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These are: • Polymorphonuclear leucocytes/granulocytes o Neutrophils o Eosinophils o Basophiles • Mononuclear leucocytes oLymphocytes oMonocytes Fig discount 20mg prednisolone mastercard. Basophiles have a kidney shaped nucleus frequently obscured by a mass of large deep purple/blue staining granules 10mg prednisolone amex. Their cytoplasmic granules contain heparin and histamine that are released at the site of inflammation order prednisolone 40 mg visa. Mononuclear Leucocytes Lymphocytes There are two varieties:  Small Lymphocytes Their size ranges from 7-10µm in diameter purchase prednisolone 10 mg amex. Their cytoplasm stains pale grayish blue and contains reddish blue dust-like granules and a few clear vacuoles. They are capable of ingesting bacteria and particulate matter and act as "scavenger cells" at the site of infection. Platelets These are small, non nucleated, round/oval cells/cell fragments that stain pale blue and contain many pink granules. They 8 Hematology are produced in the bone marrow by fragmentation of cells called megakaryocytes which are large and multinucleated cells. When blood vessels are injured, platelets rapidly adhere to the damaged vessel and with one another to form a platelet plug. During this process, the soluble blood coagulation factors are activated to produce a mesh of insoluble fibrin around the clumped platelets. This assists and strengthens the platelet plug and produces a blood clot which prevents further blood loss. It also carries nutrients from the gastrointestinal tract to the cells, heat and waste products away from cells and hormones form endocrine glands to other body cells. It also adjusts body temperature through the heat-absorbing and coolant properties of its water content and its variable rate of flow through the skin, where excess heat can be lost to the environment. Blood osmotic pressure also influences the water content of cells, principally through dissolved ions and proteins. In postnatal life in humans, erythrocytes, granulocytes, monocytes, and platelets are normally produced only in the bone marrow. Lymphocytes are produced in the secondary lymphoid organs, as well as in the bone marrow and thymus gland. Although many questions 10 Hematology remain unanswered, a hypothetical scheme of hemopoiesis based on a monophyletic theory is accepted by many hematologists. According to this theory, the main blood cell groups including the red blood cells, white blood cells and platelets are derived from a pluripotent stem cell. The pluripotent stem cells may mature along morphologically and functionally diverse lines depending on the conditioning stimuli and mediators (colony-stimulating factors, erythropoietin, interleukin, etc. During fetal life, hemopoiesis is first established in the yolk sac mesenchyme and later transfers to the liver and spleen. The splenic and hepatic contribution is gradually 11 Hematology taken over by the bone marrow which begins at four months and replaces the liver at term. From infancy to adulthood there is progressive change of productive marrow to occupy the central skeleton, especially the sternum, the ribs, vertebrae, sacrum, pelvic bones and the proximal portions of the long bones (humeri and femurs). Hemopoiesis occurs in a microenvironment in the bone marrow in the presence of fat cells, fibroblasts and macrophages on a bed of endothelial cells. An extracellular matrix of fibronectin, collagen and laminin combine with these cells to provide a setting in which stem cells can grow and divide. In the bone marrow, hemopoiesis occurs in the extravascular part of the red marrow which consists of a fine supporting reticulin framework interspersed with vascular channels and developing marrow cells. A single layer of endothelial cells separates the extravascular marrow compartment from the intravascular compartment. When the hemopoietic marrow cells are mature and ready to circulate in the peripheral blood, the cells leave the marrow parenchyma by passing through fine "windows" in the endothelial cells and emerge into the venous sinuses joining the peripheral circulation. Increased demands for cells as a consequence of disease or physiologic 14 Hematology change are met by increased cell production. Several hematopoietic growth factors stimulate differentiation along particular paths and proliferation of certain progenitor cells. In addition, there are several different cytokines that regulate hematopoiesis of different blood cell types. Cytokines are small glycoproteins produce by red bone marrow cells, leucocytes, macrophages, and fibroblasts. They act locally as autocrines or paracrines that maintain normal cell functions and stimulate proliferation. Also fatty marrow that starts to replace red marrow during childhood and which consists of 50% of fatty space of marrow of the central skeleton and proximal ends of the long bones in adults can revert to hemopoiesis as the need arises. Formation of apparently normal blood cells outside the confines of the bone marrow mainly in the liver and spleen in post fetal life is known as Extramedullary Hemopoiesis. Formation of Red blood cells (Erythropoiesis) 17 Hematology Erythropoiesis is the formation of erythrocytes from committed progenitor cells through a process of mitotic growth and maturation. The first recognizable erythyroid cell in the bone marrow is the proerythroblast or pronormoblast, which on Wright or Giemsa stain is a large cell with basophilic cytoplasm and an immature nuclear chromatin pattern. Subsequent cell divisions give rise to basophilic, polychromatophilic, and finally orthochromatophilic normoblasts, which are no longer capable of mitosis. At the same time the nuclear chromatin pattern becomes more compact tan clumped until, at the level of the orthochromatophilic normoblast, there remains only a small dense nucleus, which is finally ejected from the cell. Under normal conditions the transit time from the pronormoblast to the reticulocyte entering the peripheral blood is about 5 days. Pronormoblast (Rubriblast) Pronormoblast is the earliest morphologically recognizable red cell precursor. The chromatin forms delicate clumps so that its pattern appears to be denser and coarser than that seen in the pronormoblast. Cytoplasm: slightly wider ring of deep blue cytoplasm than in the pronormoblast and there is a perinuclear halo. Polychromatophilic Normoblast Size: 12-14µm in diameter Nucleus: smaller than in the previous cell, has a thick membrane, and contains coarse chromatin masses. Reticulocyte After the expulsion of the nucleus a large somewhat basophilic anuclear cell remains which when stained with new methylene blue, is seen to contain a network of bluish granules. As the bone marrow reticulocyte matures the network becomes smaller, finer, thinner, and finally within 3 days disappears. Mature erythrocyte Size: 7-8µm in diameter 21 Hematology Cytoplasm: biconcave, orange-pink with a pale staining center occupying one-third of the cell area. Regulation of Erythropoiesis Erythropoietic activity is regulated by the hormone erythropoietin which in turn is regulated by the level of tissue oxygen. Erythropoietin is a heavily glycosylated hormone (40% carbohydrate) with a polypeptide of 165 aminoacids. Normally, 90% of the hormone is produced in the peritubular (juxtaglomerular) complex of the kidneys and 10% in the liver and elsewhere. There are no preformed stores of erythropoietin and the stimulus to the production of the hormone is the oxygen tension in the tissues (including the kidneys). Ineffective erythropoiesis/Intramedullary hemolysis Erythropoiesis is not entirely efficient since 10-15% of eryhtropoiesis in a normal bone marrow is ineffective, i. In megaloblastic erythropoiesis, the nucleus and cytoplasm do not mature at the same rate so that nuclear maturation lags behind cytoplasmic hemoglobinization. The end stage of megaloblastic maturation is the megalocyte which is abnormally large in size (9-12µm in diameter). Formation of white blood cells (Leucopoiesis) Granulopoiesis and Monocytopoiesis Neutrophils and monocytes, which evolve into macrophages when they enter the tissues, are arise form a common committed progenitor. The myeloblast is the earliest recognizable precursor in the granulocytic series that is found in the bone marrow. On division the myeloblast gives rise to promyelocyte which contain 24 Hematology abundant dark “azurophilic” primary granules that overlie both nucleus and cytoplasm. With subsequent cell divisions these primary granules become progressively diluted by the secondary, less conspicuous “neutrophilic” granules that are characteristic of the mature cells. This concomitant cell division and maturation sequence continues form promyelocytes to early myelocytes, late myelocytes, and they metamyelocytes, which are no longer capable of cell division. As the metamyelocyte matures the nucleus becomes more attenuated and the cell is then called a “band” or “stab” form. Subsequent segmentation of the nucleus gives rise to the mature neutrophil or polymorphonuclear leucocyte. The average interval from the initiation of granulopoiesis to the entry of the mature neutrophil into the circulation is 10 to 13 days. The mature neutrophil remains in the circulation for only about 10 to 14 hours before entering the tissue, where it soon dies after performing its phagocytic function.

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Boyle discovered that the pressure of a gas is inversely proportional to its volume: If volume increases prednisolone 40 mg with amex, pressure decreases discount 40mg prednisolone visa. Therefore buy 20 mg prednisolone with mastercard, the pressure in the one-liter container (one-half the volume of the two-liter container) would be twice the pressure in the two-liter container buy generic prednisolone 5 mg line. Boyle’s law is expressed by the following formula: P1 V1 = P2 V2 In this formula, P1 represents the initial pressure and V1 represents the initial volume, whereas the final pressure and volume are represented by P2 and V2, respectively. If the two- and one-liter containers were connected by a tube and the volume of one of the containers were changed, then the gases would move from higher pressure (lower volume) to lower pressure (higher volume). Pulmonary ventilation is dependent on three types of pressure: atmospheric, intra-alveolar, and intrapleural. Atmospheric pressure is the amount of force that is exerted by gases in the air surrounding any given surface, such as the body. Atmospheric pressure can be expressed in terms of the unit atmosphere, abbreviated atm, or in millimeters of mercury (mm Hg). Therefore, negative pressure is pressure lower than the atmospheric pressure, whereas positive pressure is pressure that it is greater than the atmospheric pressure. Intra-alveolar pressure (intrapulmonary pressure) is the pressure of the air within the alveoli, which changes during the different phases of breathing (Figure 22. Because the alveoli are connected to the atmosphere via the tubing of the airways (similar to the two- and one-liter containers in the example above), the intrapulmonary pressure of the alveoli always equalizes with the atmospheric pressure. Intrapleural pressure is the pressure of the air within the pleural cavity, between the visceral and parietal pleurae. Similar to intra-alveolar pressure, intrapleural pressure also changes during the different phases of breathing. However, due to certain characteristics of the lungs, the intrapleural pressure is always lower than, or negative to, the intra-alveolar pressure (and therefore also to atmospheric pressure). Although it fluctuates during inspiration and expiration, intrapleural pressure remains approximately –4 mm Hg throughout the breathing cycle. One of these forces relates to the elasticity of the lungs themselves—elastic tissue pulls the lungs inward, away from the thoracic wall. Surface tension of alveolar fluid, which is mostly water, also creates an inward pull of the lung tissue. This inward tension from the lungs is countered by opposing forces from the pleural fluid and thoracic wall. Too much or too little pleural fluid would hinder the creation of the negative intrapleural pressure; therefore, the level must be closely monitored by the mesothelial cells and drained by the lymphatic system. Since the parietal pleura is attached to the thoracic wall, the natural elasticity of the chest wall opposes the inward pull of the lungs. Ultimately, the outward pull is slightly greater than the inward pull, creating the –4 mm Hg intrapleural pressure relative to the intra- alveolar pressure. Transpulmonary pressure is the difference between the intrapleural and intra-alveolar pressures, and it determines the size of the lungs. Physical Factors Affecting Ventilation In addition to the differences in pressures, breathing is also dependent upon the contraction and relaxation of muscle fibers of both the diaphragm and thorax. The lungs themselves are passive during breathing, meaning they are not involved in creating the movement that helps inspiration and expiration. This is because of the adhesive nature of the pleural fluid, which allows the lungs to be pulled outward when the thoracic wall moves during inspiration. Contraction and relaxation of the diaphragm and intercostals muscles (found between the ribs) cause most of the pressure changes that result in inspiration and expiration. These muscle movements and subsequent pressure changes cause air to either rush in or be forced out of the lungs. A small tubular diameter forces air through a smaller space, causing more collisions of air molecules with the walls of the airways. The following formula helps to describe the relationship between airway resistance and pressure changes: F = ∆ P / R This OpenStax book is available for free at http://cnx. If the tissues of the thoracic wall are not very compliant, it will be difficult to expand the thorax to increase the size of the lungs. Pulmonary Ventilation The difference in pressures drives pulmonary ventilation because air flows down a pressure gradient, that is, air flows from an area of higher pressure to an area of lower pressure. Air flows into the lungs largely due to a difference in pressure; atmospheric pressure is greater than intra-alveolar pressure, and intra-alveolar pressure is greater than intrapleural pressure. Air flows out of the lungs during expiration based on the same principle; pressure within the lungs becomes greater than the atmospheric pressure. Inspiration is the process that causes air to enter the lungs, and expiration is the process that causes air to leave the lungs (Figure 22. In general, two muscle groups are used during normal inspiration: the diaphragm and the external intercostal muscles. When the diaphragm contracts, it moves inferiorly toward the abdominal cavity, creating a larger thoracic cavity and more space for the lungs. Contraction of the external intercostal muscles moves the ribs upward and outward, causing the rib cage to expand, which increases the volume of the thoracic cavity. Due to the adhesive force of the pleural fluid, the expansion of the thoracic cavity forces the lungs to stretch and expand as well. This increase in volume leads to a decrease in intra-alveolar pressure, creating a pressure lower than atmospheric pressure. The process of normal expiration is passive, meaning that energy is not required to push air out of the lungs. Instead, the elasticity of the lung tissue causes the lung to recoil, as the diaphragm and intercostal muscles relax following inspiration. In turn, the thoracic cavity and lungs decrease in volume, causing an increase in intrapulmonary pressure. The intrapulmonary pressure rises above atmospheric pressure, creating a pressure gradient that causes air to leave the lungs. There are different types, or modes, of breathing that require a slightly different process to allow inspiration and expiration. Quiet breathing, also known as eupnea, is a mode of breathing that occurs at rest and does not require the cognitive thought 1052 Chapter 22 | The Respiratory System of the individual. In contrast, forced breathing, also known as hyperpnea, is a mode of breathing that can occur during exercise or actions that require the active manipulation of breathing, such as singing. In addition to the contraction of the diaphragm and intercostal muscles, other accessory muscles must also contract. During forced inspiration, muscles of the neck, including the scalenes, contract and lift the thoracic wall, increasing lung volume. During forced expiration, accessory muscles of the abdomen, including the obliques, contract, forcing abdominal organs upward against the diaphragm. In addition, accessory muscles (primarily the internal intercostals) help to compress the rib cage, which also reduces the volume of the thoracic cavity. Respiratory Volumes and Capacities Respiratory volume is the term used for various volumes of air moved by or associated with the lungs at a given point in the respiratory cycle. There are four major types of respiratory volumes: tidal, residual, inspiratory reserve, and expiratory reserve (Figure 22. Respiratory volume is dependent on a variety of factors, and measuring the different types of respiratory volumes can provide important clues about a person’s respiratory health (Figure 22. Explain how spirometry test results can be used to diagnose respiratory diseases or determine the effectiveness of disease treatment. In addition to the air that creates respiratory volumes, the respiratory system also contains anatomical dead space, which is air that is present in the airway that never reaches the alveoli and therefore never participates in gas exchange. Alveolar dead space involves air found within alveoli that are unable to function, such as those affected by disease or abnormal 1054 Chapter 22 | The Respiratory System blood flow. Total dead space is the anatomical dead space and alveolar dead space together, and represents all of the air in the respiratory system that is not being used in the gas exchange process. Respiratory Rate and Control of Ventilation Breathing usually occurs without thought, although at times you can consciously control it, such as when you swim under water, sing a song, or blow bubbles. Respiratory rate can be an important indicator of disease, as the rate may increase or decrease during an illness or in a disease condition. The respiratory rate is controlled by the respiratory center located within the medulla oblongata in the brain, which responds primarily to changes in carbon dioxide, oxygen, and pH levels in the blood.

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Natural antibodies: are red cell antibodies in the serum of an individual that are not provoked by previous red cell sensitization purchase 10 mg prednisolone. But order generic prednisolone from india, it is believed that these antibodies must be the result of some kind of outside stimulus and the term naturally occurring gives an inaccurate connotation order prednisolone uk, so they are called non- red cell or non- red cell immune antibodies proven prednisolone 5mg. Characteristics - Exhibit optimum in vitro agglutination when the antigen bearing erythrocytes are suspended in physiologic saline (0. Immune antibodies: are antibodies evoked by previous antigenic stimulation either by transfusion or pregnancy, i. Characteristics - Do not exhibit visible agglutination of saline- suspended erythrocytes, and called incomplete antibodies 0 - React optimally at a temperature of 37 C, and are so called warm agglutinins. These antibodies obviously have more serious transfusion implications than the naturally occurring ones. Classification of the blood group was based on his observation of the agglutination reaction between an antigen on erythrocytes and antibodies present in the serum of individuals directed against these antigens. The antibody that reacted with the A antigens was known as anti A, and the antibody that reacted with the B antigen was known as anti B. According to 20 the theory of Bernstein the characters A,B and O are inherited by means of three allelic genes, also called A,B and O. The O gene is considered to be silent (amorphic) since it does not appear to control the development of an antigen on the red cell. This four allelic genes give rise to six phenotypes: A1, A2, B, O, A1B and A2B and because each individual inherits one chromosome from each parent, two genes are inherited for each characteristic and these four allelic gene give rise to ten possible genotypes (table 3. In serological testing, individuals of this type have a weaker B antigen and possess some kind of anti- B in the serum. For example, it can be seen that for the matings A1xB, A2 and A2 B children never occur in the same family as B or O children. However, the finding of, for instance, a group O child in a family where other children are A2 and A2 B would not be possible if they all had the same parents. The antiserum has two be specific: does not cross react, and only reacts with its own corresponding antigen, avid: the ability to agglutinate red cells quickly and strongly, stable: maintains it specificity and avidity till the expiry date. It should also be clear, as turbidity may indicate bacterial contamination and free of precipitate and particles. Agglutination: is the clumping of particles with antigens on their surface, such as erythrocytes by antibody molecules that form bridges between the antigenic determinants. When antigens are situated on the red cell membrane, mixture with their specific antibodies causes clumping or agglutination of the red cells. In hemagglutination the antigen is referred to as agglutinogen and the antibody is referred to as agglutinin. In the first stage- sensitization, antibodies present in the serum become attached to the corresponding antigen on the red cell surface. In the second stage, the physical agglutination or clumping of the sensitized red cells takes place, which is caused by an antibody attaching to antigen on more than one red cell producing a net or lattice that holds the cells together. Agglutination reaction is interpreted as a positive (+) test result and indicates, based on the method used, the presence of specific antigen on erythrocytes or antibody in the serum of an individual. No agglutination reaction produces a negative (-) test indicating the absence of specific antigens on erythrocytes or antibody in the serum of an individual. The maximum span of IgG molecules is 14 nanometer that they could only attach the antigens, coating or sensitizing the red cells and agglutination can not be effected in saline media. On the other hand, IgM molecules are bigger and because of their pentameric arrangement can bridge a wider gap and overcome the repulsive forces, causing cells to agglutinate directly in saline. Temperature: The optimum temperature for an antigen- antibody reaction differs for different antibodies. Most IgG 0 antibodies react best at warm temperature(37 C) while IgM antibodies, cold reacting antibodies react best at room 0 temperature and coldest temperature(4 to 22 C). Ionic strength: lowering the ionic strength of the medium increases the rate of agglutination of antibody with antigen. IgM antibodies, referred to as complete antibodies, are more efficient than IgG or IgA antibodies in exhibiting in vitro agglutination when the antigen - bearing erythrocytes are suspended in physiologic saline. Centrifugation: centrifugation at high speed attempts to over come the problem of distance in sensitized cells by physically forcing the cells together. Trypsin, ficin, bromelin, papain) removes surface sialic acid residue- by which red cells exert surface negative charge, thereby reducing the net negative charge of the cells, thus lowering the zeta potential, and allowing the cells to come together for chemical linking by specific antibody molecules. Colloidal media: certain anti-D sera especially some IgG antibodies of the Rh system would agglutinate Rh positive erythrocytes suspended in colloid (bovine albumin) if the zeta potential is carefully adjusted by the addition of the colloid. Ratio of antibody to antigen: There must be an optimum ratio of antibody to antigen sites for agglutination of red cells to occur. In prozone phenomena (antibody excess), a surplus of antigens combining site which are not bound to antigenic determinants exist, producing false- negative reactions. It is also important to ensure that the red cell suspension used in agglutination test must not be too week or too strong, as heavy suspension might mask the presence of a weak antibody. Red cell suspension can be prepared directly from anticoagulated blood or from packed red cell (after separating the serum or plasma). Proper concentration of suspensions can be prepared visually as experience allows; however, as a student you should follow the following procedures. The procedures include a red blood cell washing step to remove certain impurities; and when necessary you can use this formula to prepare different red cell concentrations. Immediately before use, mix the suspension by inverting the tube several times until the cells are in suspension. Add one drop of anti- A serum to the tube labeled ‘anti-A’ and one drop of anti- B to the tube labeled anti- B’ 3. Mix the antiserum and cells by gently tapping the base of each tube with the finger or by gently shaking 5. Read the results by tapping gently the base of each tube looking for agglutination or haemolysis against a well- lighted white background. Slide reverse grouping is not reliable as serum antibodies agglutinate most cell samples when centrifuged, and use of test tube enhances the agglutinated reaction. Add one drop of 2-5% A cells to the tube labeled ‘A cells’ and one drop of 2-5% B cells to the tube labeled ‘B cells’. Read the results by tapping gently the base of each tube looking for agglutination or haemolysis against a well- lighted white background. These include: contaminated reagents or dirty glass ware, over centrifugation, incorrect serum: cell ratio, under centrifugation or incorrect incubation temperature, failure to add test specimen or reagents, and the like. If carefully controlled repeat testing yields the same agglutination patterns, the variation can be assigned to one of the following four categories. Missing or weak reacting antibodies Age: testing of infants who have not begun to produce their own antibodies, or who possess antibodies that have been passively acquired from the mother, or during testing of elderly persons whose antibody levels have declined. Hypogamaglobulininemia: in conditions in which hypogamaglobulininemia may be demonstrated, these include lymphomas, leukemias, immunodeficiency disorders, use of 42 immunosuppressive drugs, and following bone marrow transplantation. Resolution: Enhancing reaction in reverse grouping by incubating of patients serum with the red cells at room 0 0 temperature for 15 min or incubation at 16 C or 4 C for 15 min. Missing weak antigens Sub groups of A or B antigens: The A or B antigens may be weakly expressed because of an unusual genotype (i. Blood group specific substances: in conditions like ovarian cyst & carcinomas, blood group specific substance may be of such high concentration is that anti-A & and – B are neutralized when unwashed cells are used. Acquired B antigen: effect of bacterial enzymes & absorption of bacterial polysaccharide on to the red cells of group A or O patients results in B specificity which involve weak B antigen reaction in the forward grouping. Mixtures of blood: Mixture of cell types in recently transfused patients or recipients of bone marrow transplants can produce unexpected reactions in forward typing. Resolution: - Investigating the possibility of sub groups of A&B - Investigating the diagnosis - Washing the patient’s red cells in saline to eliminate the problem with blood group specific substances. Additional antibody Autoantibody: cold autoantibodies can cause spontaneous agglutination of the A and B cells used in reverse grouping. Patients with warm autoimmune hemolytic anemia may have 44 red cells coated with sufficient antibody to promote spontaneous agglutination. Irregular antibodies: Irregular antibodies in some other blood group system may be present that react with antigens on the A or B cells used in reverse grouping. Resolution: 0 - Washing the patient red cells in warm (37 C) saline to establish cold autoantibodies as the cause. Plasma Abnormalities Increased gamma globulin: elevated levels of globulin from certain disease states such as multiple myeloma result in rouleaux formation. Wharton’s jelly: when cord blood is used, reverse grouping may be affected by wharton’s jelly which causes rouleaux.

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If he does not want to eat buy 5mg prednisolone amex, we have to feed him through a tube in health facilities prednisolone 20 mg with visa. The danger signs that show that a malnourished child needs treatment quickly are edema generic 40 mg prednisolone free shipping, apathy and not eating well generic 40 mg prednisolone with amex. Prevention of malnutrition The following are some of the important approaches in prevention of malnutrition in children. Classification of malnutrition: Signs classification Severe visible wasting or Severe palmer pallor or severe malnutrition/severe Edema on both feet anemia Some palmer pallor or Very low wt. Since the body doe not manufacture vitamins small amounts must be included in the diet. Some are soluble in fat and are ingested in dietary fat (vitamin A, D, E and K), and some are water soluble (Vitamin B complex and Vitamin C). Vitamin A Normal growth, normal vision, normal reproduction Maintenance of epithelial cell structure and function Immunity to infection 95 Pediatric Nursing and child health care Deficiencies results in: • xerophthalmia, (night blindness, conjunctiva dryness, Bitot spots, Keratomalacia, and even eyeball perforation and blindness) • Increased risk of infections (Viral is more). Excess results in: • Raised intracranial pressure, irritability,dry skin, hair loss, brittle bones 2. Parasthesia, weakness, gastrointestinal symptoms • Dry beriberi (peripheral neuropathy, mental confusion,nystagmus) • wet beriberi ( biventricular cardiac enlargement, systemic venous hypertension, bounding pulse) • Infantile beriberi (acute cardiac failure) 3. Riboflavine (B2) • Coenzyme in oxidative –reduction reaction 96 Pediatric Nursing and child health care Deficiency results in; • Angular stomatitis, cracking and fissuring of lips • Glositis, papillary atrophy • Scrotal or vulvae dermatitis • Photophobia, corneal vascularisation • Anaemia, hair loss , ataxia • Personality changes, retarded intellectual development 4. Niacin (nicotinic Acid) • Oxidative –reduction reactions , fat synthesis, glucolysis • Deficiency results in: Pellagra (dermatitis, diarrhea, dementia) • loss of weight, poor appetite, sore mouth, indigestion • insomina, confusion • skin erythema, pruritus, discoloration, flaking 5. Pyriodoxine (B6) • Coenzyme in amino acid metabolism and • Muscle glucogen phosphorylase Deficiency results in: Infants: hyperirritability, convulsions, weakness anemia, and dermatitis 6. Ascorbic Acid (vitamine C) • Formation of collagen, amino-acid metabolism • Iron and copper metabolism • Protection against free radicals (oxidents) Deficiency results in: Scurvy • ulceration ,poor wound healing, anemia • Scurvy: irritability , unproductive cough, bone tenderness, sub-periosteal hemorrhages 8. Vitamin D: • Calcium and phosphate homeostasis • Normal mineralisation of bone and teeth Deficiency result in: • Rickets, Osteomalacia Excess result in: • Hypocalcaemia, ectopic calcification • Failure to thrive 98 Pediatric Nursing and child health care 9. Vitamin E (tocopherol): • Antioxidant (protects against free radicals) • Preserve cell membrane integrity Deficiency result in: • Hemolytic anemia, skin changes • Encephalomalacia 10. Vitamin K Synthesis of coagulation factors Deficiency results in: • Coagulophathy: haematuria, hematomas, and heamorragic disease of newborn • Hemolytic anemia may be caused by the water soluble form of vitamin K Iron deficiency Anemia: Anemia refers to a deficit of red blood cells or hemoglobin in the blood. Nutritional deficiency • Iron deficiency • Folic acid deficiency 99 Pediatric Nursing and child health care Vitamin B12 deficiency b) Decreased erythrocyte production: • Pure red cell anemia • Secondary hemolytic anemia’s associated with infection, renal disease, and chronic disorders Aplastic anemias Invasion of bone marrow by A, Leukemia B, Tumors 3. Assessment of the child’s condition Building resistance to infection Administering blood transfusion as ordered Nursing management: 1. Assist parents to select iron rich foods that are affordable and culturally acceptable 5. Teach parents how to administer medications 101 Pediatric Nursing and child health care Study Questions 1. How can a nurse contribute to decrease morbidity and mortality among under five children? During growth monitoring intervention what important points should be considered to promote normal growth and development? Acute respiratory infections are anatomically divided into Acute Upper and Acute Lower Respiratory infections. Present evidence indicates that bacteria play a great role as causes of pneumonia in children. Streptococcus pneumonia and Homophiles influenza accounts for more than 2/3 of all bacteria isolates. Pneumoniae and H-influenza can prevent deaths from pneumonia in children with a substantial decrease on pneumonia mortality. Fast- breathing helps to categorize children with cough into two groups with high and low probability of pneumonia and it is a better predictor of pneumonia than auscultatory findings (stethoscope). As pneumonia progresses and becomes more severe, lung elasticity is gradually reduced and chest in 104 Pediatric Nursing and child health care drawing develops. The presence of lower chest in drawing means that the child has severe pneumonia and is at a higher risk of death. Because of the high probability of bacterial pneumonia and the reliability of these two diagnostic criteria, there is a strong justification for the empirical use of antibacterial based on simple diagnostic criteria. Since many children have slight intercostals retraction in absence of severe pneumonia, in order to avoid and over classification of severe pneumonia and needless referral, chest in drawing is considered present only when the lower part of the chest wall (the lower ribs and lower sternum) is drawn in (or retracts) when the child breathes in. In absence of any danger sign or chest in drawing a child is classified as having pneumonia if s/he has fast breathing that is when the 106 Pediatric Nursing and child health care respiratory rate is above • 50 per minute (50/m) or more in infants 2-12 months • 40 per minute (40/m) or more in children 1-4 years If there are no danger signs, chest in drawing or fast breathing, the child is classified as having no pneumonia cough or cold. In this age group the danger signs are: • Stopping feeding well • Convulsions • Abnormally sleepy or difficult to wake • Stridor in calm child • Wheezing • Fever or low body temperature In the absence of any danger sign, a young infant presenting with chest in drawing or fast breathing is classified as having severe pneumonia. Fast breathing is present when the respiratory rate is 60/min or more (counted twice). Due to the 107 Pediatric Nursing and child health care higher chest compliance in young infants, the presence of severe chest in drawing is required to classify an infant below 2 months as having severe pneumonia. There is no pneumonia if there is no danger signs, no severe chest in drawing or not fast breathing. It should be noted that young infants could become sick and die very quickly from pneumonia. For this reason, any young infant who has signs of pneumonia (chest in drawing or fast breathing) is classified as having a severe pneumonia. Children with very severe disease or severe pneumonia must be refereed to a health center or a hospital with inpatient capacity where adequate treatment can be given/provided. Before referral, a first dose of antibiotic should be given and fever treated if present. Children with pneumonia must be treated for 5 days on ambulatory basis with a first line antibiotic recommended by the program. If the child shows sign of a very severe disease or severe pneumonia she/he must be referred. If the child does not show signs of a very severe disease or severe pneumonia but did not improve, different antibiotics 108 Pediatric Nursing and child health care should be given for other two days. A child having cough for more than 30 days (chronic cough) should be referred for further assessment. Advice to the mother should be given on home care and other problems assessed and treated. Children with no pneumonia and children with pneumonia (in addition to antibiotic therapy) must receive appropriate home care. Before leaving the health unit, mothers should receive the following instructions - Feed the child during illness and increase the feeding after illness - Give the child more fluids to drink. Increase breast- feeding - Sooth the throat and relieve cough with a safe remedy - Return quickly to the health unit, if the child develops any of the following signs a. If this is not the case, the child should be treated with the available antibiotics and needless referral avoided. If you think the mother will not take the child to hospital or the referral will be delayed, whatever the reason, you should take the following steps: - If timely referral is likely give first dose of antibiotic - If there is long referral time give additional doses - If referral is uncertain give full course - Treat any other problem present (fever, malaria etc) 8. Then the child suddenly develops a croupy cough and inspiratory stridor as a result of obstruction in the area. C) In some the condition becomes worse, retraction of intercostal space, the supraclavicular space and even of the ribs themselves become more evident. The child become restless, pale, shows obvious sign of air hunger Treatment: A) Steam: liquefies the dry secretions and results in marked improvement. Mild pharyngitise or tonsillitis without much fever, pus, swelling of lymph glands is almost always a viral disease. Moderate or severe tonsillitis (usually accompanied by pharyngitis) with high fever, pus and often with enlarged lymph glands in neck is more often than not due to beta-hemolytic streptococci. Beta-hemolytic streptococci secrete toxic substances into the blood stream that, as an allergic reaction can cause rheumatic fever or acute glomerulonephritis. As streptococci are extremely sensitive to penicillin it is sufficient reason to treat tonsillitis of this type with penicillin. Refusal of food, difficulty in swallowing, may or may not complain of sore throat. Streptococal tonsilitis has high fever, pus on tonsilar surface and marked cervical lymp gland swelling 5.

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The salts contained in bile act like a detergent to emulsify fat buy discount prednisolone 10mg online, that is order prednisolone 10mg with visa, to break up fat into small droplets that can be acted on more effectively by digestive enzymes safe 20 mg prednisolone. After collecting bile from the gallbladder purchase prednisolone master card, this 327 Human Anatomy and Physiology duct, now called common bile duct, delivers bile into the duodenum. The Gallbladder The gallbladder is a muscular sac on the inferior surface of the liver that serves as a storage pouch for bile. Although the liver may manufacture bile continuously, the body is likely to need it only a few times a day. Consequently, bile from the liver flows into the hepatic ducts and then up through the cystic duct connected with the gallbladder. When chyme enters the duodenum, the gallbladder contracts, squeezing bile through the cystic duct and into the common bile duct leading to the duodenum. The protein digesting enzymes are produced in inactive forms, which must be converted to active forms in the small intestine by other enzymes. The pancreas also produces large amounts of alkaline fluid, which neutralizes the chyme in the small intestine, thus protecting the lining of the digestive tract. These juices collect in a main duct that joins the common bile duct or empties into the duodenum near the common bile 328 Human Anatomy and Physiology duct. Also, in some cases of gallbladder disease, disease, infection may extend to the pancreas and cause abnormal activation of the pancreatic enzymes. In either circumstance, the pancreas suffers destruction by its own juice, and the outcome can be fatal; this condition is known as acute pancreatitis. The pancreas also functions as an endocrine gland, producing the hormones insulin and glucagons that regulate sugar metabolism. Digestion and Absorption of Carbohydrates, Fats, and Proteins Digestion Digestion, a complex process that occurs in the alimentary canal, consists of physical and chemical changes that prepare food for absorption. Mechanical digestion breaks food into tiny particles, mixes them with digestive juices, moves them 329 Human Anatomy and Physiology along the alimentary canal, and finally eliminates the digestive wastes from the body. Chewing or mastication, swallowing or deglutition, peristalsis, and defecation are the main processes of mechanical digestion. Chemical digestion breaks down large, nonabsorbable food molecules−molecules that are able to pass through the intestinal mucosa into blood and lymph. Chemical digestion consists of numerous chemical reactions catalyzed by enzymes in saliva, gastric juice, pancreatic juice, and intestinal juice. Carbohydrate Digestion Very little digestion of carbohydrates (starches and sugars) occurs before food reaches the small intestine. Salivary amylase usually has little time to do its work because so many of us swallow our food so fast. But after the food reaches the small intestine, pancreatic and intestinal juice enzymes digest the starches and sugars. A pancreatic enzyme (amylase) starts the process by changing starches into a double sugar, namely, maltose. Three intestinal enzymes−rnaltase, sucrase, and lactase−digest double sugars by changing them into simple sugars, chiefly glucose (dextrose). Maltase digests maltose (malt sugar), sucrase digests sucrose (ordinary cane sugar), and lactase digests lactose (milk sugar). The end product of carbohydrate 330 Human Anatomy and Physiology digestion is the so-called simple sugar; the most abundant is glucose. Two enzymes (renin and pepsin) in the gastric juice cause the giant protein molecules to break up into somewhat simpler compounds. Pepsinogen, a component of gastric juice, is converted into active pepsin enzyme by hydrochloric acid (also in gastric juice). In the intestine, other enzymes (trypsin in the pancreatic juice and peptidases in the intestinal juice) finish the job of protein digestion. When enzymes have split up the large protein molecule into its separate amino acids, protein digestion is completed. Fat Digestion Very little carbohydrate and fat digestion occurs before food reaches the small intestine. Most fats are undigested until after emulsification by bile in the duodenum (that is, fat droplets are broken into very small droplets). After this takes place, pancreatic lipase splits up the fat molecules into fatty acids and glycerol (glycerine). For example, the name amylase indicates that the enzyme digests carbohydrates (starches and sugars), protease indicates a protein- digesting enzyme, and lipase means a fat-digesting enzyme. When carbohydrate digestion has been completed, starches (polysaccharides) and double sugars (disaccharides) have been changed mainly to glucose, a simple sugar (monosaccharide). Absorption After food is digested, it is absorbed; that is, it moves through the mucous membrane lining of the small intestine into the blood and lymph. In other words, food absorption is the process by which molecules of amino acids, glucose, fatty acids, and glycerol goes from the inside of the intestines into the circulating fluids of the body. As long as food stays in the intestines, it cannot nourish the millions of cells that compose all other parts of the body. Their lives depend on the absorption of digested food and its transportation to them by the circulating blood. Table 11-1 Chemical Digestion Digestive juices and Substance Digested Resulting Products* enzymes (or hydrolysed) Saliva Starch (Polysaccharide) Maltose (disaccharide) Amylase Gastric Juice Proteins Partially digested Protease (Pepsin) proteins plus hydrochloric acid Pancreatic Juice Proteins (intact of Peptides Protease (trypsin) and partially digested) Fatty acids, amino Lipase Fats emulsified by bile acids and glycerol Amylase Starch Maltose Intestinal Juice Amino acids Peptidases Peptides Glucose and fructose Sucrase Sucrose (cane sugar) (simple sugars) Lactase Lactase (Milk sugar) Glucose and galactose Maltase Maltase (malt sugar) (Simple sugars Glucose *Substances underlined are end products of digestion (that is, completely digested foods ready for absorption) 333 Human Anatomy and Physiology Review Questions 1. If you inserted 9 inches of an enema tube through the anus, the tip of the tube would probably be in what structure? The urinary system consists of: - Two kidneys: this organ extracts wastes from the blood, balance body fluids and form urine. They 338 Human Anatomy and Physiology are protected at least partially by the last pair of ribs and capped by the adrenal gland. On the medial concave border is the hilus (small indented area) where blood vessels, nerves & ureters enter and leave the kidney. Covering and supporting each kidney are three layers of tissue: • Renal capsule – innermost, tough, fibrous layer • Adipose capsule – the middle layer composed of fat, giving the kidney protective cushion. The renal pelvis is the large collecting space with in the kidney formed from the expanded upper portion of the ureters. Filters (by hydrostatic presure) water, dissolved substances (minus most plasma proteins, blood cells) from blood plasma. The major functions of the kidneys are: 343 Human Anatomy and Physiology All the functions are directly or indirectly related to the formation of urine. The series of events leads to: - To the elimination of wastes - Regulation of total body water balance. Tubular secretion Average Comparison of filtration, re-absorption and excretion, here variation in urine composition will occur during variation in the daily diet, fluid intake, weather and exercise. The ureters pass between the parietal peritoneum and the body wall to the pelvic cavity, where they enter the pelvic cavity. The lumen of the ureters is composed of three layers: - Innermost, Tunica Mucosa - The middle, Tunica Muscularis (made of smooth muscle) - The outer, Tunica Adventitia 12. It is located on the floor of the pelvic cavity and 346 Human Anatomy and Physiology like the kidneys and ureters. The opening of ureters and urethra in the cavity of the bladder outline triangular area called the trigone. At the site where the urethra leaves the bladder, the smooth muscle in the wall of the bladder forms spiral, longitudinal and circular bundles which contract to prevent the bladder from emptying prematurely. Far there along the urethra in the middle membranous portion a circular sphincter of voluntary skeletal muscle form the external urethral sphincter. In male it pass through prostate, membranous portion (pelvic diaphragm muscle), spongy portion (that pass through corpus spongosus) and open at the tip of penis. However, it is composed of mainly water, urea, chloride, potassium, sodium, cretinin, phosphate, sulfates and uric acid. Proteins, glucose, casts (decomposed blood) and calculi from minerals are abnormal if present in urine. To maintain the proper osmotic concentration of the extra cellular fluid to excrete wastes and to maintain proper kidney function the body must excrete at least 450ml of urine per day. The volume and concentration of urine is controlled by: - Antidiuretic hormone - Aldestrone - The Renin – angiotensin mechanism 349 Human Anatomy and Physiology 12. Steps of urination are: Conscious desire to urinate Pelvic diaphram muscle relax Smooth muscle of Urinary bladder neck Moves Urinary bladder down, outlet Opens, wall Contracts & urine stretch, and wall stretch ejects Receptors are stimulated 350 Human Anatomy and Physiology Study Questions 1. The apex of each renal pyramid end in the a) Cortical region b) Papilla c) Juxta medullary region d) Capsule e) Tubule 2. The inner most layer of the ureters is the a) Mucosa b) Muscularis c) Adventitia d) Longitudinal layer e) Circular layer 3.