermatocytic seminomas (occur around age 55, grow slowly, and do not metastasize). Nonseminomas show varying degrees of cell differentiation and include embryonal carcinoma (occur most often in 20- to 30-year-olds, grows rapidly, and metastasizes), teratoma (can occur in children and adults), choriocarcinoma (rare and highly malignant), and yolk cell carcinoma derivatives (most common in children up to 3 years of age and have a very good prognosis). Sometimes, testicular tumors are “mixed,” containing elements distinctive to both groups.

Although specific causative factors for testicular cancer are unknown, research findings suggest a connection between the incidence of cryptorchidism (failure of testicles to descend) and testicular cancer. If an undescended testis is noted in a child, orchiopexy (surgical descent of the testes into its normal position within the scrotum) is recommended as soon as possible after birth. Although orchiopexy does not completely eliminate the risk of testicular cancer, it is believed that the sooner after birth orchiopexy is performed, the less the chance of developing testicular cancer later in life. An increased incidence of testicular cancer has been found in men infected with human immunodeficiency virus (HIV) (seminomas) and men with testicular disorders such as Klinefleter’s syndrome.

Exogenous estrogen has also been linked to testicular cancer. Male offspring of mothers who took diethystilbestrol (DES) during their pregnancy have an increased risk of developing testicular cancer. In addition, patients who have had mumps, orchitis, or a childhood inguinal hernia are also considered to be at higher risk for developing testicular cancer.

Nursing care plan assessment and physical examination
Obtain a thorough health history, particularly about the occurrence of risk factors. Any male born between 1940 and 1971 should be asked if his mother took any drugs to maintain her pregnancy. The earliest sign of testicular cancer is a small, hard, painless lump that cannot be separated from the testicle; it is occasionally accompanied by low back pain. Men often describe a feeling of “heaviness” or “dragging” in the testicles. These symptoms are often mistaken for epididymitis or muscle strain. Tenderness in the breast may also be present. Inquire about back pain, vague abdominal pain, nausea and vomiting, anorexia, and weight loss, all findings that suggest metastasis. Only 25% of men experience symptoms related to metastasis prior to diagnosis.

The testes may be enlarged and swollen. A hydrocele or hematocele may be present. A testicular tumor can be distinguished from a hydrocele by transillumination (inspection of the testes by passing a light through its walls): a tumor does not transilluminate, whereas a hydrocele appears red and a normal testicle illuminates clearly. Because the tumor produces estrogen, inspect the patient for gynecomastia.

A testicular examination is accomplished by placing the index and middle finger on one side of the testicle with the thumb on the other side. Digital separation of the anterior testes from the posterior elements, including the epididymis and cord, is performed with care so that the intrascrotal contents can be palpated. A gentle rolling motion enables the examiner to palpate each testicle completely. A normal testicle is egg-shaped and feels smooth and firm but not hard. One testicle may naturally be larger than the other. A change in size or the presence of a lump is considered to be an abnormal finding. With testicular cancer, the lump is generally painless. Also, palpate the surrounding area for the presence of enlarged lymph nodes. Lymphadenopathy, especially in the abdominal and supraclavicular regions, is also found in more advanced disease.

The diagnosis of cancer at any time is a lifestyle-altering event, but it is particularly disrupting to this young population. Interruption of schooling or work schedules, financial coverage for medical expenses, transportation to and from scheduled therapies, and childcare issues are a few of the concerns expressed by patients.

Nursing care plan primary nursing diagnosis: Pain (acute) related to inflammation, tissue damage, tissue compression, or nerve irritation from tumor metastasis in the perineum, groin, or abdomen.

Nursing care plan intervention and treatment plan
The initial treatment for testicular cancer is surgical resection of the involved testicle (orchiectomy). A testicular prosthesis can be placed if the patient so desires. If a bilateral orchiectomy is performed, the patient may need hormonal replacement. It is controversial whether or not the retroperitoneal nodes should be resected or treated with chemotherapy. Surgical resection carries with it the likelihood of impotence. To preserve fertility, nerve-sparing retroperitoneal lymph node surgery protects the nerves and allows for normal ejaculation.

Postoperatively, edema and intrascrotal hemorrhage are the two most common problems. Monitor the patient closely for swelling and bleeding. Elevate the scrotum on a rolled towel, and apply ice to assist with discomfort and decrease swelling. Observe for signs of infection. Encourage the patient to wear an athletic supporter during ambulation to minimize discomfort. Usually, the patient is encouraged to do so within 12 hours of surgery.

Depending on staging of the disease, radiation or chemotherapy may also be used. Tumors classified as seminomas are especially radiosensitive. External beam radiation is usually given after surgery if the peritoneal lymph system is diseasepositive or if the pelvis and mediastinal and supraclavicular lymph nodes are involved. Inform the patient that, although the unaffected testicle is shielded during radiation, it does receive some radiation that is scattered, which may decrease spermatogenesis. Nonseminomatous tumors are not radiosensitive, and chemotherapy is the preferred treatment.

Nurses can play a role in the early detection of testicular cancer. Patients should be taught how to do a testicular self-examination and should be encouraged to perform the examination monthly. Provide private time for the patient and his partner to ask questions, express concerns, and clarify information. Offer the patient an opportunity for sexuality and fertility counseling after discussing the impact of the surgery on his anatomy and function. Make sure the patient understands the need to perform coughing and deep-breathing exercises to limit pulmonary complications. Before surgery, instruct the patient on the use of an incentive spirometer.

Because stomatitis is a common occurrence, check the mouth regularly for open irritated areas and encourage the patient to use warm mouthwashes. If the patient becomes nauseated, offer small, frequent feedings and eliminate any noxious stimuli such as bad odors. In addition, have the patient drink at least 3 L of fluid per day to ensure adequate hydration. If the patient is receiving radiation, monitor for side effects. Avoid rubbing the skin near the site of radiation to prevent discomfort and skin breakdown.

Ask about pain regularly and assess pain systematically. Believe the patient and family in their reports of pain. Inform the patient and family of options for pain relief as proposed by the National Cancer Institute (pharmacologic, physical, psychosocial, and cognitive-behavior interventions) and involve the patient and family in determining pain relief measures. To manage the discomfort of chemotherapy in addition to medications, consider the use of biofeedback or other alternative relaxation techniques.

The diagnosis of testicular cancer is a devastating one to most men. Discuss the patient’s concerns with him. Explain the role of hormonal replacement in maintaining the secondary sex characteristics. If the patient is at risk for sterility, explain sperm banking procedures before treatment if infertility and impotence may result from surgery. Refer the patient to a support group or ask that another man who has experienced a similar diagnosis and treatment share his experiences to provide support. If the patient or partner is struggling to cope with the diagnosis, arrange for a counselor.

Nursing care plan discharge and home health care guidelines
If hormonal replacement is ordered, be sure the patient understands the dosage, schedule, actions, and side effects of the medication. Have the patient demonstrate a testicular self-examination before leaving the hospital. The patient should understand that testicular cancer can recur in the remaining testes and that early detection is a critical factor in the outcome.

Inform the patient that if a unilateral orchiectomy was performed, he is still fertile and should not experience impotence. Make sure the patient understands that he has the option of undergoing reconstructive surgery and placement of a testicular prosthesis. Refer the patient to the American Cancer Society to assist with obtaining information and support.

Teach the patient to do the following: Avoid prolonged standing because this can increase scrotal edema. Wear an athletic supporter or snug-fitting undershorts until the area is completely healed. Avoid heavy lifting for 4 to 6 weeks. Take a 20-minute tub bath three times a day for 1 week after discharge.

Nursing Care Plan | NCP Vaginal Cancer

Vaginal cancer (VC) is a neoplastic disease of cells within the vaginal canal. Because primary cancer of the vagina is rare, VC is usually secondary as a result of metastasis from choriocarcinoma (cancer of the cervix or adjacent organs). VC often extends to the bladder and rectum, which makes treatment difficult. Approximately 85% to 90% of vaginal cancers are squamous cell carcinomas, which begin in the epithelial lining in the upper areas of the vagina near the cervix. Less common are adenocarcinomas, which develop in women over 50 years of age who were exposed to diethylstilbestrol (DES) in utero; melanomas (14% 5-year survival rate), which tend to affect the lower or outer portion of the vagina; or sarcomas that form in the deep wall of the vagina.

VC is rare and accounts for only 3% of all gynecologic malignancies. It is most commonly located in the upper one-third of the posterior vagina. The vagina has a thin wall and extensive lymphatic drainage; the severity of the cancer, therefore, varies, depending on its location in relation to the lymphatic system and the thickness of the neoplastic involvement. Stage 0 VC is limited to epithelial tissue (96% 5-year survival rate). Stage 1 VC is limited to the vaginal wall (73% 5-year survival rate). Stage 2 VC involves the subvaginal tissue but not the pelvic wall (58% 5- year survival rate). Stage 3 VC extends to the vaginal wall (36% 5-year survival rate). Stage 4 VC extends beyond the pelvis or involves the bladder or rectum (36% 5-year survival rate).

Low survival rates are caused by the advanced stage of the disease at the time of diagnosis, difficulty in treatment resulting from the proximity of important structures, and the rarity of the disease that makes it difficult to determine the best treatment. It was estimated that in 2005, 2140 new cases of VC would be diagnosed in the United States and 810 women would die of this disease.

The cause of VC is not known, although ingestion of DES, a drug at one time given to women to limit spontaneous abortion, has been identified as one possible cause. Risk factors include a previous malignancy of the vagina, vulva, or cervix and advancing age. Women who have had cervical cancer previously should be examined on a regular basis to assess for vaginal lesions. Other risk factors include exposure to DES in utero, the improper use of pessaries (infrequent cleaning, infrequent examination to ensure proper fit), exposure to radiation therapy, trauma, exposure to chemical carcinogens found in some sprays and douches, a history of human papillomavirus, and smoking.

Nursing care plan assessment and physical examination
A complete reproductive history of the patient and the patient’s mother is important. Evaluate the patient for any risk factors. Ask if the patient’s mother was taking DES when pregnant with the patient. Determine a thorough history of the patient’s physical symptoms. One of the symptoms of VC is spontaneous vaginal bleeding after either intercourse or a pelvic examination. Vaginal discharge of a watery nature may also be present. Other symptoms include pain, urinary or rectal symptoms, pruritus, dyspareunia (pain during sexual intercourse), and groin masses. Question the patient about any pain. Assess the use and effectiveness of any analgesics for pain. Document the location, onset, duration, and intensity of the pain. The patient may also describe urinary retention or urinary frequency if the lesion is near the bladder neck.

Inspection of any bleeding or vaginal discharge, with particular attention to the characteristics and amount of bleeding, is imperative. Palpate the groin area to detect any masses. An internal pelvic exam may reveal an ulcerated vaginal lesion.

A thorough assessment of each woman’s perception of the disease process and her coping mechanisms is required. Changes in sexual patterns and body image present stressors to patients. The family of the patient should also be included in the assessment to examine the extent of support they can provide. Her partner may experience anxiety over the potential loss of his mate or fear about altered patterns of sexuality.

Nursing care plan primary nursing diagnosis: Altered sexuality patterns related to tissue damage, pain, and change in body structures.

Nursing care plan intervention and treatment plan
Most often, the treatment of choice for VC is radiation therapy delivered either by external beam or internally (brachytherapy). Treatment decisions are made based on the extent of the lesion and the age and condition of the patient. Patients with early-stage disease are treated so that the malignant area is removed but the vagina is preserved. Laser surgery is often used during stages 0 and 1. Patients in the later stages of disease are treated with surgery or radiation. The type of surgery or radiation depends on the extent of the disease, the patient’s desire to preserve a functional vagina, and the location of the lesion. A radical hysterectomy may be done with removal of the upper vagina and dissection of the pelvic nodes. Most patients receive total external pelvic radiation therapy to shrink the tumor before surgery or before internal intracavity radiation. Internal radiation with radium or cesium into the vagina can be provided for 2 to 3 days. Current survival rates are similar for patients with VC whether they are treated with radiation or surgery.

Collaborative postoperative management includes analgesics for pain relief and careful assessment for signs of postoperative infection or poor wound healing. Before discharge, discuss with the physician the patient’s timetable for resumption of physical and sexual activity, and be
certain that the patient understands any limitations.

The nursing management of patients with VC is challenging because of the interaction between the patient’s physical and emotional needs. If the woman has pain from either the surgical procedure or the disease process, explore pain-control methods such as imagery and breathing techniques to manage discomfort. The woman may be depressed and angry. Allow the patient to express her anger and concerns without fear of being judged or discouraged. Provide a private place for her to discuss her concerns with the nurse or significant others. Provide a list of support groups for the patient and her partner.

Teach all female patients to be alert for signs of VC, particularly any unusual discharge or bleeding. Encourage all women over the age of 18 to seek annual checkups, including gynecologic examination. Women should also be taught to perform a genital self-examination at the same time they perform breast self-examination. Teach them to use a mirror to inspect for any changes in the female anatomy and to report any lesions, sores, lumps, or the presence of a persistent itch.

Nursing care plan discharge and home health care guidelines
Explain any procedures such as wound care or skin care that need to be continued at home. If the patient has had internal radiation therapy, teach her to use a stent or dilator to prevent vaginal stenosis; sexual intercourse also prevents vaginal stenosis. Teach the patient any limitations on the resumption of sexual activity or activity such as lifting or driving. Emphasize the importance of follow up visits, which may include procedures such as x-rays, computed tomography (CT) scans, ultrasound (US), or magnetic resonance imaging (MRI). If the patient had vaginal reconstruction, teach her about the need for using a lubricant during sexual intercourse. Also inform her that, owing to neural pathways, she may feel as if her thigh is being stroked during intercourse.

Teach the woman with VC to report any further vaginal bleeding or signs of infection (fever, poor wound healing, fatigue, drainage with an odor). Discuss helpful coping patterns with the patient if this was not done previously. Encourage her to be open about her concerns and needs with her family and friends. Provide her with a referral to the American Cancer Society if appropriate.

Teach teenage and preteenage girls who have been exposed to DES to have examinations at least once annually beginning at menarche regardless of the absence of symptoms of VC. Practicing safe sex will reduce the likelihood of contracting human papillomavirus (HPV), which is a contributing factor to the development of VC.

Nursing Care Plan | NCP Volvulus

Avolvulus is a mechanical obstruction of the bowel that occurs when the intestine twists at least 180 degrees on itself. Although it can occur in either the large or the small bowel, the most common areas in adults are the sigmoid and ileocecal areas. Compression of the blood vessels occurs, and an obstruction both proximal and distal to the volvulus also occurs. The direction of the chyme flow is obstructed, but the secretions of bile, pancreatic juices, and gastric juices continue. The internal pressure of the bowel rises when fluids and gases accumulate, thus causing a temporary stimulation of peristalsis that increases the distension of the bowel and causes colicky pain. The bowel wall becomes edematous and capillary permeability increases, causing fluid and electrolytes to enter the peritoneal cavity.

These changes place the patient at risk for severe electrolyte imbalance, decreased circulating blood volume, and development of peritonitis. When the volvulus is near or within the ileum, regurgitation and vomiting increase fluid, electrolyte, and acid-base imbalances. Blockage within the cecum or large intestine leads to bowel distension and eventual perforation. Reflux can occur if the ileocecal valve is incompetent. Perforation of the bowel releases bacteria and endotoxins into the peritoneal cavity, causing endotoxic shock and even death.

In some patients, the cause of a volvulus is never discovered. In most cases, however, the condition occurs at the site of an anomaly, tumor, diverticulum, foreign body (dietary fiber, fruit pits), or surgical adhesion.

Nursing care plan assessment and physical examination
Take a complete history of the patient’s eating patterns, bowel patterns, onset of symptoms, and distension. Elicit a gastrointestinal history from the patient, with particular attention to those with a history of constipation and Meckel’s diverticulum (a blind pouch found in the lower portion of the ileum). Ask if the patient has had abdominal surgery because adhesions make the patient at risk for a volvulus. Ask the patient to describe any symptoms, which may include abdominal distension, thirst, and abdominal pain. Patients may also report anorexia and food intolerance, with vomiting after eating. Late signs include colicky abdominal pain of sudden onset and vomiting with sediment and a fecal odor. The patient may also describe chronic constipation with no passage of gas or feces, or when a stool is passed, there may be blood in it.

The patient usually appears in acute distress from abdominal pain and pressure. The patient’s abdomen appears distended, and the patient may show signs of dehydration such as poor skin turgor and dry mucous membranes. Measure the abdominal girth to identify the amount of distension. When you auscultate the abdomen, you may hear no bowel sounds at all, indicating a paralytic ileus, or you may hear high-pitched peristaltic rushes with high metallic tinkling sounds, indicating intestinal obstruction. You may be able to palpate an abdominal mass, although the patient experiences pain and guarding on palpation.

The patient may have lived with constipation for a long time and may be embarrassed to discuss the issue of bowel movements or may hold certain beliefs about the frequency and consistency of bowel movements. Assess the patient’s self-image and the patient’s ability to cope with possible body disfigurement from surgical correction. If the patient is an adult, determine the patient’s ability to provide self-care.

Nursing care plan primary nursing diagnosis: Pain (acute) related to inflammation.

Nursing care plan intervention and treatment plan
A tube that is inserted into the small intestine (such as a Miller-Abbott) may be used to decompress the bowel and relieve the volvulus. If a lower bowel volvulus is suspected, a proctoscopy is performed to check for an infarcted bowel, followed by a sigmoidoscopy with a flexible scope to deflate the bowel. If these procedures are successful, the patient immediately expels gas and receives relief from abdominal pain.

Children with small bowel volvulus generally require immediate surgery. In adults, when nonsurgical treatments fail to resolve the volvulus, surgery is performed. The objective of treatment is to relieve the obstruction, although the cause is not always apparent and sometimes is discovered only during surgery. Vascular and mechanical obstructions are relieved by the surgeon, who excises the affected bowel. Depending on the location and extent of the bowel resection, a colostomy or bypass procedure may be performed.

The collaborative postoperative management often includes intravenous analgesia with narcotic agents or patient-controlled analgesia, antibiotic therapy, nasogastric drainage to low continuous or intermittent suction, and intravenous fluids. Monitor the patient for complications such as wound infection (fever, wound drainage, poor wound healing), pneumonia (lung congestion, shallow breathing, fever, productive cough), and bleeding at the surgical site.

When the patient is first admitted to the hospital, she or he is in acute discomfort. Usually, strategies are initiated immediately to correct the underlying condition rather than provide analgesia to minimize the discomfort. Explain to the patient that large doses of analgesics mask the symptoms of volvulus and may place the patient at risk for perforation. Remain with the patient as much as possible until the decision is made to use surgical or nonsurgical treatment to correct the volvulus. If the patient receives successful nonsurgical treatment, the symptoms subside immediately. At that time, provide teaching about strategies to limit constipation, such as diet, adequate fluid intake, and appropriate exercise.

If the patient requires surgery, provide a brief explanation of the procedures and what the patient can expect postoperatively. Have the patient practice coughing and deep breathing, and reassure the patient that postoperative analgesia will be available to manage pain. When the patient returns from surgery, use pillows to splint the abdomen during coughing and deepbreathing exercises. Get the patient out of bed for chair rest and ambulation as soon as the patient can tolerate activity. Notify the physician when bowel sounds resume, and gradually advance the patient from a clear liquid diet to solid food. If the patient experiences any food intolerance at all (nausea, vomiting, pain), notify the surgeon immediately.

If a colostomy or other surgical diversion is needed, work with the patient to accept the change in body image and body function. Allow the patient to verbalize his or her feelings about the ostomy and begin a gradual program to assist the patient to assume self-care. Be honest and explain whether the ostomy is temporary or permanent. If the patient or significant other is going to care for the ostomy at home and is having problems coping, contact the enterostomal therapist or clinical nurse specialist to consult with the patient.

Nursing care plan discharge and home health care guidelines
Teach the patient about strategies to maintain healthy bowel function, such as diet, exercise, drinking fluids, and avoiding laxatives. Provide phone numbers and agencies that can be supportive, such as colostomy and ileostomy groups. Encourage the patient to report any recurrence of symptoms immediately, particularly if the patient has been treated nonsurgically. Encourage patients who have had surgery to avoid strenuous activity for up to 6 weeks.

Kiplinger's Best Value Public Colleges

Following are the best performers in the Kiplinger's Personal Finance magazine's rankings of the "100 Best Values in Public Colleges" 2010:

Indiana University - The University moved into the top 30 for the first time in Kiplinger's rankings of the "100 Best Values in Public Colleges", ranked 28th overall, and 3rd among Big Ten universities. IU was ranked behind Big Ten peers at the University of

Little Things Mean A Lot

THE last post herein was devoted to a run-down of how the SFA works (or doesn't). I bet not many of you knew how important the Forfarshire, Stirlingshire, West of Scotland or Southern Counties FAs were in running the national game.

These bodies may not do sweet FA, but some of the competitions they run have as much relevance to modern football as Ye all-England Jousting Tournament have to the efficiency and potency of our armed forces. I deliberately wrote all-England there, the all-Scotland Jousting Tournament is still running, it is now called the Emirates Scottish Junior Cup.

I note also that I am not the solitary cynic abounding in Scottish football, young Michael Grant in the Herald has joined me in pointing-out what a pointless exercise Henry McLeish's review will become - with nobody taking a blind bit of notice of his findings

YOU have to hand it to those lovely people at Ibrox - they don't do irony. There is Walter Smith, a manager who would rather crawl over broken glass than put-on a young player complaining that Scottish Football is letting down young players, while Martin Bain, a man who is deeply complicit in bringing some only slightly better than useless while remarkable over-priced "talent" to Ibrox, crying out for a government hand-out for the game in Scotland.

OK Government investment in Scottish sport is a joke. Millions are poured into SportScotland or whatever it's called this week - this has created an industry of sports developers, who don't develop sport, facilitators, who don't facilitate and providers who fail to provide. The last thing we want to do is make sport yet another arm of state provision in Scotland. Mind you, the second-last thing we want to do is allow a lot of the people from within sport today to continue to run it.

Just a thought you understand - it's the press's job to point these things out, you see we don't have to resolve the problems.

I note this morning that fans-owned Stirling Albion are doing away with complimentary tickets - and about time too.

(I know, this is rich coming from a journalist who gets free entry to every game through his press pass).

But, comps are a pure racket and while stopping them at a stroke may make Albion some money, it will cost them in terms of friends within the game; we don't use the term "freemasonry of football" loosely, a lot is still done via nods, winks and friendships.

Another part of the comps racket which needs overhauling is in the murky world of press box passes. Particularly where the Old Firm is concerned, you will find in any press pack, supposedly working at the game, perhaps a team (i.e. an XI) of "journalists" who are there purely as spectators.

The expansion of the internet has not helped. You now have the ever-expanding army of website operators turning up and getting press priveleges. Last season one First Division club was followed by a crew of eight embedded "journalists", writing for fanzines and websites associated with that club. Not one was a qualified or recognised journalist. These people truly were: "fans with lap tops" and football is encouraging them.

One very-well-respected freelance football writer, whose work finds favour right across the board of journalism, from "red-top" tabloid to patrician broadsheet was telling me recently, he was covering a midweek Alba Cup match for one of the red-tops; there were six "journalists" in the press box, he was the solitary, full-time, qualified, card-carrying journalist. It is very wrong.

AND finally, Anthony Stokes is off to Celtic for, depending on which paper you read, between £800,000 and £1,200,000.

Good business by Celtic - they've got him cheaply, Hibs are immediately down a few goals, while with the service he should get at Celtic, he'll score a few.

Already Rod Petrie is getting pelters for selling his top-scorer so cheaply. Might it be a case of Hibs thinking they are well-rid of a disruptive dressing room influence. Team dynamic often plays a part in such moves.

I remember, some years ago, asking Craig Brown what had possessed him to buy a particular, very ordinary player, a man of more clubs that Jack Nicklaus.

"Aye well, when you've got him - you've got one happy dressing room", was the Motherwell Mauler's response.

Similarly I remember a St Mirren dressing room which went very flat when a particular "donkey defender" left, but cheered up very quickly thereafter when another player, who felt (wrongly) he was a star because he had once been on the bench for the Rangers first team was off-loaded.

CNA's for Immediate Hire - New Grads Welcome!!! (Nassau County - Close to Queens, USA)

NEW GRADS WELCOME!!!
CNA's needed for immediate hire in Nassau County close to the Queens Bordes!
We are currently hiring CNA's for immediate positions in Long-Term Care settings in Nassau County - ALL SHIFTS and ALL DAYS currently available!


Requirements:
NY State CNA license,
Recent Physical,
PPD,
MMR Titers,
Proof of Citizenship,
Social Security Card,

Please fax your resume to 347-402-7350 or email info@approvedstaffing.com

Take care.

NP Wanted For Holistic Pain Mgmt Trigger Point Clinic (NYC & LI , USA)

Please only respond if serious about following through Thanks :)

Nurse Practitioner (NP) Wanted P/T for Trigger Point Clinics in NYC and on Long Island
NICE Holistic Family oriented practices.​ Great part-time job mainly in afternoons.​
Training is provided.
Please be nice and have afternoons available as the position is mostly in the afternoons

Email or Fax (917-386-2586) resume & cover letter explaining your situation and availability.

Thanks.

America's Top 20 Party Schools

The University of Georgia took the top spot in The Princeton Review's annual list of party schools for 2011. It was ranked 4th last year (2010 party school list), behind Penn State University, University of Florida, and University of Mississippi. UGA was also ranked highly in several categories, including 2nd in lots of hard liquor (usage reported high), 7th in lots of beer (usage reported high)

Health Nation's Top 50 Midwife Blogs

SQUAT made the list!

Health Nation has compiled links to 50 midwifery and birth related blogs. Each blog is listed by title and features a brief description, making it simple to find out which blogs you'll likely fancy.

With the rise of blogging over the past decade, we see the sharing of real and uncensored information about current events and trends. In the radical midwifery movement, blogs are an essential tool to share thoughts around the world and to find out what radical birth workers are up to (since we're almost never featured on the nightly news). Reading blogs is also a great way to network with like-minded individuals, make allies and stay strong during tough times.

To check out Health Nation's list go here: http://onlinenursepractitionerprograms.com/2010/top-50-midwife-blogs/

See you in the blogosphere!

Download Nursing Care Plan for Appendicitis

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Dr. Marcia Costello interviewed on FOX news

Thanks to Dr. Marcia Costello, RD, assistant professor, who shared her expertise about contaminated eggs on Sunday night on Philly's Fox news.



See the clip here http://www.criticalmention.com/components/url_gen/play_flash.php?autoplay=1&clip_info=1543863515|23|36^1543864799|0|59^1543866103|0|59^1543867050|0|50^

Free Download EKG Guide

A Guide to Reading and Understanding the EKG
Written by Henry Feldman, '01
Reviewed by Mariano Rey, MD, '76

This guide will help you learn to interpret 12-lead EKG patterns. This is not a comprehensive guide to EKG interpretation, and for further reading, the Dubin textbook is the introductory book of choice.

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Nursing Care Plan | NCP Ventricular Dysrhythmias

Aventricular dysrhythmia is a disturbance in the normal rhythm of the electrical activity of the heart that arises in the ventricles. Types of ventricular dysrhythmias include premature ventricular contractions (PVCs), which can have one focus or can arise from multiple foci; ventricular tachycardia (VT), which can lead to ventricular fibrillation or sudden cardiac death; ventricular fibrillation (VF), which results in death if not treated immediately; and ventricular asystole (cardiac standstill), in which no cardiac output occurs and full cardiopulmonary arrest results.

Conditions that are associated with cardiac dysrhythmias include myocardial ischemia, myocardial infarction, electrolyte imbalance, drug toxicity, and degeneration of the conduction system by necrosis. A dysrhythmia can be the result of a disturbance in the ability of the myocardial cell to conduct an impulse (conductivity), a disturbance in the ability to initiate and maintain an inherent rhythm spontaneously (automaticity), or a combination of both.

Nursing care plan assessment and physical examination
If the patient is unable to provide a history of the life-threatening event, obtain it from a witness. Many patients with suspected cardiac dysrhythmias describe a history of symptoms indicating periods of decreased cardiac output. Although occasional PVCs do not usually produce symptoms, some patients report a history of dizziness, fatigue, activity intolerance, a “fluttering” in their chest, shortness of breath, and chest pain. In particular, question the patient about the onset, duration, and characteristics of the symptoms and the events that precipitated them. Obtain a complete history of all illnesses, dietary and fluid restrictions, activity restrictions, and a current medication history.

If the patient does not have adequate airway, breathing, or circulation, initiate cardiopulmonary resuscitation (CPR) as needed. If the patient is stable, complete a general head-to-toe physical examination. Pay particular attention to the cardiovascular system by inspecting the skin for changes in color or the presence of edema. Auscultate the heart rate and rhythm, and note the first and second heart sounds and also any adventitious sounds. Auscultate the blood pressure. Perform a full respiratory assessment, and note any adventitious breath sounds or labored breathing.

Ventricular dysrhythmias may cause a life-threatening event and a great deal of anxiety and fear because of the potential alterations to current lifestyle and functioning. Assess the ability of the patient and significant others to cope. If the dysrhythmia requires a pacemaker insertion or an automatic implantable cardioverter defibrillator (ICD), determine the patient’s response.

Nursing care plan primary nursing diagnosis: Altered tissue perfusion (cardiopulmonary, cerebral, renal, peripheral) related to rapid heart rates or the loss of the atrial kick.

Nursing care plan intervention and treatment plan
The first step of treatment is to maintain airway, breathing, and circulation. Low-flow oxygen by nasal cannula or mask may decrease the rate of PVCs. Higher flow rates are usually needed for the patient with VT, and if pulseless VT or VF occurs, the patient needs immediate endotracheal intubation, support of breathing with a manual resuscitator bag, and closed chest compressions (CPR). The most important intervention for a patient with pulseless VT or VF is rapid defibrillation (electrical countershock). If a defibrillator is not available, give a sharp blow to the precordium (precordial thump or thumpversion) to try to convert VT or VF into a regular sinus rhythm. Maintain CPR between all other interventions for patients without adequate breathing and circulation.

The drug of choice to manage PVCs or VT with a pulse is lidocaine at 1.0 to 1.5 mg/kg of body weight given intravenously (IV). If the patient has pulseless VT or VF, the treatment of choice is to defibrillate the patient as discussed previously, intubate the patient, administer epinephrine, and then administer lidocaine. If the patient has electrolyte imbalances, or they are suspected, supplemental potassium and magnesium is administered IV.

In stable patients, trials of various medications or combinations of medications may be used to control the dysrhythmia. Antidysrhythmics, such as bretylium and procainamide, may be used if lidocaine is not successful. Other drugs such as quinidine, propranolol, metoprolol, and verapamil may be used, depending on the cause and nature of the dysrhythmia. Other alternatives include surgical implantation of either a pacemaker or an ICD and surgical ablation of aberrant electrical conduction sites.

The patient with ventricular asystole is managed with CPR. Initiate CPR, intubate the patient immediately, provide oxygenated breathing with a manual resuscitator bag, and obtain IV access. Confirm the ventricular asystole in a second lead to make sure the patient is not experiencing VF, which would indicate the need to defibrillate. If the rhythm still appears as ventricular asystole, administer epinephrine and then atropine in an attempt to have the patient regain an effective cardiac rhythm. The physician may consider a transcutaneous or transvenous pacemaker, but if efforts do not convert the cardiac rhythm, the physician may terminate resuscitation efforts.

As with all potentially serious conditions, the first priority is to maintain the patient’s airway, breathing, and circulation. If the patient is not having a cardiopulmonary arrest, maximize the amount of oxygen available to the heart muscle. During periods of abnormal ventricular conduction, encourage the patient to rest in bed until the symptoms are treated and subside. Remain with the patient to ensure rest and to allay anxiety.

For some patients with PVCs, strategies to reduce stress help limit the incidence of the dysrhythmia. A referral to a support group or counselor skilled at stress reduction techniques is sometimes helpful. Teach the patient to reduce the amount of caffeine intake in the diet. Explain the need to read the ingredients of over-the-counter medications to limit caffeine intake. If appropriate, encourage the patient to become involved in an exercise program or a smoking cessation group. Patients who experience dysrhythmias are often facing alterations in their lifestyle and job functions. Provide information about the dysrhythmia, the precipitating factors, and mechanisms to limit the dysrhythmia. If the patient is placed on medications, teach the patient and significant others the dosage, route, action, and side effects. If the patient is at risk for electrolyte imbalance, teach the patient any dietary considerations to prevent electrolyte depletion of vital substances.

The most devastating outcome of a ventricular dysrhythmia is sudden cardiac death. If the patient survives the episode, provide an honest accounting of the incident and support the patient’s emotional response to the event. If the patient does not survive, remain with the family and significant others, support their expression of grief without being judgmental if it varies from your own ways to express grief, and notify a chaplain or clinical nurse specialist if appropriate to provide additional support.

Nursing care plan discharge and home health care guidelines
Explain to the patient the importance of taking all medications. If the patient needs periodic laboratory work to monitor the effects of the medications (such as serum electrolytes or drug levels), discuss with the patient the frequency of these laboratory visits and where to have the tests drawn. Explain the actions, the route, the side effects, the dosage, and the frequency of the medication. Discuss methods for the patient to remember to take the medications, such as numbered medication boxes or linking the medications with other activities such as meals or sleep. Teach the patient how to take the pulse and recognize an irregular rhythm. Explain that the patient needs to notify the healthcare provider when symptoms such as irregular pulse, chest pain, shortness of breath, and dizziness occur.

Stress the importance of stress reduction and smoking cessation. If the patient has the placement of a pacemaker or an ICD, provide teaching about the settings, signs of pacemaker failure (dizziness, syncope, palpitations, fast or slow pulse rate), and when to notify the physician. Explain any environmental hazards based on the manufacturer’s recommendations, such as heavy machinery and airport security checkpoints. Make sure the patient understands the schedule for the next physician’s checkup. If the patient has an ICD, encourage the patient to keep a diary of the number of times the device discharges. Most physicians want to be notified the first time the ICD discharges after implantation.

Nursing Care Plan | NCP Varicose Veins

Varicose veins (varicosities) are abnormally dilated tortuous veins. They occur most often in the lower extremities but can appear anywhere in the body. Primary varicosities are caused by incompetent valves in the superficial saphenous veins, whereas secondary varicosities are the result of impaired blood flow in the deep veins. Primary varicosities tend to occur in both legs, whereas secondary varicosities usually occur in only one leg.

In a ladder-like fashion, perforator veins connect the deep vein and the superficial vein systems, promoting drainage of the lower extremities. Blood can be shunted from one system to the other in the event of either system’s being compressed. Incompetence in one system can lead to varicosities. Varicose veins are considered a chronic disease, and along with valvular incompetence can progress to chronic venous insufficiency (CVI).

Several factors cause increased venous pressure and venous stasis that result in dilation and stretching of the vessel wall. Increased venous pressure results from being erect, which shifts the full weight of the venous column of blood to the legs. Prolonged standing increases venous pressure because leg muscle use is less; therefore, blood return to the heart is decreased.

Heavy lifting, genetic factors, obesity, thrombophlebitis, pregnancy, trauma, abdominal tumors, congenital or acquired arteriovenous fistulae, and congenital venous malformations are among the causes of varicose veins. Chronic liver diseases such as cirrhosis can cause varicosities in the rectum, abdomen, and esophagus.

Nursing care plan assessment and physical examination
Elicit a history of symptoms, with particular attention to pain and discomfort, changes in appearance of vessels and skin, and complaints of a sensation of fullness of the lower extremities. Ask the patient to describe the amount of time each day spent standing. Take an occupational history with particular attention to those jobs that require long hours of walking or standing. Question the patient about lifetime weight changes, such as changes during pregnancy and sustained periods of being overweight. Ask the patient if there is a personal or family history of heart disease, obesity, or varicose veins.

The number, severity, and type of varicosities determine the symptoms experienced by the individual. With the patient standing, examine the legs from the groin to the foot in good lighting. Inspect the ankles, measure the calves for differences, and assess for edema. Time of examination is a factor because secondary varicosities are more symptomatic earlier in the day. Palpate both legs for dilated, bulbous, or corkscrew vessels. Patients may complain of heaviness, aching, edema, muscle cramps, increased fatigue of lower leg muscles, and itching. Severity of discomfort may be difficult to assess and is unrelated to the size of the varicosity.

The patient with varicose veins has usually been dealing with a progressively worsening condition. Assess the patient for any problems with body image because of the changed appearance of skin surface that is caused by varicose veins. Question the patient to determine possible lifestyle adjustments to decrease symptoms. The patient may need job counseling or occupational retraining.

Nursing care plan primary nursing diagnosis: Altered tissue perfusion (peripheral) related to increased venous pressure and obstruction.

Nursing care plan intervention and treatment plan
Treatment for varicose veins is aimed at improving blood flow, reducing injury, and reducing venous pressure. Pharmacologic treatment is not indicated for varicose veins. To give support and promote venous return, physicians recommend wearing elastic stockings. If the varicosities are moderately severe, the physician may recommend antiembolism stockings or elastic bandages or, in severe cases, custom-fitted heavy-weight stockings with graduated pressure. When obesity is a factor, the patient is placed on a weight loss regimen. Experts also recommend that the patient stop smoking to prevent vasoconstriction of the vessels.

A nonsurgical treatment is the use of sclerotherapy for varicose and spider veins. Sclerotherapy is palliative, not curative, and is often done for cosmetic reasons after surgical intervention. A sclerosing agent, such as sodium tetradecyl sulfate (Sotradecol), hypertonic saline, aethoxysclerol, or hyperosmolar salt-sugar solution, is injected into the vein, followed by a compression bandage for a period of time.

A surgical approach to varicose veins is vein ligation (tying off) or stripping (removal) of the incompetent veins. Removal of the vein is performed through multiple short incisions from the ankle to the groin. A compression dressing is applied after surgery and is maintained for 3 to 5 days. Patients are encouraged to walk immediately postoperatively. Elevate the foot of the bed 6 to 9 inches to keep the leg above the heart when the postoperative client is in bed.

Nursing interventions are aimed at educating the patient to decrease venous stasis, promote venous return, and prevent tissue injury. To prevent vein distension by compression of superficial veins, teach the patient to apply elastic support stockings before standing and to avoid long periods of standing. The patient should be encouraged to engage in an exercise program of walking to strengthen leg muscles. Teach the patient to avoid crossing the legs when sitting and to elevate the legs when sitting or lying down. The patient should be taught to observe the skin when removing stockings to check for signs of irritation, edema, decreased nerve sensation, and discoloration. Preventive measures are similar to those for a patient with thrombophlebitis.

For patients who have had sclerotherapy, teaching should focus on activity restrictions. The patient should learn to avoid heavy lifting. Teach the patient to wait 24 to 48 hours after the procedure before showering and to avoid tub baths. Teach the patient to wear supportive stockings as ordered. Prepare the patient by advising him or her to expect ecchymosis and some scarring, which will fade in several weeks. Caution the patient that some residual brown staining may remain at the injection sites. Inform the patient that the sclerotherapy may need to be repeated in other areas.

Nursing care plan discharge and home health care guidelines
To prevent worsening of varicosities, teach the patient to avoid prolonged standing in one place, to avoid sitting with the legs crossed, to elevate the legs frequently during the day, to wear support stockings as ordered, and to drink 2 to 3 L of fluid daily. The patient should wear shoes that fit comfortably and are not too tight. Teach the patient the purpose, dosage, route, and side effects of any medications ordered. Teach the patient to recognize, and observe daily for, signs of thrombophlebitis, which include redness, local swelling, warmth, discoloration (not related to
surgery area), and back pain on bending. Teach the patient which signs to report to the physician. Teach the patient to report any signs of infection, such as redness at incision sites or injection sites, severe pain, purulent drainage, fever, or swelling.

Nursing Care Plan | NCP Vaginitis

Vaginitis is an inflammation of the vagina that includes three infections: Candidiasis, trichomoniasis, and bacterial vaginosis. Generally, it occurs with a hormonal imbalance and an infection with a microorganism. Vaginitis is associated with changes in normal flora, alkaline pH, insertion of foreign bodies such as tampons and condoms, chemical irritations from douches and sprays, and medications such as broad-spectrum antibiotics.

Trichomoniasis is an infection caused by Trichomonas vaginalis, a single-celled, anaerobic, protozoan parasite that is shaped like a turnip and has three or four anterior flagella. This parasite feeds on the vaginal mucosa and ingests bacteria and leukocytes.

Vulvovaginal candidiasis is caused by Candida albicans (most often), C. glabrata, or C. tropicalis. These organisms are normally present in approximately 50% of women and cause no symptoms until the vaginal environment is altered. Contributing factors to altering the vaginal environment and causing an overgrowth of Candida are: taking broad-spectrum antibiotics, which alter the protective bacterial flora; higher hormone levels from birth control pills and pregnancy, which increase glycogen stores that facilitate yeast growth; and diabetes mellitus or human immunodeficiency virus (HIV) infection that alters the immune system. Repeated candida infections may be an indicator of unrecognized HIV infections.

Bacterial vaginosis (nonspecific vaginitis) is characterized by an imbalance in the vaginal flora (absence of the normal Lactobacillus species) and an overgrowth of Gardnerella, Mycoplasma species, and anaerobic bacteria. The anaerobe raises the vaginal pH, producing favorable conditions for bacterial growth. Cervicitis and urethritis are frequent manifestations of gonococcal or chlamydial infections and result from infection by Neisseria gonorrhoeae or Chlamydia trachomatis, but other agents may also cause vaginitis.

Nursing care plan assessment and physical examination
Elicit a history of the onset and description of symptoms, with particular attention to the nature and amount of vaginal discharge, which may be frothy, thick, or malodorous. Question the patient to determine if she is experiencing discomfort such as external inflammation and pain, and pruritus. Patients may describe exertional dysuria, dyspareunia, and vulvular inflammation. Determine the medications that the patient is taking, with particular attention to antibiotics, hormone replacement therapy, and contraceptives. Take a menstrual history. Ask about the patient’s rest, sleep, nutrition, exercise, and hygiene practices. Ask the patient if she is pregnant or a diabetic, both of which place the patient at risk for vaginitis.

Vaginal examination should take place under the following conditions: not on menses; no douching or vaginal sprays for 24 hours prior to exam; no sexual intercourse without a condom for 24 hours prior to the exam. Physical examination generally reveals some type of discharge, such as frothy, malodorous, greenish-yellow, purulent vaginal discharge (trichomoniasis); thick, cottage cheese–like discharge (candidiasis); or malodorous, thin, grayish-white, foul, fishy odor discharge (bacterial). The external and internal genitalia are often reddened, inflamed, and painful on examination. Women with candidiasis often have patches on vaginal walls and cervix and signs of inflammation. Women with trichomoniasis have a strawberry spot on the vaginal surface and cervix. Bacterial vaginitis is often asymptomatic with a normal vaginal mucosa. Palpate the patient’s abdomen for tenderness or pain, which may indicate pelvic inflammatory disease.

Psychosocial assessment should include evaluation of the patient’s home situation and a sexual history. Ask the patient about the type of contraception she and her partner use. Provide a private environment to allow the patient to answer questions without being embarrassed.

Nursing care plan primary nursing diagnosis: Risk for infection related to invasion or proliferation of microorganisms.

Nursing care plan intervention and treatment plan
Encourage the patient to get adequate rest and nutrition. Encourage the patient to use appropriate hygiene techniques by wiping from front to back after urinating or defecating. Teach the patient to avoid wearing tight-fitting clothing (pantyhose, tight pants or jeans) and to wear cotton underwear rather than synthetics. Explain to patients that the risk of getting vaginal infections increases if one has sex with more than one person. Teach the patient to abstain from sexual intercourse until the infection is resolved. If the patient has Trichomonas, her partner needs treatment as well. Teach the patient that the inflammation caused by the Trichomonas increases her susceptibility to HIV.

The pain and itching from vaginitis may be quite intense until the medication is effective. Some women find that by applying wet compresses and then using a hair dryer on a cool setting several times a day provides some relief of itching. Other women find that a cool sitz bath provides comfort. For yeast infections, tepid sodium bicarbonate baths and applying cornstarch to dry the area may increase comfort during treatment. Be informed about which sexually transmitted diseases need to be reported to the local health department.

Nursing care plan discharge and home health care guidelines
Teach the patient how to maintain lifestyle changes with regard to rest, nutrition, and medication management. Make sure that the patient understands all aspects of the treatment regime with particular attention to taking the full course of medication therapy. Make sure the patient understands the necessity of any follow-up visits.

Top Business Schools in South Africa

South African business schools are ranked highly in international rankings. According to the Financial Times rankings of business schools and MBA programs, University of Cape Town is ranked in the global top 100 for its M.B.A. program (rated 71st in 2009 and 89th in 2010). It is also rated highly in the FT "Executive Education Customised" rankings 2010, ranked 2nd in South Africa and 49th in the

Jobs For The Boys

I am feeling a bit better after my last rant, so the pills must be working. However, that's not something which can be said about Scottish Football.

The (English) FA is even longer-established than that mob at Hampden, but at least, they acknowledge there are two games of football played in these islands. In England they have "the professional game" and "the community game".

Now there may well be as huge a gulf between Chelsea and Manchester United and whichever team is bottom of their Fourth Division as there is between the Old Firm and the bottom of the SFL's Third Division, but, at least all 92 "league" clubs in England are full-time.

If the SFA was to be split into a professional and a community game (which would be no bad thing), less than half of our "league" clubs would qualify for the entry to the "professional" game.

A "professional" club should be full-time, have if not an all-seater, certainly a clean, safe, covered stadium, proper youth development programmes and players who had a professional attitude to their job.

Even this basic and of necessity broad brush criteria for a professional club would rule out all but a minority of our so-called "league" clubs - but it will not happen. And it will not happen because of the way the SFA is set-up.

I spent a mind-boggling time today trying to make sense of the Byzantine internal politics of this body, it is chilling.

The day-to-day running of the SFA is currently, pending Stuart Regan being given out lbw at Yorkshire CCC, in the hands of George Peat and the Board of Directors, a board which sadly does not meet Tommy Docherty's criteria for the ideal board - three-strong, one dead and two dying.

The SFA "parliament" is the Council, which meets quarterly. This body is 35-strong - if you include those two living fossils, Jack McGinn and John McBeth, the last two presidents, neither of whom has any current affiliation with a club.

Only Aberdeen, Inverness Caledonian Thistle, Motherwell and St Mirren of the 12 SPL clubs are not represented on the SFA Council, while eight of the 30 SFL clubs have a man therein. But, only Rangers' Andrew Dickson, (or should that be Andrew Who?), Dundee United's Stephen Thompson and Kilmarnock's Michael Johnston are actually elected as SPL representatives.

Campbell Ogilvie is first vice president, but owes his position to his Heart of Midlothian affiliation; Celtic's Eric Riley represents the Glasgow FA (members: Celtic, Clyde, Glasgow University??, Partick Thistle, Queen's Park and Rangers); Hibs' Rod Petrie supposedly represents the 26 East of Scotland FA clubs, of whom just three, Hearts, Hibs and Berwick Rangers are "league" clubs; Steven Brown of St Johnstone represents the seven Forfarshire FA clubs and Hamilton Accies' Scott Struthers sits on behalf of the seven West of Scotland FA clubs (Albion Rovers, Ayr United, Hamilton, Kilmarnock, Motherwell, St Mirren and junior side Girvan).

It's much the same as regards the SFL clubs. Airdrie United's Jim Ballantyne, Ewen Cameron of Alloa Athletic and Lachlan Cameron of Ayr United are the three SFL reps, but East Fife's Derrick Brown, sits on behalf of the five Fife FA clubs (Cowdenbeath, Dunfermline, East Fife, Raith Rovers and Burntisland Shipyard??); SFA board member Richard Shaw of Annan Athletic sits on behalf of the 15 Southern Counties FA clubs, just three of which - his own, Queen of the South and Stranraer are "league" clubs; Falkirk's Martin Ritchie represents the six Stirlingshire FA clubs (Alloa, Dumbarton, East Stirlingshire, Falkirk, Stenhousemuir and Stirling Albion).

You have the East of Scotland League, represented by former referee Dr Andrew Waddell of Preston Athletic, Findlay Noble of Fraserburgh sitting on behalf of the Highland League clubs, while David Dowling of Clachnacuddin represents the North of Scotland FA's 13 clubs and Keith's Sandy Stables sits on behalf of the 12 Aberdeen & District FA Clubs (Aberdeen, nine Highland League clubs and two North Junior clubs) and Colin Holden the Threave Rovers chairman represents the dozen or so South of Scotland League clubs.

The Council is completed by the representatives of the affiliated associations: the Juniors, Amateurs, Scottish Welfare FA, Scottish Schools FA, Scottish Youth FA and the Scottish Women's FA, plus four "Regional Representatives", whose function they themselves would be hard-pushed to explain.

At a time when the full United Kingdom of Great Britain and Northern Ireland government is considering boundary changes to level-out the playing field of constituency sizes, so each MP is representing more or less the same number of constituents, how can the SFA justify a system whereby Eric Riley represents six clubs, Rod Petrie 26 and so on; each senior club has in effect two votes - one through the SPL or SFL representatives, another via their affiliated local FA, while the SJFA and the SAFA, the two organisations which represent respectively over 150 and 1500 community clubs have just two representatives on the SFA Council?

The whole system is slewed towards keeping power in the hand of a very few and democracy at bay. It's about getting as many snouts as possible into the feeding trough and for as long as two clubs' supporters bank-roll every other Scottish "league" club, the system will not change.

By the way, the make-up of the SFA Council disproves the old theory that these two clubs effectively run Scottish football. Ignoring Jack McGinn, Celtic's Riley and Rangers' Andrew Dickson are the only Old Firm men inside the Hampden corridors of power, and with every respect to the two men concerned - within their clubs they are hardly big hitters. They are just as body of the kirk in the SFA, Dickson sitting on the professional football and general purposes committees, Riley on the appeals committee.

I finish with a story told me by a now-retired freelance football writer, who was chuffed to bits to be elected as the Scottish Football Writers Association's representative onto the SFA's international match sub-committee, his remit, to ensure that the needs of the working press were met when it came to covering Scottish internationals.

He emerged from his first sub-committee meeting to announce: "They spent more time arguing about what type of wine to serve at the post-match banquet than about arrangements for the actual game".

I think that tale sums-up Scottish football and guys with that me-first attitude will never make the necessary changes.

It's going to be a long, hard, winter.

Top Universities in Portugal

Following are the top leading universities in Portugal:

University of Porto
- It is the largest education and research institution in Portugal.
- The University provides an exceptional variety of courses, covering the whole range of study areas and all levels of higher education.
- Ranked among the world's top 500 institutions in the Academic Ranking of World Universities (ARWU) 2009.

Gordon Institute of Business Science

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Nursing Care Plan | NCP Uterine Cancer

Uterine cancer most commonly occurs in the endometrium, the mucous membrane that lines the inner surface of the uterus. Endometrial cancer, specifically adenocarcinoma (involving the glands), accounts for more than 95% of the diagnosed cases of uterine cancer. There has been an increase noted in the number of women with endometrial cancer, partly owing to women living longer and more accurate reporting. Endometrial cancer is the fourth most common cause of cancer in women, ranking behind breast, colorectal, and lung cancer. It is the most common neoplasm of the pelvic region and reproductive system of the female, and it occurs in 1 in 100 women in the United States. Other uterine tumors include adenocarcinoma with squamous metaplasia (previously referred to as adenoacanthoma), endometrial stromal sarcomas, and leiomyosarcomas.

Endometrial cancer can infiltrate the myometrium, thus resulting in an increased thickness of the uterine wall, and it can eventually infiltrate the serosa and move into the pelvic cavity and lymph nodes. It can also spread by direct extension along the endometrium into the cervical canal; pass through the fallopian tubes to the ovaries, broad ligaments, and peritoneal cavity; or move via the bloodstream and lymphatics to other areas of the body. It is a slow-growing cancer, taking 5 or more years to develop from hyperplasia to adenocarcinoma. Endometrial cancer is very responsive to treatment, provided it is detected early. Prognosis depends on the stage, uterine signs, and lymph node involvement. In 2005, 40,880 new cases of uterine cancer would be diagnosed and 7310 women would die in the United States.

The exact cause of uterine cancer is not known, although it is considered to be dependent on endogenous hormonal levels for growth. Risk factors associated with the development of uterine adenocarcinoma include age, genetic and familial factors, early menarche (before age 12), late menopause (after 52 years), hypertension, nulliparity, unopposed estrogen hormonal replacement therapy, pelvic irradiation, polycystic ovarian disease, obesity, and diabetes mellitus. Leiomyosarcomas are more common among African Americans.

Nursing care plan assessment and physical examination
Establish a history of risk factors. The major initial symptom of endometrial cancer occurring in 85% of women is abnormal, painless vaginal bleeding, either menometrorrhagia or postmenopausal. A mucoid and watery discharge may be noted several weeks to months before this bleeding. Postmenopausal women may report bleeding that began a year or more after menses stopped. A mucosanguineous, odorous vaginal discharge is noted if metastases to the vagina has occurred. Younger women may have spotting and prolonged, heavy menses. Inquire about pain, fever, and bowel/bladder dysfunction, which are late symptoms of uterine cancer. Assess the use and effectiveness of any analgesics for pain relief and also the location, onset, duration, and intensity of the pain.

Conduct a general physical and gynecologic examination. The woman should be directed to not douche or bathe for 24 hours before the examination so that tissue is not washed away. Inspection of any bleeding or vaginal discharge is imperative. The characteristics and amount of bleeding should be noted. Upon palpation, the uterus will feel enlarged and may reveal masses.

Women with the disease often exhibit depression and anger, especially if they are a nulligravida. Therefore, a thorough assessment of the woman’s perception of the disease process and her coping mechanisms is required. The family should also be included in the assessment to examine the extent of support they can provide for the patient. Family anger, ineffective coping, and role disturbances may interfere with family functioning and need careful monitoring.

Nursing care plan primary nursing diagnosis: Knowledge deficit related to treatment procedures, treatment regimens, medications, and disease process.

Nursing care plan intervention and treatment plan
If uterine cancer is detected early, the treatment of choice is surgery. A total abdominal hysterectomy (TAH) with removal of the fallopian tubes and ovaries, bilateral salpingo-oophrectomy (BSO) is generally performed. Common complications after a hysterectomy are hemorrhage, infection, and thromboembolitic disease. Premenopausal women who have a BSO become sterile and experience menopause. Hormone replacement therapy may be warranted and is appropriate. In a total pelvic exenteration (evisceration or removal of the contents of a cavity), the surgeon removes all pelvic organs, including the bladder, rectum, and vagina. This procedure is performed if the disease is contained in the areas without metastasis. If the lymph nodes are involved, this procedure is usually not curative.

Radiation therapy may also be given in combination with the surgery (before or after) or it may be used alone, depending on the staging of the disease, whether the tumor is not well differentiated, or whether the carcinoma is extensive. Radiation may be the treatment of choice for the very elderly woman with an advanced stage of endometrial cancer for whom surgery would not improve quality of life. With radiation, the possible complications are hemorrhage, cystitis, urethral stricture, rectal ulceration, or proctitis. Intracavity radiation or external radiation therapy may be given 6 weeks before surgery to limit recurrence or to improve the chance of survival. An internal radiation device may be implanted during surgery (preloaded) or at the patient’s bedside (afterloaded). If the device is inserted during the surgical procedure, the postoperative management needs to include radiation precautions. Provide a private room for the patient and follow the key principle to protect against radiation exposure: distance, time, and shielding. The greater the distance from the radiation source, the less exposure to ionizing rays. The less time spent providing care, the less radiation exposure. The source of radiation determines if lead shields are necessary to provide care. All healthcare workers coming in contact with a “hot” patient (a patient with an internal radiation implant) need to monitor their exposure with a monitoring device such as a film badge.

The major emphasis is prevention, either primary by reduction of risk factors or secondary by early detection. Encourage women to seek regular medical checkups, which should include gynecologic examination. Discuss risk factors associated with the development of endometrial cancer, particularly as they apply or do not apply to the particular woman. Encourage the older menopausal woman to continue with regular examinations. If the woman is bleeding heavily, monitor her closely for signs of dehydration and shock (dry mucous membranes, rapid and thready pulses, delayed capillary refill, restlessness, and mental status changes). Encourage her to drink liberal amounts of fluids, and have the equipment available for intravenous hydration if necessary. A balanced diet promotes wound healing and maintains good skin integrity.

Patients require careful instruction before radiation therapy or surgery. Explain the procedures carefully, and notify the patient what to expect after the procedure. For surgical candidates, teach coughing and deep-breathing exercises. Fit the patient with antiembolism stockings. If the patient is premenopausal, explain that removal of her ovaries induces menopause. Unless she undergoes a total pelvic exenteration, her vagina is intact and sexual intercourse remains possible. During external radiation therapy, the patient needs to know the expected side effects (diarrhea, skin irritation) and the importance of adequate rest and nutrition. Explain that she should not remove ink markings on the skin because they direct the location for radiation. If a preloaded radiation implant is used, the patient has a preoperative hospital stay that includes bowel preparation, douches, an indwelling urinary catheter, and diet restrictions the day before surgery.

If the woman has pain from either the surgical procedure or the disease process, teach her pain-relief techniques such as imagery and deep breathing. Encourage her to express her anger and feelings without fear of being judged. Note that surgery and radiation may profoundly affect the patient’s and partner’s sexuality. Answer any questions honestly, provide information on alternatives to traditional sexual intercourse if appropriate, and encourage the couple to seek
counseling if needed. If the woman’s support systems and coping mechanisms are insufficient to
meet her needs, help her find others. Provide a list of support groups that may be helpful.

Nursing care plan discharge and home health care guidelines
Teach the need for regular gynecologic examinations, even though she had a hysterectomy. Teach the patient to report any abnormal vaginal bleeding to the healthcare provider. The woman who has had a TAH with BSO is at risk for developing osteoporosis. Recommend a daily intake of up to 1500 mg of calcium through diet and supplements. Recommend vitamin D supplements to enable the body to use the calcium. Stress the need for regular exercise, particularly weight-bearing exercise. Discuss the exercise schedule and type with the patient in light of her treatment and expected recovery time.

Ensure that the patient understands the dosage, route, action, and side effects of any medication she is to take at home. Note that, to monitor her response, some of the medications require her to have routine laboratory tests following discharge from the hospital.

Discuss any incisional care. Encourage the patient to notify the surgeon for any unexpected wound discharge, bleeding, poor healing, or odor. Teach the patient to avoid heavy lifting, sexual intercourse, and driving until the surgeon recommends resumption.

To decrease bulk, teach the patient to maintain a diet high in protein and carbohydrates and low in residue. If diarrhea remains a problem, instruct the patient to notify the physician or clinic because antidiarrheal agents can be prescribed. Encourage the patient to limit her exposure to others with colds because radiation tends to decrease the ability to fight infections. To decrease skin irritation, encourage the patient to wear loose-fitting clothing and avoid using heating pads, rubbing alcohol, and irritating skin preparations.

Teach the patient appropriate self-care for her specific treatment. Teach the patient to be able to identify where she can obtain assistance should postoperative or posttreatment complications occur. Make sure that the significant others are aware of the expectations of a normal convalescence and whom to call should concerns arise.

Nursing Care Plan | NCP Urinary Tract Infection

Urinary tract infections (UTIs) are common and usually occur because of the entry of bacteria into the urinary tract at the urethra. Approximately 20% to 25% of women have a UTI sometime during their lifetime, and acute UTIs account for approximately 7 million healthcare visits per year for young women. About 20% of women who develop a UTI experience recurrences. Women are more prone to UTIs than men because of natural anatomic variations. The female urethra is only about 1 to 2 inches in length, whereas the male urethra is 7 to 8 inches long. The female urethra is also closer to the anus than is the male urethra, increasing women’s risk for fecal contamination. The motion during sexual intercourse also increases the female’s risk for infection.

Urinary reflux is one reason that bacteria spread in the urinary tract. Vesicourethral reflux occurs when pressure increases in the bladder from coughing or sneezing and pushes urine into the urethra. When pressure returns to normal, the urine moves back into the bladder, taking with it bacteria from the urethra. In vesicoureteral reflux, urine flows backward from the bladder into one or both of the ureters, carrying bacteria from the bladder to the ureters and widening the infection. If they are left untreated, UTIs can lead to chronic infections, pyelonephritis, and even systemic sepsis and septic shock. If infection reaches the kidneys, permanent renal damage can occur, which leads to acute and chronic renal failure.

The pathogen that accounts for about 90% of UTIs is Escherichia coli. Other organisms that are commonly found in the gastrointestinal tract and may contaminate the genitourinary tract include Enterobacter, Pseudomonas, group B beta-hemolytic streptococci, Proteus mirabilis, Klebsiella species, and Serratia. Two growing causes of UTI in the United States are Staphylococcus saprophyticus and Candida albicans. Predisposing factors are urethral damage from childbirth, catheterization, or surgery; decreased frequency of urination; other medical conditions such as diabetes mellitus; and in women, frequent sexual activity and some forms of contraceptives (poorly fitting diaphragms, use of spermicides).

Nursing care plan assessment and physical examination
The patient with a UTI has a variety of symptoms that range from mild to severe. The typical complaint is of one or more of the following: frequency, burning, urgency, nocturia, blood or pus in the urine, and suprapubic fullness. If the infection has progressed to the kidney, there may be flank pain (referred to as costovertebral tenderness) and low-grade fever.

Question the patient about risk factors, including recent catheterization of the urinary tract, pregnancy or recent childbirth, neurological problems, volume depletion, frequent sexual activity, and presence of a sexually transmitted infection (STI). Ask the patient to describe current sexual and birth control practices because poorly fitting diaphragms, the use of spermicides, and certain sexual practices such as anal intercourse place the patient at risk for a UTI.

Physical examination is often unremarkable in the patient with a UTI, although some patients have costovertebral angle tenderness in cases of pyelonephritis. On occasion, the patient has fever, chills, and signs of a systemic infection. Inspect the urine to determine its color, clarity, odor, and character. Surveillance for STIs is recommended as part of the examination.

UTIs rarely result in disruption of the patient’s normal activities. The infection is generally acute and responds rapidly to antibiotic therapy. The general guidelines to increase fluid intake and concomitant frequent urination may be problematic for some patients in restrictive work environments. The accompanying discomfort may result in temporary restriction of sexual activity, especially if an STI is diagnosed.

Nursing care plan primary nursing diagnosis: Altered urinary elimination related to infection.

Nursing care plan intervention and treatment plan
An acid-ash diet may be encouraged. A diet of meats, eggs, cheese, prunes, cranberries, plums, and whole grains can increase the acidity of the urine. Foods not allowed on this diet include carbonated beverages, anything containing baking soda or powder, fruits other than those previously stated, all vegetables except corn and lentil, and milk and milk products. Because the action of some UTI medications is diminished by acidic urine (nitrofurantoin), review all prescriptions before instructing patients to follow this diet.

UTIs are treated with antibiotics specific to the invading organism. Usually, a 7- to 10-day course of antibiotics is prescribed, but shortened and large single-dose regimens are currently under investigation. Most elderly patients need a full 7- to 10-day treatment, although caution is used in their management because of the possibility of diminished renal capacity. Women being treated with antibiotics may contract a vaginal yeast infection during therapy; review the signs and symptoms (cheesy discharge and perineal itching and swelling), and encourage the woman to purchase an over-the-counter antifungal or to contact her primary healthcare provider if treatment is indicated.

Encourage patients with infections to increase fluid intake to promote frequent urination, which minimizes stasis and mechanically flushes the lower urinary tract. Strategies to limit recurrence include increasing vitamin C intake, drinking cranberry juice, wiping from front to back after a bowel movement (women), regular emptying of the bladder, avoiding tub and bubble baths, wearing cotton underwear, and avoiding tight clothing such as jeans. These strategies have been beneficial for some patients, although there is no research that supports the efficacy of such practices.

Encourage the patient to take over-the-counter analgesics unless contraindicated for mild discomfort but to continue to take all antibiotics until the full course of treatment has been completed. If the patient experiences perineal discomfort, sitz baths or warm compresses to the perineum may increase comfort.

Nursing care plan discharge and home health care guidelines
Treatment of a UTI occurs in the outpatient setting. Teach the patient an understanding of the proposed therapy, including the medication name, dosage, route, and side effects. Explain the signs and symptoms of complications such as pyelonephritis and the need for follow-up before leaving the setting. Explain the importance of completing the entire course of antibiotics even if symptoms decrease or disappear. If the patient experiences gastrointestinal discomfort, encourage the patient to continue taking the medications but to take them with a meal or milk unless contraindicated. Warn the patient that drugs with phenazopyridine turn the urine orange.