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Interestingly insomnia hd buy provigil 200mg low cost, there is reduced activity in the amygdala insomnia 49 generic provigil 200mg on-line, indicating a different brain response during sexual activity than in the desire/ interest phase sleep aid quetiapine cheap 200 mg provigil overnight delivery. During excitement and late excitement, of course, there can be small waves of decreased excitement or de-arousal. This brings up the topic of pheromones and their role in sexual behavior, which we discuss later in the chapter. Neurochemical Influences on Sexual Response Orgasm the most prominent brain response related to orgasm is decreased activity in the prefrontal cortex. There is increased activity in the left orbitofrontal cortex, which is associated with subjective ratings of pleasure by the participant. Resolution and Post-Orgasmic Refractory Period this period is more easily studied in men (because they almost always have an orgasm in response to genital stimulation). The results suggest a de-arousal neural network that includes these areas and others as well. We just described activity in various regions of the brain that are associated with sexual response. Distinctive neurochemicals are involved in sexual excitation and sexual inhibition. During excitement and arousal, or the anticipatory and consummatory phases of sexual response, dopamines, melanocortins, oxytocin, and norepinephrine are involved (Pfaus, 2009). Dopamine and melanocortin stimulate attention to sexual stimuli and sexual desire, within the limbic system. In part, the activation of these neurochemicals also blocks the action of inhibitory processes. Neurochemicals involved in inhibitory processes include opioids, which are released in the cortex, limbic system, hypothalamus, and midbrain in response to sexual pleasure and orgasm/ejaculation. Endocrinologists generally make a distinction between the organizing effects of hormones and the activating effects of hormones. As we discussed in the chapter "Sex Hormones, Sexual Differentiation, and the Menstrual Cycle," hormones present during prenatal development have important influences on genital anatomy, creating male or female genitals. Hormone effects such as these are called organizing effects, because they cause a relatively permanent change in the organization of some structures, whether in the nervous system or in the reproductive system. Typically there are critical periods during which these hormone effects may occur. It has also been known for some time that if an adult male mouse or rat is castrated (has the testes removed, which removes the source of testosterone), it will cease engaging in sexual behavior (and will be less aggressive). If that animal is then given injections of testosterone, it will start engaging in sex again. Hormone effects such as these are called activating effects because they activate (or deactivate) certain behaviors. The organizing effects of hormones on sexual behavior have been well documented (Keefe, 2002). In a classic experiment, testosterone was administered to pregnant female guinea pigs. It is thought that this result occurred because the testosterone "organized" the brain tissue (particularly the hypothalamus) in a male fashion. These female offspring were also born with masculinized genitals-evidence that their reproductive systems had also been organized in the male direction. But the important point here is that the prenatal doses of testosterone had masculinized their sexual behavior. These hormonally masculinized females in adulthood displayed mounting behavior, a male5 sexual behavior. Organizing versus Activating Effects showed about as much mounting behavior as males did. In this way, the testosterone administered in adulthood activated male patterns of sexual behavior.
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A uterine abnormality is particularly suspect with repeated late abortion (second trimester) sleep aid prescription buy generic provigil 200 mg line. Infection (septic abortion) seen most commonly with criminally-induced abortion but may ensue in spontaneous or therapeutic abortion quinine sleep aid buy provigil 100 mg overnight delivery. Threatened Abortion - no specific therapy is effective since the majority of abortions result from failure of normal fetal development and the fetus usually is dead by the time of onset of bleeding sleep aid vitamin shoppe cheap provigil 200mg visa. Management is directed toward avoiding the complications of infection or excessive blood loss. Of all women who present with uterine bleeding in early pregnancy, fewer than half proceed to abortion. Inevitable and incomplete abortion - the aim of therapy is prompt evacuation of the uterus to prevent hemorrhage or infection. An exception in the management of "inevitable" abortion is that of cervical incompetence. In this condition painless dilatation of the cervix has occurred (without bleeding) in the mid trimester. In this circumstance, a purse-string suture of the cervix (cerclage) may help in retaining the pregnancy. Complete Abortion: No further therapy is required, but the patient must be observed closely for continued bleeding or evidence of infection. These complications most often indicate that not all of the tissue has been passed. Missed Abortion: Most missed abortions will evacuate spontaneously and should then be evaluated for completion of the process. Patients can be given the option of scheduling a dilation and curettage (D&C) procedure, or awaiting the spontaneous onset of a miscarriage (make take weeks to occur). If uterine evacuation is delayed beyond four weeks from diagnosis, intervention to empty the uterus should be considered to prevent coagulopathy. Definition: Ectopic pregnancy refers to implantation of the zygote outside the uterus or in an abnormal location within the uterus such as interstitial (the tubal portion within the uterine muscle), and intracervical pregnancies. Blighted (anembryonic) conceptus sac- features of blighted ovum are seen twice as often in tubal compared to intrauterine pregnancies. In first two months uterus growth may be comparable to normal pregnancy due to the circulating hormonal changes of early pregnancy. Normal decidual changes of the endometrium from progesterone exposure are identified histologically despite an ectopic pregnancy. Heterotopic pregnancy (intrauterine combined with an ectopic pregnancy ~1:7,000) 3. Look for the triad of delayed menses, low abdominal pain, abnormal uterine bleeding. Pregnancy testing: A true positive test is required by definition to make the diagnosis. Culdocentesis: quick and simple with extremely high correlation if the ectopic is ruptured (90% to 95%). The location and extent of the ectopic must be ascertained to select the appropriate procedure. If a tubal ectopic is detected, options include extracting the ectopic gestational sac out of the tubal end, performing a segmental resection of the portion of tube containing the ectopic, performing a fimbriectomy if the ectopic is bleeding uncontrollably at the distal end, or a complete salpingectomy. A tubal ectopic pregnancy can rupture as early as the fifth week from a last menstrual period, although the median time is during the sixth or seventh weeks 2. If only one tube has been removed due to an ectopic pregnancy, the remaining tube (even if it looks normal grossly) will have an elevated chance of ectopic in a subsequent pregnancy. This is attributed to the higher likelihood of microscopic ciliary damage and/or intraluminal adhesions from the underlying pathology that led to the first ectopic. If a woman has had one ectopic pregnancy, she must be placed on high alert for having another in subsequent pregnancies.
Increasing Knowledge · Teach patient about situations that can precipitate a sickle cell crisis and steps to sleep aid zen discount provigil 200 mg amex take to sleep aid japan buy cheap provigil prevent or diminish such crises (eg insomnia risk factors buy 100 mg provigil with amex, keep warm, maintain adequate hydration, avoid stressful situations). Monitoring and Managing Potential Complications Management measures for many of the potential complications are delineated in the previous sections; additional measures should be taken to address the following issues. Promoting Home- and Community-Based Care · Involve the patient and his or her family in teaching about the disease, treatment, assessment, and monitoring needed to detect complications. Evaluation Expected Patient Outcomes · Reports control of pain · Is free of infection A 54 Aneurysm, Aortic · Expresses improved sense of control · Increases knowledge about disease process · Experiences absence of complications For more information, see Chapter 33 in Smeltzer, S. Aneurysm, Aortic An aneurysm is a localized sac or dilation formed at a weak point in the wall of the artery. Historically, the cause of abdominal aortic aneurysm, the most common type of degenerative aneurysm, has been attributed to atherosclerotic changes in the aorta. Occasionally, in an aorta diseased by arteriosclerosis, a tear develops in the intima or the media degenerates, resulting in a dissection. Arterial dissections are three times more common in men than in women and occur most commonly in the age group of 50 to 70 years. Thoracic aortic aneurysms occur most frequently in men between the ages of 40 and 70 years. The thoracic area is the most common site for the development of a dissecting aneurysm. Abdominal aortic aneurysms are more common among Caucasians and affect men four times more often than women. Gerontologic Considerations Most abdominal aortic aneurysms occur in patients between 60 and 90 years of age. Rupture is likely with coexisting hypertension and with aneurysms more than 6 cm wide. In most cases at Aneurysm, Aortic 55 A this point, the chances of rupture are greater than the chance of death during surgical repair. If the elderly patient is considered at moderate risk of complications related to surgery or anesthesia, the aneurysm is not repaired until it is at least 5. Clinical Manifestations Thoracic Aortic Aneurysm · Symptoms vary and depend on how rapidly the aneurysm dilates and affects the surrounding intrathoracic structures; some patients are asymptomatic. An alternative for treating an infrarenal abdominal aortic aneurysm is endovascular grafting, which involves the transluminal placement and attachment of a sutureless aortic graft prosthesis across an aneurysm. Nursing Management Preoperative Assessment · Assessment is guided by anticipating a rupture (signs include persistent or intermittent back or abdominal pain that may be localized in the middle or lower abdomen or lower back) and by recognizing that the patient may have cardiovascular, cerebral, pulmonary, and renal impairment from atherosclerosis. Aneurysm, Intracranial 57 A Postoperative Assessment · Frequently monitor pulmonary, cardiovascular, renal, and neurologic status. Hematomas into the scrotum, perineum, flank, or penis indicate retroperitoneal rupture. Aneurysm, Intracranial An intracranial (cerebral) aneurysm is a dilation of the walls of a cerebral artery that develops as a result of weakness in the arterial wall. Its cause is unknown, but it may be due to atherosclerosis, a congenital defect of the vessel walls, hypertensive vascular disease, head trauma, or advancing age. Most commonly affected are the internal carotid, anterior or posterior cerebral, anterior or posterior communicating, and middle cerebral arteries. Symptoms are produced when the aneurysm presses on nearby cranial nerves or brain tissue or ruptures, causing subarachnoid hemorrhage. Prognosis depends on the age and neurologic condition of the patient, associated diseases, and the extent and location of the aneurysm. Clinical Manifestations · Neurologic deficits (similar to those of ischemic stroke) · Rupture of the aneurysm causes sudden, unusually severe headache; often, loss of consciousness for a variable period; pain and rigidity of the back of the neck and spine; and visual disturbances (visual loss, diplopia, ptosis). A 58 Aneurysm, Intracranial · If the aneurysm leaks blood and forms a clot, patient may show little neurologic deficit or may have severe bleeding, resulting in cerebral damage followed rapidly by coma and death. Medical Management · Allow the brain to recover from the initial insult (bleeding). Diagnosis Nursing Diagnoses · Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm · Disturbed sensory perception due to the restrictions of aneurysm precautions · Anxiety due to illness or restrictions of aneurysm precautions Collaborative Problems/Potential Complications · Vasospasm · Seizures · Hydrocephalus · Aneurysm rebleeding · Hyponatremia Planning and Goals Patient goals include improved cerebral tissue perfusion, relief of sensory and perceptual deprivation, relief of anxiety, and absence of complications. Nursing Interventions Improving Cerebral Tissue Perfusion · Monitor closely for neurologic deterioration, and maintain a neurologic flow record. A 60 Aneurysm, Intracranial · Avoid any activity that suddenly increases blood pressure or obstructs venous return (eg, Valsalva maneuver, straining), instruct patient to exhale during voiding or defecation to decrease strain, eliminate caffeine, administer all personal care, and minimize external stimuli.
Close to sleep aid vitamin melatonin purchase provigil mastercard the crura are the vestibular bulbs insomnia upset stomach cheap 100mg provigil, which will be discussed in the section on internal organs insomnia nolan order provigil 100mg otc. As we will see in the chapter "Sex Hormones, Sexual Differentiation, and the Menstrual Cycle," female sexual organs and male sexual organs develop from similar tissue before birth; thus we can speak of the organs of one gender as being homologous (in the sense of developing from the same source) to the organs of the other gender. The clitoris has a structure similar to that of the penis in that both have corpora cavernosa. The clitoris varies in size from one woman to the next, much as the penis varies in size from man to man. Its erection is possible because its internal structure contains corpora cavernosa that fill with blood, as the similar structures in the penis do. The corpora cavernosa and the mechanism of erection will be considered in more detail in the discussion of the male sexual organs. Like the penis, the clitoris has a rich supply of nerve endings, making it very sensitive to stroking. Most women find it to be more sensitive to erotic stimulation than any other part of the body. The clitoris is unique in that it is the only part of the sexual anatomy with no known reproductive function. For example, not only is the vagina used for sexual intercourse, but it also receives the sperm and serves as the passageway through which the baby travels during childbirth. The penis not only produces sexual arousal and pleasure but also is responsible for ejaculation and impregnation. Unlike the other sexual organs, however, it appears to have no direct function in reproduction. The Labia the Mons Other parts of the vulva are the mons pubis, the inner lips, and the outer lips. The mons pubis (also called the mons or the mons veneris, for "mountain of Venus") is the rounded, fatty pad of tissue, covered with pubic hair, at the front of the body. The outer lips (or labia majora, for "major lips") are rounded pads of fatty tissue lying along both sides of the vaginal opening; they are covered with pubic hair. The inner lips (or labia minora, for "minor lips") are two hairless folds of skin lying between the outer lips and running right along the edge of the vaginal opening. Sometimes they are folded over, concealing the vaginal opening until they are spread apart. The inner lips extend forward and come together in front, forming the clitoral hood. The inner and outer lips are well supplied with nerve endings and thus are also important in sexual stimulation and arousal. Some women trim theirs and others remove some or all of it, using methods ranging from shaving to waxing. In one study, 60 percent of Australian undergraduate women reported that they removed some of their pubic hair, and 48 percent said they removed most or all of it (Tiggemann & Hodgson, 2008). The women gave a number of reasons for removing pubic hair, including feeling cleaner, feeling attractive, feeling sexy, and making the sexual experience better. Some experts attribute increases in pubic hair removal to increased access to pornography on the Internet (Ramsey et al. Men, too, both gay and tissue lying on either side of the straight, are increasingly likely vaginal entrance. They seem to have no significant function, and they are of interest only because they sometimes become infected. The place where the inner lips come together behind the vaginal opening is called the fourchette. The area of skin between the vaginal opening and the anus is called Bartholin glands: Two tiny glands the perineum. The vaginal openlocated on either side of the vaginal ing itself is sometimes called the entrance.
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