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Once this distinction was made buy prednisone 5 mg on-line, it was possible to conceptualize and define a broad range of interpreting skills that could be used as strategic interventions to ensure accuracy and completeness while accommodating differing levels of linguistic proficiency buy prednisone 20 mg on line. Thus purchase prednisone 20mg with amex, at one end of the linguistic continuum are those individuals whose mastery of the two languages and breadth of understanding of the content ensure that they have little need to interrupt speakers purchase prednisone 20 mg online, whether for retention or clarification, and whose depth of knowledge of linguistic variations virtually eliminates the need to pause to search for the appropriate form of expression. At the other end of the continuum are those individuals who are somewhat limited in their comprehension and depth of expression. However, with supportive skills such as the ability to ask for clarification, manage the flow of communication, and be aware of their personal limitations, such interpreters can maintain accuracy and completeness in their interpretations. To be able to do this, the interpreter must not only be fluent in both the source and target languages but must also have the skills and knowledge base to be able to comprehend the message quickly in the source language and just as quickly re-express it in the target language. If all that the provider and patient need to achieve the goals of the clinical encounter is this linguistic conversion, then the interpreter’s role is fulfilled simply by providing such a conversion. The standards, however, go beyond the skills of conversion and recognize the complexities of interpretation and the clinical interview. The medical encounter is a highly interactive process in which the provider uses language (the provider’s and the patient’s) as a powerful tool to understand, evaluate, and diagnose symptoms (Woloshin et al. The interpreter, therefore, cannot simply be a ‘black box converter” but must know how to engage both provider and patient effectively and efficiently in accessing the nuances and hidden socio-cultural assumptions embedded in each other’s language, which could lead to dangerous consequences if left unexplored. These standards of practice also recognize the importance of the medical encounter in establishing a therapeutic connection between provider and patient. The formation of a therapeutic relationship is especially difficult when parties cannot communicate directly, and it becomes even more complex when different culturally based belief systems are involved. A competent interpreter can mediate these barriers by attending not only to the linguistic but also to the extra-linguistic aspects of communication. The Medical Interpreting Standards of Practice are organized into three major task areas: (1) interpretation, (2) cultural interface, and (3) ethical behavior. Interpretation As noted earlier, the primary task of the interpreter is to interpret, that is, to convert a message uttered in a source language into an equivalent message in the target language so that the intended recipient of the message responds to it as if he or she had heard it in the original (Seleskovitch, 1978; Cokely, 1988; Downing and Swabey, 1992). The primary test of a competent interpreter, therefore, is the accuracy and completeness of the interpretation. Although the main task of the interpreter is to interpret, there are other complementary skills that an interpreter must possess, although they are not necessarily used in every encounter. The standards of practice in this section focus on both the skills of straight interpreting and these complementary skills. The skills in this section can be organized around five subtasks: 1) Setting the stage. The role of the professional interpreter is still new and largely unknown in the medical setting. For this reason, it is important for interpreters to set clear expectations of their role at the very start of the triadic (provider-patient-interpreter) encounter, stressing in particular the elements of accuracy, completeness, and confidentiality. It is also important in the early moments of the triadic encounter for the interpreter to attend to other concerns, such as arranging the spatial configuration of the parties in the encounter, addressing any discomfort a patient or provider may have about the presence of an interpreter, or assessing the linguistic style of the patient, keeping in mind at all times the goal of establishing a direct relationship between the two main parties. The most basic task of the interpreter is to transmit information accurately and completely. Therefore, interpreters must operate under a dual commitment: (1) to understand fully the message in the source language, and 2) to retain the essential elements of the communication in their conversion into the target language. Interpreters whose linguistic proficiency (in terms of breadth and depth) in both languages is very high and who have a solid working knowledge of the subject matter are more likely to be able to make the conversions from one language to another without needing to ask for much clarification Those whose linguistic proficiency is limited can use appropriate strategies to ensure that they themselves understand the message before they make the conversion and that all the pertinent information has been transmitted. In the interest of accuracy and completeness, interpreters must be able to manage the flow of communication so that important information is not lost or miscommunicated. Interpreters may also have to attend to the dynamics of the interpersonal interaction between provider and patient, for example when tension or conflict arises. The introduction of a third party into the medical encounter generates dynamics that are inherent in triadic interactions. A primary characteristic of a triadic, as opposed to a dyadic, relationship is the potential for the formation of an alliance between two of the three parties. Because the interpreter is the party to whom both provider and patient can relate most directly, both have a propensity to want to form an alliance with the interpreter. The provider and patient often exhibit this tendency by directing their remarks to the interpreter rather than to each other, which leads to the ‘tell the patient/doctor’ form of communication. Thus, the interpreter must work at encouraging the parties to address each other directly, both verbally and nonverbally. The natural tendency of both providers and patients is to perceive interpreters as an extension of either their own world or the other, rather than as partners in their own right, with their own role responsibilities and obligations. For patients, the desire to form an alliance with the interpreter is heightened because they are likely to perceive the interpreter as understanding not only their language but also their culture. This perceived cultural affinity often leads patients to act as if the interpreter were there as their friend and advocate. For providers, the danger lies in assuming that the interpreter is part of their world and therefore expecting that the interpreter can and should take on other functions, such as obtaining a medical history. On the other hand, when providers assume that interpreters are extensions of the patient’s world, they tend to dismiss the importance of their role and ascribe inferior status to their work. As professionals in their own right, in the interpreter-mediated encounter interpreters owe their allegiance to the therapeutic relationship and its goals of quality health care. Their commitment is to support the other two parties in their respective domains of expertise – the provider as the technical expert with the knowledge and skills in medicine and health care, and the patient as the expert on his or her symptoms, beliefs, and needs. The provider offers informed opinions and options, while the patient remains the ultimate decision maker in terms of treatment. The role of the interpreter is not to take control of the substance of the messages but rather to manage the process of communication. The responsibility of the interpreter in the closing moments of the clinical encounter is to encourage the provider, when necessary, to provide follow-up instructions that the patient understands and will therefore be likely to follow. In addition, the role of the interpreter is to make sure that the patient is connected to the services required (including additional interpreter services) and to promote patient self-sufficiency, taking into consideration the social context of the patient. Cultural Interface Language is not the only element at work in the interaction between providers and patients who speak different languages. The meaning inherent in the messages conveyed is rooted in culturally based beliefs, values, and assumptions. According to the linguists Whorf (1978) and Sapir (1956), language is an expression of culture and the way in which culture organizes reality. The interpreter, therefore, has the task not only of knowing the words that are being used but of understanding the underlying, culturally based propositions that give them meaning in the context in which they are spoken. Interpreting in the health care arena requires the interpreter to understand the ways in which culturally based beliefs affect the presentation, course, and outcomes of illness as well as perceptions of wellness and treatment. If provider and patient share similar assumptions about medicine and its positivistic, scientific principles, it is more likely that the interaction will go as smoothly as if they were speaking the same language. In such a case, the interpreter simply has to make the conversion from one linguistic system into the other; the layers of meaning will automatically be understood. As the dissimilarities between providers’ and patients’ assumptions increase, however, literal interpretations become inadequate, even dangerous. In such cases, to convey the intent of the message accurately and completely, the interpreter may have to articulate the hidden assumptions or unstated propositions contained within the discourse. Here the role of the interpreter is to assist in uncovering these hidden assumptions and, in doing so, to empower both patient and provider with a broader understanding of each other’s culture. Another major cultural linguistic problem occurs when a speaker uses ‘untranslatable’ words. For example, the concept of bacteria, a living physical organism that is not visible to the naked eye, is a concept that has no equivalent in many rural, non-literate societies. To get the concept across, the interpreter may have to work with the provider to find ways to transmit the essential information underlying this concept. Interpreters, therefore, have the task of identifying those occasions when unshared cultural assumptions create barriers to understanding or message equivalence. Their role in such situations is not to ‘give the answer’ but rather to help both provider and patient to investigate the intercultural interface that may be creating the communication problem. Cultural patterns, after all, are generalized abstractions that do not define the individual nor predict what an individual believes or does. They are simply hypotheses that may be more likely to occur in a member of that culture than in someone who is not a member (Avery, 1992). Ethical Behavior The role of interpreter, on the surface, appears to be straightforward and uncomplicated. The interpreter is present to convert a message uttered in one language into another. Professional interpreters, however, understand the profound complexities of what appears to be a simple task.

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It’s a water- hygiene precautions 5mg prednisone fast delivery, particularly for those persons borne infection purchase prednisone 20mg online, found in epidemics and sporadic handling food and those working in nursery and cases prednisone 5 mg with mastercard. The virus is probably widespread in the school units eastern Mediterranean area as well as in Asia order prednisone 20mg with mastercard, and • Knowledge of vaccines available north and sub-Saharan Africa. The disease primarily affects young adults, is clinically similar Role of hospital and community settings to hepatitis A and does not lead to chronic disease. There is no vaccine against hepatitis E and immunoglobulin prepared in Europe does not give protection. Poliomyelitis - a guide for developing countries including appliances and • Factors that increase the risk of diarrhoea are more rehabilitation: http://worldortho. If the child is less than 6 months old and not yet taking solid food, dilute milk or formula with an equal amount of water for 2 days. When dehydration has been corrected, the child usually passes urine and may also be tired and fall asleep. When babies are about 1 year old, they have quite a lot of fat under the skin of their arms. The distance around the upper arm remains almost the same between the ages of 1 and 5 years. By placing a special measuring strip around the upper arm one can find out whether a child between the ages of 1 and 5 is undernourished or not. To use this strip: Put the strip around the mid upper arm of the child and see which colour is touched by the 0 cm end of the strip. This method of measuring the arm is useful because the health worker can identify undernutrition in a child without using a scale or knowing the child’s age. However, since it only shows large changes in a child’s nutrition, it is not suitable for determining whether the child is improving or becoming worse. The severity of these diseases varies from “subclinical” requiring little or no treatment to life threatening requiring intensive care. The diseases have been indexed alphabetically rather than by severity, incidence or mode of transmission. Two of the most important diseases, tetanus and rabies, stand alone because of their severity and widespread distribution throughout much of Europe. In addition you should be able to identify the needs of a patient requiring intensive nursing care. Such infections are spread to humans by arthropods (insects and their close relatives), especially mosquitoes, ticks and flies, which bite the human and consequently introduce the infection into the human blood stream. Such organisms are capable of surviving for long periods in hostile environments and of reactivating under suitable conditions. It environmental, seasonal, economic and social is primarily a disease of herbivorous animals, but factors. The severity of these diseases varies from it can infect all mammals including humans. The diseases such as wool, hair, hides, skins, bones, bonemeal have been indexed alphabetically rather than by and the carcasses of infected animals. There are three main modes of transmission: • direct contact with skin – infection is passed on by the handling of contaminated animal products, resulting in a cutaneous infection. Epidemiological summary Anthrax is now unusual in Western Europe but sporadic cases still occur especially in animals such as cattle. Cutaneous infection: • The bacterium enters through a cut or abrasion on the skin when handling contaminated wool, hides, leather or hair products of infected animals. Module 4 Page 99 • Within a few days a painless ulcer (1–3cm) with the typical Gram positive bacilli of Bacillus anthracis a black necrotic area in the centre develops; this is from skin lesions, respiratory secretions, blood or called an eschar. Methods of treatment Respiratory infection To be effective, treatment should be initiated as • Very difficult to diagnose early. Antibiotic therapy does not affect the cyanosis, stridor and possible subcutaneous oedema healing process or evolution of the skin lesion, but of the neck and chest can develop. If the • Death usually results soon after the onset of acute infection is spreading or if systemic symptoms are symptoms. Successful prevention • Abdominal pain, haematemisis and bloody depends upon: diarrhoea develop. Nursing care Patients with cutaneous anthrax may require dressings to prevent secondary infection of the lesions. Soiled dressings should be incinerated, autoclaved or otherwise disposed of as biohazardous waste (see Module 1). The patient is likely to be very unwell and may have an elevated pulse, respiratory rate and temperature. Although person-to-person transmission of anthrax has never been documented, universal precautions should be adopted when providing care for such patients. Most cases occur in persons involved with the • Through direct transmission, that is, through contact livestock industry, such as farmers, agricultural with blood or tissues from infected livestock. Manifestations Treatment • The incubation period following a tick bite is 1– General supportive therapy is the mainstay of 3 days. The antiviral drug Ribavirin, • The incubation period following contact with given both orally and intravenously, has been used infected blood or tissue may be 5–6 days with good results. Nursing care • Nausea, vomiting, sore throat, abdominal pain Many of these patients will develop complications and diarrhoea may present. It is therefore imperative that adequate control measures are taken to prevent this. Prevention of spread Persons living in endemic areas should be aware of the disease and how it is transmitted. Personal protective measures include: • avoiding areas where tick vectors are abundant, especially during April and September when they are active; • wearing protective clothing (long trousers, socks); • using an insect repellent, and • skin should be inspected for ticks every few hours and any ticks found should be removed immediately. Persons who work closely with livestock in endemic areas should wear gloves and protective clothing to prevent skin contact with infected tissue or blood. Vaccine Although an inactivated, mouse brain-derived vaccine has been developed and used on a small scale in eastern Europe, there is no safe and effective vaccine widely available for human use. Page 103 Page 103 Hantavirus Definition Yugoslavian army demonstrated an association Several types of hantavirus exist. While hantaviruses between outbreaks of this disease and army field found in the Far East (Korea and China) can cause exercises. Mode of transmission Diagnosis These viruses are spread in the urine and respiratory This is made by identifying specific hantavirus secretions of infected rodents, especially field mice antibodies in the blood. Treatment and nursing care Epidemiological summary There is no specific treatment for this virus, but Most cases are reported during the summer for severe cases, supportive measures and intensive especially in rural and semi-rural areas. Manifestations • Nephropathia epidemica • Initially a flu-like illness then renal failure and oliguria • Raised liver enzymes • Less than 0. Early diagnosis can be made by the detection of • Further complications include disseminated antigen in urine. Treatment Intravenous Erythromycin and/or oral Rifampicin Risk factors is the treatment of choice, substituted with oral A person’s risk of acquiring legionellosis following Erythromycin once symptoms improve. With exposure to contaminated water depends upon a appropriate antibiotic therapy the mortality of number of factors including: legionnaires disease is low in immunocompetent • The type and intensity of exposure patients. Intensive supportive care will be required Page 105 • The exposed person’s health status (those with for those who develop severe symptoms. Module 4 Page 105 Leishmaniasis Infection control Definition This disease is not contagious from person to Leishmaniasis is caused by the protozoan person, so isolation precautions are not required. Sterile water should be used to fill reservoirs of devices used for nebulization or for rinsing such Mode of transmission devices and other respiratory care equipment after Leishmaniasis is transmitted to humans by the disinfection. The sandfly bites on an animal or create aerosols should not be used unless they can human in order to obtain a blood meal to develop be sterilised or subjected to high-level disinfection. If this blood contains the leishmania parasites, these will continue to develop inside the Prevention of spread sandfly over a period of 4–25 days. When the Environmental health measures should include sandfly feeds again on a fresh source, transmission regular cleaning and maintenance of water supplies of the disease continues. Diagnosis The most accurate way to diagnose is to identify Manifestations of Visceral Leishmaniasis (also the parasite by microscopy or to culture material known as Kala-azar) on a medium that allows their growth. This type This is the most serious form of leishmaniasis, and of diagnosis will involve obtaining material from is fatal if left untreated.

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In a child with diarrhoea purchase prednisone 5mg without prescription, after assessing for dehydration order cheap prednisone on line, what other problems should be considered? Manifestations • Thirst purchase genuine prednisone on-line, followed by: • decreased skin turgor buy prednisone with a visa, tachycardia, dry mucous membranes, sunken eyes, lack of tears, a sunken anterior fontanelle in infants, and oliguria. Page 70 Module 3 • As the fluid deficit approaches 10% of body Hypotomic dehydration weight, dehydration becomes severe and anuria, Children with diarrhoea who drink large amounts hypotension, a feeble and very rapid pulse, cool of water or other hypotonic fluids containing very and moist extremities, diminished consciousness, low concentrations of salt and other solutes, or who and signs of shock appear. Some children with diarrhoea, especially young infants, develop hypernatraemic dehydration. It usually results from: • serum sodium concentration is low (<130 • the ingestion and inefficient absorption, during mmol/l); and diarrhoea, of fluids that are hypertonic (owing to their • serum osmolality is low (<275 mOsmol/l). Base-deficit acidosis (metabolic acidosis) The hypertonic fluids create an osmotic gradient During diarrhoea, a large amount of bicarbonate that causes a flow of water from extracellular fluid may be lost in the stool. However, this compensating mechanism fails when the renal function deteriorates, as Principal features include: happens when there is poor renal blood flow due • a deficit of water and sodium, but the deficit of to hypovolaemia. Acidosis can also result • serum sodium concentration is elevated (>150 from excessive production of lactic acid when mmol/l); and patients have hypovolaemic shock. These losses are greatest in infants and can be Fluid losses can be replaced either orally or especially dangerous in malnourished children, who intravenously; the latter route is usually needed are frequently potassium-deficient before diarrhoea only for initial rehydration of patients with severe starts. However, when metabolic acidosis is derived from the breakdown of sucrose or cooked corrected by giving bicarbonate, this shift is rapidly starches) or l-amino acids (which are derived from reversed, and serious hypokalaemia can develop. This can be prevented by replacing potassium Fortunately, this process continues to function whilst simultaneously correcting the base deficit. Manifestations • General muscular weakness Thus, if patients with secretory diarrhoea drink an • Cardiac arrhythmias isotonic salt solution that contains no source of • Paralytic ileus, especially when drugs are taken glucose or amino acids, sodium is not absorbed that also affect peristalsis (such as opiates) and the fluid remains in the gut, adding to the volume of stool passed by the patient. However, when an isotonic solution of glucose and salt is given, glucose-linked sodium absorption occurs and this is accompanied by the absorption of water and other electrolytes. To attain the latter cooled before mixing if there is any doubt); two objectives, salts of potassium and citrate (or • 3. Page 73 Oral rehydration therapy solutions are designed to approximate the composition of gut fluid losses Module 3 Page 73 Use of antimicrobials Antimicrobials should not be used routinely. This antibiotics (furazolidone, co-trimoxazole, is because, except as noted below, it is not possible erythromycin, or chloramphenicol) are usually to clinically distinguish episodes that might effective. Selecting an effective but may also cause delayed clearance of Salmonellae antimicrobial requires knowledge of the causative from the intestinal tract. Prognosis The prognosis of infective diarrhoea depends upon Antimicrobial agents are helpful for the treatment the infecting organism, the development of of dysenteric shigellosis and amoebiasis. Antibiotic usage for selected infections Shigella: Antibiotics to which Shigellae are sensitive provide effective treatment, but antibiotic resistance is a common problem. The most useful antibiotics are co-trimoxazole and nalidixic acid; ampicillin is effective in some areas. Campylobacter jejuni: Erythromycin or clarythromycin shortens the illness if given soon after the symptoms start. However, erythromycin is often ineffective if therapy is delayed until the diagnosis is confirmed by a laboratory. Vibrio cholerae 01: Antibiotics can shorten the duration of the illness and thus simplify case management. Thetracycline (or doxycycline) is most widely used, but resistance has been observed in some areas. When resistance occurs, other Page 74 Module 3 Prevention of spread of diarrhoea This is dependent upon: • improving nutritional status by improving the • prevention of diarrhoea; and nutritional value of weaning foods and giving • interruption of transmission of pathogens. Although a wide variety of infectious agents cause Nursing care diarrhoea, they are all transmitted through common Nursing care of the patient with infective diarrhoea pathways such as contaminated water, food, and requires: hands. Measures to interrupt the transmission • assessment and continuous observation of the should focus on the following pathways: clinical state; • supervision and administration of appropriate • giving only breast milk for the first 6 months of fluid and food; life; • maintenance of a fluid input and output chart; • avoiding the use of infant feeding bottles; • maintenance of a stool chart; • improving practices related to the preparation and • monitoring of temperature, pulse and blood storage of weaning fluids and feeds; pressure; • washing hands after defecation or handling faeces, • monitoring of weight, daily if the patient is a and before preparing food or eating; child; • minimizing microbial contamination and growth • encouraging a scrupulous personal hygiene of foods by preventing breaks in the food hygiene regime; and chain including: use of human excrement as • skin care to prevent excoriation. Rehabilitation may be more protracted • the importance of hand washing, safe disposal in individuals with serious underlying disorders. Giving a nutritious diet, appropriate for the child’s age, when the child is well is important. In addition, the hospital must determine the infecting organism and report it to the relevant public health authority; this is of primary importance in epidemic situations. Role of the community The community is responsible for ensuring the maintenance of good standards of food and water hygiene, educating about careful hand washing and other aspects of personal hygiene, and home Page 76 Module 3 Typhoid Definition approximately 600 000 deaths. Typhoid is Typhoid fever (also known as enteric fever) is a predominantly a disease of countries with poor severe systemic infection caused by the Gram sanitation and poor standards of personal and food negative bacterium Salmonella typhi. Multi-drug resistant strains have been a large number of organisms is usually necessary reported in Asia, the Middle East, and Latin America. The organisms are absorbed from the gut and Manifestations transported via the blood stream to the liver and • In the early stages fever, severe headache, spleen. They are released into the blood after 10 to constipation and a dry cough may be present. The • The fever rises in a “step ladder” pattern for 4 or 5 organisms localise in the lymphoid tissue of the days. This • Abdominal tenderness and an enlarged liver or is the main cause of death from typhoid fever. The • If untreated, complications can occur during the incubation period is from 10 to 21 days. Most patients who have typhoid will excrete • Other complications may affect any patient organisms at some stage of their illness. About because of the occurrence of septicaemia during 10% who have typhoid fever excrete the organisms the first week. These may include cholecystitis, for approximately three months after the acute stage pneumonia, myocarditis, arthritis, osteomyelitis of the illness and 2 to 5% of untreated patients and meningitis. Incidence of becoming • Bone and joint infection is seen, especially in a carrier increases with age, especially in females. Epidemiological summary Age groups affected The organism responsible for typhoid fever was Typhoid can affect any age. Typhoid fever affects Case-fatality rates of 10% can be reduced to less 17 million people in the world annually, with than 1% with appropriate antibiotic therapy. Module 3 Page 77 Diagnosis Treatment of carriers: this can often be very Blood culture is the most important method for difficult to implement, but spread through carriers diagnosis. Isolation of the organism from the stool is unusual if good personal hygiene is practised and is more common in the second and third weeks of stools are disposed of hygienically. In some cases, isolation of the bacteria in the urine can be used as a diagnostic method. Selective immunization of groups: during an epidemic in an endemic country, selective Methods of treatment immunization of groups such as school children, Four different antibiotics are often used for institutionalized people and healthcare workers is treatment: Ciprofloxacin, Co-trimoxazole, of great benefit. Effective treatment does not always prevent complications, Immunization against typhoid the disease recurring or the patient becoming a There are three types of typhoid vaccine: carrier. A chronic carrier may be treated for four weeks with aminoquinalones and in some cases it • Monovalent whole cell typhoid vaccine contains may be necessary to perform a cholecystectomy, in excess of 1000 million S. Two doses, given four to Prevention of spread is dependent upon: six weeks apart, give protection for three years, but • Clean water supply: protection and chlorination side effects include a painful reaction at the of public water supplies is necessary. It provides equally effective protection as the whole cell vaccine but with fewer Page 78 Module 3 febrile side effects, although it can cause irritation general examination for complications; at the vaccine site. Length Rehabilitation of protection may be less and vaccination may need Recovery may be complete after treatment, but may repeating after one year. The vaccine is unstable at also be delayed with recurrence of the symptoms room temperature and must be kept refrigerated. Recurrence is more It should be emphasized that whilst these vaccines likely to occur after inadequate treatment. Consequently strict food, water and personal Role of primary health care team hygiene protection continue to be of great • Education regarding food, water and personal importance. Blood • Awareness of the risks and management of patient cultures can provide early confirmation; the with carrier status organism can then be tested for antibiotic sensitivity. Stool and urine culture may also be Role of health education and health promotion performed from one week following confirmation • Heighten public awareness of the disease and of the disease. Water and food samples from its prevention suspected sources also need to be tested.