Timothy T. Brown PhD
- Associate Adjunct Professor, Health Economics
https://publichealth.berkeley.edu/people/timothy-brown/
Medication Therapy Medications are often used to treat specific types of incontinence allergy medicine you can give to dogs promethazine 25 mg overnight delivery, including stress incontinence and those categories associated with an overactive bladder allergy shots mercury cheap promethazine 25mg amex, which may involve symptoms including urge incontinence allergy symptoms under eye generic promethazine 25 mg overnight delivery, urinary urgency allergy symptoms red spots order 25 mg promethazine free shipping, frequency and nocturia. The current literature identifies classifications and names of medications used for various types of incontinence. When using medications, potentially problematic anticholinergic and other side effects must be recognized. The use of medication therapy to treat urinary incontinence may not be appropriate for some residents because of potential adverse interactions with their other medications or other co-morbid conditions. The resident/representative must be provided with the risks and benefits of using medications for continence management. Pessary A pessary is an intra-vaginal device used to treat pelvic muscle relaxation or prolapse of pelvic organs. Women whose urine retention or urinary incontinence is exacerbated by bladder or uterine prolapse may benefit from placement of a pessary. The assessment should note whether the resident has a pessary in place or has had a history of successful pessary use. If a pessary is used, the plan of care must address the use, care and ongoing management of the pessary including monitoring for complications. Absorbent Products, Devices, and External Collection Devices Absorbent incontinence products include perineal pads or panty liners for slight leakage, undergarments and protective underwear for moderate to heavy leakage, guards and drip collection pouches for men, and products (called adult briefs) for moderate or heavy loss. Absorbent products can be a useful, rational way to manage incontinence; however, every absorbent product has a saturation point. Factors contributing to the selection of the type of product to be used should include the severity of incontinence, gender, fit, and ease of use. It is important that residents using various devices, absorbent products, external collection devices, etc. Skin-Related Complications Skin problems associated with incontinence and moisture can range from irritation to increased risk of skin breakdown. Moisture may make the skin more susceptible to damage from friction and shear during repositioning. One form of early skin breakdown is maceration or the softening of tissue by soaking. The persistent exposure of perineal skin to urine and/or feces can irritate the epidermis and can cause severe dermatitis, skin erosion and/or ulcerations. Skin erosion is the loss of some or all of the epidermis (comparable to a deep chemical peel) leaving a slightly depressed area of skin. Because frequent washing with soap and water can dry the skin, the use of a perineal rinse may be indicated. Conversely, an improperly or indiscreetly used catheter may negatively impact independence and dignity. For care of a resident with a suprapubic catheter, refer to current professional guidelines such as the following; c. This evaluation is to include detection of reversible causes of incontinence and identification of individuals with incontinence caused by conditions that may not be reversible, such as bladder tumors and spinal cord diseases. The assessment of continence/incontinence is based upon a comprehensive, interdisciplinary review and assessment. The comprehensive assessment should include identifying the underlying factors which support the clinical indication for the initiation and continuing need for catheter use, determination of which factors can be modified or reversed (or rationale for why those factors should not be modified), and the development of a plan for removal. Because of the risk of substantial complications with the use of indwelling urinary catheters, they should be reserved primarily for short-term decompression of acute urinary retention. The assessment should include consideration of the risks and benefits of an indwelling (suprapubic or urethral) catheter; the potential for removal of the catheter; and consideration of complications resulting from the use of an indwelling catheter, such as symptoms of blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort and bleeding. Intermittent Catheterization Intermittent catheterization can often manage overflow incontinence effectively. Residents who have new onset incontinence from a transient, hypotonic/atonic bladder (usually seen following indwelling catheterization in the hospital) may benefit from intermittent bladder catheterization until the bladder tone returns. A voiding trial and post void residual can help identify when bladder tone has returned.
A broader question was raised as to whether draft articles 8 and 9 should be reformulated to reflect the distinction between immunity ratione personae and immunity ratione materiae allergy medicine chlor trimeton order promethazine 25mg. Depending on the type of immunity involved allergy forecast greenville sc buy 25 mg promethazine mastercard, the timing of consideration of immunity by the forum State may vary (see paragraph 172 below) allergy testing exeter promethazine 25 mg otc. A number of members agreed in substance with draft article 10 (Invocation of immunity) allergy jokes order promethazine 25mg free shipping, whereas there were differing opinions regarding a differentiated approach between immunity ratione personae and immunity ratione materiae. In particular, it appeared from draft article 10, paragraph 6, that the forum State shall decide proprio motu in a case concerning immunity ratione personae, whereas the State of the official was expected to invoke immunity ratione materiae before consideration by the forum State. A proposal was made to indicate that, in a case where immunity ratione materiae was not invoked, the forum State should likewise consider or decide proprio motu as soon as it was aware of the status of the foreign State official or of the acts involved. Another proposal was that, for the purposes of immunity ratione materiae, the acts of the foreign State official should be considered separable, with the effect that invocation or waiver of immunity may be applicable to some acts but not others. It was acknowledged that the right to invoke or waive immunity belonged to the State of the official, not to the official. However, some members noted that, as a practical matter, it was often the official who would be first to claim the immunity in practice. In this regard, it was suggested that States might be advised to stipulate the competent organ to invoke immunity in their domestic law. The obligations of the forum State should also be clarified in the event that immunity was claimed by the official but denied by the State, such as when for example a crime was committed by the official on the orders of the State. Some members considered that the invocation of immunity was not a prerequisite for its application, as immunity existed as a matter of international law and others pointed out that there was no obligation to immediately invoke immunity. The view was expressed that there should be a presumption of immunity unless the State of the official clarified the lack of immunity or waived immunity. Another view was that the lack of invocation of immunity could serve an evidentiary purpose to that effect, but it should not preclude the State of the official from invoking immunity at a later stage. It was stressed that non-invocation of immunity should not be interpreted as a waiver. Nonetheless, it was mentioned that there might be an exceptional possibility where the State of the official is presumed to have waived the immunity of its official if it fails to invoke immunity within a reasonable time after having been notified or made aware of the proceedings against the official. In the view of some 320 Advance version (20 August 2019) members, it was hoped that the consequences of failing to invoke immunity would be clarified. In relation to draft article 11 (waiver of immunity), several members agreed that waiver of immunity must be express as a general rule. Kolodkin, who concluded that waiver of immunity should be express for the troika, but waiver could be either express or implied for other officials enjoying immunity ratione personae or immunity ratione materiae. Moreover, the issue of the appearance of a State before the courts of another State was raised for further consideration, although the view was also expressed that such appearance should not be interpreted as an express waiver of immunity. In respect of draft article 11, paragraph 4, it was doubted by several members that a treaty provision applicable between the forum State and the State of the official could be interpreted as an implied or express waiver. In this regard, drafting a without prejudice clause to this effect was mentioned as an alternative. It was also suggested this matter be treated in a separate provision as this was in effect a treaty exception. As to the form of communication between the forum State and the State of the official, it was mentioned by some members that the requirement of invocation of immunity in writing did not necessarily reflect the international practice. Moreover, several members highlighted the central role of the diplomatic channel in communications between the forum State and the State of the official. The conduct of diplomacy through third-parties, such as intermediaries, was also mentioned. Support was generally expressed for a drafting proposal to emphasize the use of the diplomatic channel in a broader sense, in the context of invocation and waiver of immunity under draft articles 10 and 11, as well as the processes of notification, exchange of information and consultations under draft articles 12, 13 and 15 respectively. It was further noted that the States concerned should be free to decide on the most appropriate channel for communication. It was proposed that invocation of immunity would trigger consultations between the two States concerned, with the effect of suspending the proceedings for a reasonable period during such consultations. In addition, it was suggested to clarify that the participation of the State of the official in the processes of exchange of information and consultations with the forum State could not be construed as an implied waiver of immunity. Members generally supported the wording of draft article 11, paragraph 6, expressing the view that waiver should be presumed to be irrevocable, unless otherwise indicated by the State of the official. The need for consideration of such a provision was also highlighted, since revocation might be justified on other grounds such as concerning vital national interests. Draft articles 12 to 15 (Procedural safeguards between the forum State and the State of the official) 171.
A slow phase with exponentially increasing velocity (high-gain instability allergy treatment urdu cheap 25 mg promethazine, runaway movements) may be seen in congenital or acquired pendular nystagmus allergy forecast louisville ky generic 25 mg promethazine otc. The pathophysiology of acquired pendular nystagmus is thought to be deafferentation of the inferior olive by lesions of the red nucleus allergy medicine dry eyes buy promethazine 25 mg low cost, central tegmental tract allergy medicine benadryl side effects buy promethazine 25 mg, or medial vestibular nucleus. Central vestibular: unidirectional or multidirectional, 1st, 2nd or 3rd degree; typically sustained and persistent. Cerebellar/brainstem: commonly gaze-evoked due to a failure of gaze-holding mechanisms. Congenital: usually horizontal, pendular-type nystagmus; worse with fixation, attention, and anxiety. Many pathologies may cause nystagmus, the most common being demyelination, vascular disease, tumour, neurodegenerative disorders of cerebellum and/or brainstem, metabolic causes. Pendular nystagmus may respond to anticholinesterases, consistent with its being a result of cholinergic dysfunction. Periodic alternating nystagmus responds to baclofen, hence the importance of making this diagnosis. These symptoms are thought to reflect critical compromise of optic nerve head perfusion and are invariably associated with the finding of papilloedema. Obscurations mandate urgent investigation and treatment to prevent permanent visual loss. Cross Reference Papilloedema Obtundation Obtundation is a state of altered consciousness characterized by reduced alertness and a lessened interest in the environment, sometimes described as psychomotor retardation or torpor. An increased proportion of time is spent asleep and the patient is drowsy when awake. Cross References Coma; Psychomotor retardation; Stupor Ocular Apraxia Ocular apraxia (ocular motor apraxia) is a disorder of voluntary saccade initiation; reflexive saccades and spontaneous eye movements are preserved. Ocular apraxia may be overcome by using dynamic head thrusting, with or without blinking (to suppress vestibulo-ocular reflexes): the desired fixation point is achieved through reflex contraversive tonic eye movements to the midposition following the overshoot of the eyes caused by the head thrust. Cross References Apraxia; Saccades Ocular Bobbing Ocular bobbing refers to intermittent abnormal vertical eye movements, usually conjugate, consisting of a fast downward movement followed by a slow return to the initial horizontal eye position. The sign has no precise localizing value, but is most commonly associated with intrinsic pontine lesions. Its pathophysiology is uncertain but may involve mesencephalic and medullary burst neurone centres. Cross Reference Ocular dipping Ocular Dipping Ocular dipping, or inverse ocular bobbing, consists of a slow spontaneous downward eye movement with a fast return to the midposition. This may be observed in anoxic coma or following prolonged status epilepticus and is thought to be a marker of diffuse, rather than focal, brain damage. Reverse ocular dipping (slow upward ocular bobbing) consists of a slow upward movement followed by a fast return to the midposition. Cross Reference Ocular bobbing Ocular Flutter Ocular flutter is an eye movement disorder characterized by involuntary bursts of back-to-back horizontal saccades without an intersaccadic interval (cf. Ocular flutter associated with a localized lesion in the paramedian pontine reticular formation. It has occasionally been reported with cerebellar lesions and may be under inhibitory cerebellar control. Conjugate eye movement in a direction opposite to that in which the head is turned is indicative of an intact brainstem (intact vestibulo-ocular reflexes). With pontine lesions, the oculocephalic responses may be lost, after roving eye movements but before caloric responses disappear. It is often accompanied by a disorder of attention (obsessive, persistent thoughts), with or without dystonic or dyskinetic movements.
Capacity and Consent Residents have the right to engage in consensual sexual activity allergy treatment london purchase 25 mg promethazine otc. However allergy medicine pregnancy 25 mg promethazine, anytime the facility has reason to suspect that a resident may not have the capacity to consent to sexual activity allergy symptoms only at night order 25 mg promethazine with visa, the facility must ensure the resident is evaluated for capacity to consent allergy treatment for 1 year old quality promethazine 25 mg. Residents without the capacity to consent to sexual activity may not engage in sexual activity. When investigating an allegation of sexual abuse, the facility must conduct a thorough investigation to determine the facts specific to the case investigated, including whether the resident had the capacity to consent and whether the resident actually consented to the sexual activity. Determinations of capacity to consent depend on the context of the issue and one determination does not necessarily apply to all decisions made by the resident. For example, the resident may not have the capacity to make decisions regarding medical treatment, but may have the capacity to make decisions on daily activities. Capacity on its most basic level means that a resident has the ability to understand potential consequences and choose a course of action for a given situation. Decisions of capacity to consent to sexual activity must balance considerations of safety and resident autonomy, and capacity determinations must be consistent with State law, if applicable. However, the facility administration, nursing and medical director may wish to consider establishing an ethics committee, that includes legal consultation, in order to assist in the development and implementation of policy related to aspects of quality of life and/or care, advance directives, intimacy and relationships. Cognitive functioning may change due to health issues such as, but not limited to stroke, dementia, depression/psychiatric illnesses or other impacts such as medication(s), hearing/visual loss, and stress. Residents with Designated or Legally Appointed Representatives A resident may have a representative that has been appointed legally under State law through, for example, a power of attorney, guardian, limited guardian, or conservatorship. These legal appointments vary in the degree that they empower the appointed representative to make decisions on behalf of the resident. While a legal representative may have been empowered to make some decisions for a resident, it does not necessarily mean that the representative is empowered to make all decisions for the resident. The individual arrangements for legal representation will have to be reviewed to determine the scope of authority of the representative on behalf of the resident. A resident may also have designated an individual to speak on his/her behalf for decisions for care or other issues. However, it is necessary for the resident, his/her representative and the facility to have a clear understanding of the types and scope of decision- making authority the representative has been delegated. Any decision-making power that is not legally granted to a representative under state law is retained by the resident. It is the responsibility of the facility to ascertain what decisions the representative is legally empowered to make on behalf of the resident. More specifically, regarding consent for sexual activity, State law and the legal instruments setting up resident representation may be silent on that topic. Literature indicates that the most prevalent psychosocial outcomes of abuse are depression, anxiety, and posttraumatic disorder 4. Elder abuse and psychological well-being: a systematic review and implications for research and policy-a mini review. Also, for some health care professionals, it is prohibited by licensure or certification requirements for professionals to have a relationship with a resident (or patient). Any sexual relationship between a staff member and a resident with or without diminished capacity may constitute sexual abuse in the absence of a sexual relationship that existed before the resident was admitted to the facility, such as a spouse or partner, and must be thoroughly investigated. However, in a rare situation, it may not be considered to be sexual abuse when a nursing home employee has a pre-existing sexual relationship with an individual. Allegations of Resident To Resident Sexual Abuse Studies show that a considerable amount of unwanted sexual contact in nursing homes may be initiated by a resident who is sexually aggressive as a result of disease processes such as brain injuries or dementia. In addition, a resident may have a pre-occupation for sexual activity, or have had a prior history of sexual abuse. The resident who is sexually aggressive may target a resident who is unable to protect him/herself, and may involve various types of sexual aggression such as fondling both over and under clothing, masturbation in the presence of another resident and is unwanted by that other resident, forcing oral sex, or sexual intercourse. If there is an allegation that a resident did not wish to engage in sexual activity with another resident or may not have the capacity to consent, the facility must respond to it as an alleged violation of sexual abuse.
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