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This is an uncontentious comment but it serves to 91 92 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES indicate that support proven 35 mg nicotinell, help or assistance is a recognised way of responding to need order 52.5 mg nicotinell fast delivery. The qualification of need with regards to siblings purchase nicotinell 35mg without a prescription, according to Frank, Newcomb and Beckman (1996), is in providing opportunities to reduce emotional stress and isolation. This is achieved by promoting the development of coping strategies in dealing with day-to-day situations. The role played by sibling support groups can do much to help coping strategies to develop, often by simply making time available for young people to express their feelings and experiences in a safe environment. Richardson (1999) suggests that siblings need support groups to help them to understand the realities of disabilities because siblings are adept at denying their own needs. Barr (1999) suggests that siblings need counselling to help reduce anxieties and stress. It seems logical to suggest that, although support may have many manifestations, including individual one-to-one help, the idea of a support group for siblings appears to be a successful way of dealing with sibling needs. A support group may ensure that peer relationships are developed, which then enables a journey of self-discovery. The initial findings from the pilot study on sibling support (Burke and Montgomery 2001a), involved eight families, all of whom agreed that the experience of attending a sibling support group was a good experience for everyone. In the survey within the main stage of the research a siblings group was rated on a scale from 1 to 5, 5 being very helpful, 3 neither helpful or unhelpful and 1 not very helpful (but see appendix for a more detailed methodology). All 41 families whose children attended the siblings group were asked to rated the group within the survey question- naire (Burke and Montgomery 2003) and 38 families rated the group meetings as either very helpful or fairly helpful, of whom 33 rated the group very helpful, and 5 as fairly helpful. Three families did not complete the rating question. The response from siblings themselves (16 from group interview, and 10 within individual interviews) echoed this finding; in particular, the opportunity to meet on a regular basis was generally welcomed as an enjoyable experience. This confirmed the trend first identified within the pilot study and demonstrates that, when siblings attend a support group, they value the experience and benefit from it: it does not show that all support groups are valued in the same way, although THE ROLE OF SIBLING SUPPORT GROUPS / 93 this one was certainly appreciated by parents completing the question- naire and by siblings who were interviewed independently (at the group session held at the Family Centre). Indeed, even when a sibling group was not available (for the 15 families in the control group) all responses (from parents) were in favour of group support being offered. It should be evident then that, whether or not families had children attending a support group, all favoured the opportunity for additional activities. In only one case was there a rejection of the sibling group and that was based on an initial bad first experience; even then, the child concerned expressed the view that ‘it must be fun if you like that kind of thing (10-year-old girl on out-door adventure activities). In order to expand on the reactions of membership of the siblings group and provide a qualitative reflection on the data concerning attendance, the experience of Peter and Ian is helpful to recount. The case of Peter and Ian (low negative reaction) Peter is 14 and has a younger disabled brother Ian, aged 10. Ian goes to a special school for physically disabled young people. He says that he enjoys the sibling group experience,but freely admitted that he had not kept in contact with any of the other young people that attended with him. He liked meeting people and the activities that were followed,but apart from mentioning an interest in computers he could not say what actually happened when he went to the group sessions. He was able to express his feelings about the organisation of the groups and explained that weekly sessions were arrange for periods running for eight weeks, and sometimes these were planned twice a year, although the next group of sessions were, as far as Peter was aware, still in the planning stage. He said his parents would receive a letter to tell them when the group would run again, but he had no idea when that would be. Apart from the siblings group,Peter said he had no friends locally, a situation that seemed not to bother him,perhaps if so he would not make such an admission. Much of his time at home was spent on the computer when it was available. He also said that he got into fights 94 / BROTHERS AND SISTERS OF CHILDREN WITH DISABILITIES with his younger brother, Ian, despite his disability, but more often fighting involved ‘fighting-back, as needed’ rather than starting the fight himself. Peter seems to be a bit of a loner, a seemingly not uncommon reaction to disability in the family (echoing Joe mentioned in Chapter 4), and as he expresses it, he made the decision ‘not see my school friends after school’, thus keeping his home life separate from his school experiences. Peter explained that because his brother Ian attends a different school he felt it was better not to let children in his school know about him.

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PHYSICAL EXAMINATION With an allergic etiology purchase nicotinell 17.5 mg, the patient may complain of fatigue generic 52.5mg nicotinell fast delivery, but will not have fever buy nicotinell 17.5mg lowest price. The nasal mucosa will be boggy and pale, rather than inflamed. The nasal discharge will be clear and watery rather than purulent and yellowish green. RAST (radioallergosorbent test) studies performed on the blood will indicate the increased eosinophilia that is associated with allergies, and the use of skin testing will iden- tify specific allergens. Loss of Smell A change in olfaction can accompany any of the conditions related to nasal congestion, or it can be a more serious problem related to injury to CN I from trauma or tumor. A closed head injury along with a complaint of the loss of smell may indicate an injury in the area of CN I. Other neurological complaints will likely be present because, in a closed head injury, it would be rare to have injury only to this small portion of the brain. In a patient without a history of trauma, an isolated complaint of olfactory changes without any accompanying symptoms of cold, allergies, or sinus congestion is a red flag finding sug- gesting a brain tumor. Brain tumors can cause either a decrease in olfaction or, in some cases, olfactory hallucinations. A complaint of a headache along with olfactory changes increases the index of suspicion for a tumor etiology. A CT or MRI of the head is necessary to determine the presence of a tumor. A thor- ough neurological exam should be performed to detect other neurological abnormalities. See Chapter 14, on the neurological system, for a more in-depth discussion. DIFFERENTIAL DIAGNOSIS OF CHIEF COMPLAINTS: MOUTH Mouth Sores (Painful and Painless) Many conditions manifest themselves with lesions on the lips and/or oral mucosa. Most of these are self-limiting conditions, such as aphthous ulcers, whereas others, such as Behçet’s syndrome and oral cancers, can result in significant morbidity if not recognized and treated promptly. Oral lesions associated with pain can be very distressing to patients. Labial lesions (those on the lips) cause distress because they are obvious and difficult to conceal. Painful lesions, both on the lips and in the mouth, can significantly impair a patient’s abil- ity to take food and fluids by mouth. A diagnosis of herpes simplex can be very upsetting to a patient because of the association with herpes simplex and genital findings, as well as the chronicity of the condition. History When a patient presents with mouth sore(s), it is helpful to determine whether pain is asso- ciated with the lesion(s) early in the history, as certain conditions are more likely than oth- ers to cause painful lesions. It is important to obtain a thorough analysis of the symptom, including when the lesion was first noticed, whether the lesion’s appearance was preceded by other symptoms, and whether there is a history of similar symptoms in the past. It is important to identify any associated symptoms, including fever, malaise, joint pain, short- ness of breath, nausea, vomiting, diarrhea, photosensitivity, and so on. Identify any chronic or coexisting conditions, as well as any prescribed or OTC medications taken. Ear, Nose, Mouth, and Throat 103 Physical Examination The physical examination should include measurement of vitals signs, particularly noting the presence of fever. A thorough assessment of the specific lesion(s) should be performed, noting the type of lesion involved (ulcer, vesicle, papule, and so on), as well as the dimen- sions, coloring, shape, distribution, and other details. The surrounding tissue should be closely inspected, noting any edema, erythema, or pallor.

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Holman H generic nicotinell 52.5 mg with amex, Loric K (1987) Patient education in the rheumatic diseases: pros and cons buy cheap nicotinell 35 mg line. Rheumatic Disease Clinics of North America 18: 1–276 nicotinell 35 mg overnight delivery. Khan MA (1995) HLA-B27 and its subtypes in world populations. Khan MA, Khan MK (1982) Diagnostic value of HLA-B27 testing in ankylosing spondylitis and Reiter s syndrome. Khan MA, van der Linden SM (1990) A wider spectrum of spondyloarthropathies. Khan MA, Khan MK, Kushner I (1981) Survival among patients with ankylosing spondylitis: a life-table analysis. Kidd BL, Cawley MI (1988) Delay in diagnosis of spon- darthritis. Koh TC (1982) Tai Chi and ankylosing spondylitis – A personal experience. American Journal of Chinese Medicine 10: 59–61 Kraag G, Stokes B, Groh J, Helewa A, Goldsmith C (1990) The effects of comprehensive home physio- therapy and supervision on patients with ankylosing spondylitis: a randomized controlled trial. Laiho K, Tiitinen S, Kaarela K, Helin H, Isomaki H (1999) Secondary amyloidosis has decreased in patients with inflammatory joint disease in Finland. Lau CS, Burgos-Vargas R, Louthreno W, Mok MY, Wordsworth P, Zeng QY (1998) Features of spondy- loarthritis around the world. Rheumatic Disease Clinics of North America 24: 753–770. Lorig KR, Mazonson PD, Holman HR (1993) Evidence suggesting that health education for self-manage- ment in patients with chronic arthritis has sustained health benefits while reducing healthcare costs. McGonagle D, Khan MA, Marzo-Ortega H, O’Connor P, Gibbon W, Emery P (1999) Enthesitis in spondy- loarthropathy. Minden K, Kiessling U, Listing J, Niewerth M, Doring E, Meincke J, Schontube M, Zink A (2000) Prognosis of patients with juvenile chronic arthritis and juve- nile spondyloarthropathy. NIH (1998) NIH Consensus Development Panel on Acupuncture. Journal of the American Medical Association 280: 1518–1524. Ostensen M, Ostensen H (1998) Ankylosing spondylitis – the female aspect. Pal B (1998) What counseling do patients with ankylos- ing spondylitis receive? Prieur AM (1998) Spondyloarthropathies in childhood. Reveille JD, Ball EJ, Khan MA (2001) HLA-B27 and genetic predisposing factors in spondylo- arthropathies. Journal of the American College of Cardiology 32: 1397–1404. Rosenberg AM (2000) Juvenile onset spondylo- arthropathies. Santos H, Brophy S, Calin A (1998) Exercise in ankylos- ing spondylitis: How much is optimum? Sochart DH, Porter ML (1997) Long-term results of total hip replacement in young patients who had anky- losing spondylitis. Eighteen to thirty-year results with survivorship analysis. Journal of Bone and Joint Surgery (America) 79: 1181–1189.

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The patient is usually mouth breathing and has a deepened voice and may have difficulty articulating and moving the mouth because of the swelling and pain cheap nicotinell 17.5mg with mastercard. The tonsils are edematous and have exudate that varies in color buy 17.5 mg nicotinell free shipping. If EBV is present buy nicotinell 52.5 mg line, palatal petechiae may be visible. If herpes virus is present, tonsillar ulcera- tions are visible. Lymphadenopathy is present and the patient limits neck motion owing to pain. Definitive diagnosis is made by throat culture, rapid strep, and/or monospot test. See Figures 5-14 (enlarged tonsils) and 5-15 (exudative tonsillitis). PERITONSILLAR ABSCESS Peritonsillar abscesses may occur at any age, although most cases involve adults. Many cases evolve as a complication of tonsillitis, yet others develop as peritonsillar abscess with- out a history of tonsillitis. The condition involves infection of the peritonsillar space. A number of pathogens cause peritonsillar abscesses, although the most common cause is GABHS. The patient describes onset over several days of sore throat, fever, and malaise. Over time, the sore throat becomes very severe and localized to one side. It becomes increasingly difficult to move the neck, speak, and to swallow. The patient’s breath is fetid and the patient is often drooling, unable to swallow saliva. Fever is present and respiratory distress Figure 5-15. Nursing health assessment: A critical thinking, case studies approach. Pharyngeal examination can be very difficult, as the patient may have trismus, an inability to move the jaw due to the swelling. On examination of the pharynx, the area adjacent to the tonsil is swollen and the tonsil is often displaced and the uvula is devi- ated away from the site. There may be signs consistent with dehydration, including dry skin and tachy- cardia. The patient should be referred to a specialist, who may aspirate the abscess to obtain a culture or obtain a culture at the time of therapeutic incision and drainage. An ultrasound or CT scan are used to confirm diagnosis. EPIGLOTTITIS Epiglottitis is rare, but it carries the potential for causing significant respiratory obstruc- tion and death. The patient presents with the complaint of rapidly developing sore throat, fever, cough, and difficulty swallowing. The patient’s voice is muffled and there is drooling. Stridor and/or varying signs of respiratory distress may be evident. The patient often assumes a posture of sitting while leaning forward, to maximize airway opening. The patient has a very ill appearance and gentle palpation over the larynx causes significant pain. The patient should be closely monitored for complete airway obstruction, but urgent referral for emergency care via an ambulance is indicated prior to performing any diagnos- tic evaluation, as the potential exists for sudden loss of airway.

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