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In addition purchase exelon online from canada symptoms ebola, work is undertaken with key informants and the emic/etic dimension considered generic exelon 6mg on-line medicine 6mp medication. In ethnography researchers observe their collaborators without prejudice or prior assumptions trusted 1.5mg exelon medications for rheumatoid arthritis. Cognitive Ethnography: It has been proposed for the study of software tool development. This has been proposed because one of the criticisms of classical ethnography is that it fails to provide feedback into practice. Emic/Etic perspective: These terms were coined by Pike 1954 and widely used in ethnography. The emic perspective is the insider’s or native’s perception, while the etic perspective is the imposed framework of the researcher or outsider. Grounded Theory: This theory was developed by Barney Glaser and Anselm Strauss in the 1960’s. Researchers start with an area of interest, collect the data and allow relevant ideas to develop. Grounded theory is useful in such situations where little is known about a topic or problem area, or to generate new and exciting ideas in settings that have become static or stale. The exploration of the live experience of people which is mainly used in the areas of health, psychology and education. An analytical description of the phenomena is not affected by any prior assumptions. Contextualism: In this, participants are grounded in the context of their history and temporality. An understanding of context helps to locate the actions and perceptions, and hence grasp the meaning to be communicated. Researchers Qualitative Research–Concepts and Methods 93 primarily examine speech patterns, facial expressions, gestures and body language. According to Immy, a discourse analysis is an analysis of text and language, often used in media and communication research to analyze message data. Emphasis is placed upon the reading of documents and verbatim transcripts repeatedly until complete familiarization is gained with the data. Business is carried out through a variety of means: letter, telephone, meetings, e-mails, etc. There is a recognizable life-cycle of reflection, action, full immersion, and reflection. Researchers attempt to explain how people ‘Fit their lines of action to those of others’. In this, subjects take account of each other’s acts and interpret and reorganize their own behavior to one another, or their group. Symbolic interactionism is linked to many areas of qualitative research such as grounded theory, ethnography and conversational analysis. Multiview Multiview can be said to be an exploration in the information systems development. It is recognized that some methodologies are not always suitable for particular situations. Multiview offers a flexible framework, using a blend of methodologies, which provides an alternative for choosing between different methodologies. Multiview includes stages which relate to the human and social dimension as well as the technical aspect. Multiview 94 Research Methodology for Health Professionals provides a contingent approach whereby the tools and techniques adopted depend upon the particular circumstances. Multiview addresses problems associated with the analyses and design activities of information system definition. Multiview is a methodology to structure the tasks for the analysts and users during the analysis and design activities. Triangulation Most researchers do quantitative or qualitative research work by combining of one or more research methods is called a triangulation. The use of multiple perspectives is to interpret a single set of data: Denzin in 1978 identified four types of triangulation: 1. Methodological Multiple perspectives can be limited by cost, time, and political constraints. Selection of the right method or combination of methods is important in Triangulation as more than one methodology may warrant a drain on resources. In a constrained budget situation inadequate resources may be spread across the spectrum of selected methods, resulting in many poorly implemented methods rather than one well executed method. Traditional qualitative research assumes that: • Knowledge is subjective rather than the objective of truth. Recent perspectives on qualitative research focus upon the “complex interplay of our own personal biography, power and status, interactions with participants, and written word. It is necessary to have adequate communication practices and cultural environments to obtain data for qualitative research. The systematic observation of events inferring the meanings of these events from the self- observations of the actors and spectators and techniques of interviewing and interpreting the material traces that are left behind by the actors and the spectators are crucial for valid analysis and adequate presentation. Limitations of Observation Technique: These are: ü Time consuming, ü Too many things to observe ü May not be representative ü Difficulty in determining the root causes of the behavior. Participatory approaches offer a creative approach to investigating issues of concern to people, and to planning, implementing, and evaluating development activities. The common theme is the promotion of interactive learning, shared knowledge, and flexible, yet structured analysis. Participatory approaches can also bring together different disciplines, such as agriculture, health and community development, to enable an integrated vision of livelihoods and well-being. Principles of Participatory Inquiry The diversity and complexity is strength of these systems of inquiry. Despite the different ways in which these approaches are used, there are important common principles uniting most of them. An outside team works with members of the local community to: • Select a location and gain approval from local administrative officials and community leaders; • Conduct a preliminary visit (steps 1 and 2 include community review and a planning meeting to share the purpose and objectives of the participatory inquiry and initiate dialogue between all parties as well as full participation); • Collect both secondary and field data (spatial, time-related, social, environmental, economic and governance), and share information with selected communities; • Synthesize and analyze that data; • Identify problems and opportunities to resolve them; • Use rank opportunities and prepare maps, action plans, reports and costing (including basic work plan for all members of the community); • Adopt and implement the plan; • Follow-up, evaluate and disseminate any findings, maintain momentum through addressing new issues. It is useful for sensitive issues like politics, rape, murder, menstruation, sex behavior, etc. It is useful in: • Purchasing which involves a long time frame (car, house), and • Where the decision process is too short, e. Qualitative Research–Concepts and Methods 99 Types of Projective Techniques • Free word association • Sentence completion • Unfinished scenario/story completion • Cartoon completion test Free word association: In this technique, a list of carefully selected stimulus words or phrases related to the topic of research are read out, one at a time, to a respondent. The respondent is asked to respond with the first word or phrase that comes to his/her mind. In this technique, the respondent is presented with some sentences containing incomplete stimuli and is asked to complete them.


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Catheters are placed percutaneously by Seldinger technique using the largest cannulas tolerated for the patient’s circulation purchase genuine exelon on line symptoms 8-10 dpo. Our practice is to limit ventilator support to minimize oxygen toxicity buy exelon in united states online treatment under eye bags, barotrauma buy exelon 6mg overnight delivery medicine encyclopedia, and ventilator-induced lung injury. May be due to anticoagulation, platelet dysfunction, and/or placement technique c. A sudden change in the pressure gradient across the oxygenator suggests a thrombus has developed. Vessel perforation, dissection, and other complications are rare but may occur due to the large caliber arterial catheter. The arterial oxygen concentration of blood perfusing the heart, upper body, and brain may be significantly lower than blood in the lower extremities. To detect this, periodic arterial oxyhemoglobin saturations should be taken from the upper extremity (i. This may be performed at bedside with prolonged manual compression (at least 30 to 45 minutes for femoral arterial access). Elective versus provisional intraaortic balloon pumping in unprotected left main stenting. Complications of extracorporeal membrane oxygenation for treatment of cardiogenic shock and cardiac arrest: a meta-analysis of 1,866 adult patients. Contemporary utilization and outcomes of intra-aortic balloon counterpulsation in acute myocardial infarction: the benchmark registry. Mason Sones and colleagues at the Cleveland Clinic performed the first selective coronary arteriographic procedure. During training, the operator must be supervised by a cardiologist who is already competent in the procedure. Because there is the ability to treat a lesion with percutaneous intervention at the same time as the diagnostic angiogram, it is important to have a plan regarding how to use the information obtained. Common clinical scenarios were created and graded by various panel members on a 1 to 9 scale. The scenarios were placed into the three categories of “appropriate” (score 7 to 9), “may be appropriate” (score 4 to 6), and “rarely appropriate” (score 1 to 3; see Table 62. Patients who have refractory symptoms despite medical therapy should be considered for an early invasive strategy. High-risk findings include >10% ischemic myocardium on single- photon emission computed tomography myocardial perfusion imaging or stress positron emission tomography, or two more segmental wall motion abnormalities on stress echo or stress cardiac magnetic resonance. Transient ischemic dilation and a large drop in ejection fraction with stress are also considered high risk. Intermediate-risk stress tests in symptomatic patients are considered appropriate. It is also performed on patients with congenital heart disease to evaluate lesions such as ventricular septal defects and to rule out concomitant coronary anomalies or atherosclerotic disease, if symptomatic. The usual recommendation for patients on warfarin (Coumadin) is to discontinue it 72 hours before the procedure. If the patient is on heparin infusion, this is usually stopped 2 hours before the procedure. After thrombolytic therapy, bleeding is more likely and elective catheterization is best deferred; however, if the indication for the procedure is urgent, it is possible to proceed with caution, with blood products kept ready for support as needed. Body habitus is also a factor in deciding what level of anticoagulation is acceptable before a catheterization. Obesity increases the chances of bleeding (if multiple attempts at access are needed) and makes bleeding more difficult to detect. This recommendation is especially true in patients presenting with acute coronary syndromes when anticoagulants and antiplatelet agents are frequently used. A rising creatinine is generally a reason to defer elective cardiac catheterization. In a patient on dialysis, catheterization is generally timed immediately after the dialysis. In a patient with stable but chronic kidney disease, catheterization may be performed with an awareness of the increased risk of needing dialysis. Limited use of contrast and adequate hydration are important to minimize the risk of contrast-induced nephropathy in this population. Although an allergy to shellfish and seafood has been linked to contrast reactions in some studies, other studies dispute such a relationship and do not need routine steroid preparation. Fungal infection in groin creases should be controlled before elective cardiac catheterization by the femoral approach; this is a particular concern in obese patients. Severe anemia, hypokalemia, or hyperkalemia should be corrected before the elective procedure. At a minimum, the patient should be able to lie supine without respiratory insufficiency. A synthetic vascular graft that is older than 6 months is not a strict contraindication to catheterization, but special care should be taken in gaining access as well as in obtaining hemostasis; however, the risk of embolization of friable atheroma or thrombus is heightened, and this risk increases with the age of the graft. Blood pressure should be controlled before elective cardiac catheterization to maximize the safety of the procedure. In particular, severe bleeding can occur at the access site after sheath removal if the patient is very hypertensive, especially if above 180/100 mm Hg. A detailed discussion with the patient (and family) should outline the indication for the procedure, as well as the alternative treatment and diagnostic options. Informed consent should be documented in the medical record prior to an elective or urgent case. All peripheral pulses should be palpated, and arterial bruits, if any, should be documented before the catheterization as a baseline for future reference. In addition, an electrocardiogram and laboratory data, including a comprehensive metabolic panel, complete blood count, and coagulation studies, should be obtained for all patients. Urine human chorionic gonadotropin should be checked in female patients prior to the catheterization when appropriate. Metformin should be stopped at the time of the procedure, although the risk of lactic acidosis is extremely low in a patient with normal creatinine. Patients should be warned that they might feel a hot sensation lasting about 30 seconds because of the injection of ionic contrast dye. Patients should be specifically instructed to cough when they hear anyone in the room say “cough. Before performing a cardiac catheterization, it is essential to ensure that the monitoring equipment is fully functional. In particular, defibrillators and intubation trays must be available next to the patient. If a long procedure is anticipated, many operators prefer placement of a Foley or Texas urinary catheter.

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Appropriate pain relief and sedation should be administered prophylactically when this is clinically indicated cheap exelon 6 mg with visa treatment for 6mm kidney stone, keeping in mind its potential impact on a patient with an already tenuous hemodynamic or respiratory state 4.5 mg exelon with amex symptoms high blood sugar. The decision to intubate a patient with tamponade is challenging and controversial purchase discount exelon treatment 3rd stage breast cancer, and it is usually reserved for patients who develop severe respiratory insufficiency and is best avoided as it may worsen the hemodynamic situation. Currently, ultrasound-guided pericardiocentesis is the standard approach at most institutions. It is feasible in over 95% of patients with pericardial effusions, especially when anterior or large. Echo guidance allows the selection of the most appropriate window to access the effusion and to ascertain the depth to which the needle should be inserted to obtain pericardial fluid. The head is elevated approximately 30°, and a complete echocardiographic evaluation is performed with standard parasternal, apical, and subcostal views. In addition to these, it may also be necessary to obtain off-axis views with the purpose of identifying where the pericardial fluid is nearest and most accessible to the skin without any interposing structure. In general, there are three different approaches, apical, subcostal, and parasternal, with the first two being the most commonly used. The subcostal approach has the lowest risk of causing pneumothorax, but the greatest risk of injuring the liver, or gastrointestinal tract, especially in obese patients. Moreover, the distance from the skin to the effusion is the longest with the subcostal approach. The apical approach has the lowest risk of pneumothorax or injury to major vascular structures (coronary arteries or internal thoracic artery), but has the highest risk of injuring the left ventricle and triggering ventricular arrhythmias. The parasternal approach has the advantage of small distance between the thoracic wall and the pericardium, but has a higher risk of causing pneumothorax or puncture of an internal thoracic artery. The apical approach is most commonly used followed by the subcostal, with the remaining performed in off-axis views. When planning an apical approach, it is useful to obtain extreme apical views, with displacement of the probe laterally and posteriorly, close to the midaxillary or posterior axillary line, and if needed with inferior displacement of the probe until the largest pocket of fluid with the greatest distance to the myocardium is identified. When planning a subcostal approach, the liver should be identified to avoid accidental laceration during the procedure. Because it is air filled, lung tissue will block ultrasound waves and preclude imaging of the heart; consequently, the risk of pneumothorax is low if a good echocardiographic window is selected for the tap. While imaging, it is imperative to take note of the distance to the fluid pocket as well as the probe trajectory. Failure to maintain an appropriate trajectory is a common cause of failure in accessing a pericardial effusion percutaneously. Because real-time imaging of the needle tip accessing the pericardial fluid is not always possible, it is of vital importance to maintain the trajectory of the needle during the pericardiocentesis identical to the trajectory of the echocardiographic probe when imaging. Once the best window is selected, the probe’s location is marked with a permanent marker and scrubbed with sterile chlorhexidine–alcohol or povidone–iodine solution. The entire torso is draped with sterile towels or a full-body sterile field if available. The patient should not move between the echocardiographic examination and the procedure. We use a sterile sleeve over the echo probe so that the operator has it to hand when performing the pericardiocentesis. Using a sterile pen, a mark can be made on the pericardiocentesis needle at the approximate distance between the skin and effusion that was noted on the echocardiogram. The needle used should be 5 to 8 cm in length, with a short bevel to lessen the risk of lacerating structures at the needle’s tip. Then deeper anesthetic is given over the superior aspect of the rib (if a chest wall approach is used). Occasionally, in a relatively superficial pericardial effusion, the pericardial space will be entered with the anesthetic needle and pericardial fluid may be aspirated. Care should be taken when using an apical or intercostal approach to avoid damaging the neurovascular bundle at the lower rim of the rib at the superior aspect of the rib space. Using a three-way stopcock, an 18G Cook needle is attached to a syringe that contains a few more milliliters of local anesthetic. The needle is advanced through the anesthetized tract while maintaining negative pressure in the syringe, over the rib, along the same trajectory as the echocardiographic probe, until the fluid is aspirated. Upon aspiration of the fluid, the catheter is advanced over the needle, and the needle is withdrawn. If no fluid is retrieved at the depth calculated from the echo images, it is recommended to withdraw the needle and reassess the trajectory with the ultrasound probe as it may need to be redirected. Once fluid is obtained during aspiration, it does not necessarily confirm access to the pericardial space, because pleural and peritoneal collections may be traversed during pericardiocentesis. When confirmation that the needle is in the pericardial sac is needed, agitated saline contrast may be injected through the stopcock while imaging the heart from a remote location. The appearance of bubbles in the pericardial space confirms an appropriate location. Bubbles appearing within a cardiac chamber suggest that the heart has been perforated and that the needle or catheter should be withdrawn. If agitated saline cannot be visualized, one should reconsider the needle position. If the effusion is large, the contrast may not be visible from all echocardiographic windows; occasionally, it may be necessary to reinject saline and image from an alternative location. Of note, it is recommended to inject agitated saline when the needle is in the pericardial fluid and before using the dilator and inserting the catheter. With this approach, it is possible to avoid dilating the myocardium with a larger bore device in case of perforation of the ventricular wall. A scalpel blade is then used to nick the skin over the needle, the needle is withdrawn, and a 6F dilator is used to broaden the tract into the pericardium. Finally, the dilator is removed and a 6F to 8F pigtail angiocatheter with side holes is threaded over the wire well into the pericardial space, ensuring at all times that the end of the wire is controlled. The wire is removed, and catheter placement can again be confirmed with agitated saline injection if needed. With a three-way stopcock, fluid for laboratory analysis should be collected with a large syringe upon initial drainage; the catheter is then attached to a 30-cm length of plastic tubing, which in turn may be connected to a vacuum bottle or drainage bag. If the catheter is being left to drain for some time, it should be sutured in place. Occasionally, very bloody fluid may be aspirated during pericardiocentesis, and confirmation of the needle placement may be difficult. Therefore, differentiating between blood (chamber perforation) and bloody effusion can be challenging. A few milliliters of the aspirate can be placed on a gauze pad; classical teaching suggests that if the fluid coagulates, it is blood from chamber perforation. Conversely, fluid that spreads out on the gauze forming a pinkish halo suggests an intrapericardial origin.


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