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It is similar to the meningeal eral features discount super p-force oral jelly 160 mg on-line, the entire delicate CNS is protected by a bony layer of the cranial dura mater buy generic super p-force oral jelly 160mg online. In certain regions, however, by three membranous connective tissue coverings called the the layers separate, enclosing dural sinuses (see fig. Individually, from the out- collect venous blood and drain it to the internal jugular veins side in, they are known as the dura mater, the arachnoid, and of the neck. Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 Chapter 11 Nervous Tissue and the Central Nervous System 379 Epidural space Dura mater Arachnoid Spinal cord Subarachnoid space Pia mater Spinal nerve Body of vertebra Waldrop FIGURE 11. The epidural space in the lower lumbar region is of clinical importance as a site for an epidural block that may be administered to facilitate childbirth. The subarachnoid space, located between the mater forms distinct septa to partition major structures on the arachnoid mater and the deepest meninx, the pia mater, con- surface of the brain and anchor the brain to the inside of the cra- tains cerebrospinal fluid. These septa were identified earlier and are reviewed in tained by weblike strands that connect the arachnoid and pia table 11. The epidural space is highly vascular and tions of the brain and the irregular contours of the spinal cord, is contains loose fibrous and adipose connective tissues that form a composed of modified loose connective tissue. The pia mater is specialized over the roofs of the ventricles, where it contributes to the for- Arachnoid mation of the choroid plexuses along with the arachnoid. This delicate, netlike membrane spreads over the mentum denticulatum, which attaches the spinal cord to the CNS but generally does not extend into the sulci or fissures of dura mater (fig. Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 380 Unit 5 Integration and Coordination TABLE 11. Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 Chapter 11 Nervous Tissue and the Central Nervous System 381 Cerebrospinal fluid (CSF) is a clear, lymphlike fluid that forms a protective cushion around and within the CNS. CSF circulates through the various ventri- cles of the brain, the central canal of the spinal cord, and the sub- arachnoid space around the entire CNS. The cerebrospinal fluid returns to the circulatory system by draining through the walls of the arachnoid villi, which are venous capillaries. Ventricles of the Brain The ventricles of the brain are connected to one another and to the central canal of the spinal cord (figs. Each of the two lateral ventricles (first and second ventricles) is lo- cated in one of the hemispheres of the cerebrum, inferior to the corpus callosum. The third ventricle is located in the dien- cephalon, between the thalami. Each lateral ventricle is con- nected to the third ventricle by a narrow, oval opening called the interventricular foramen (foramen of Monro). The fourth ventricle is located in the brain stem between the pons and cere- bellum. The mesencephalic aqueduct (cerebral aqueduct) passes through the midbrain to link the third and fourth ventricles. The fourth ventricle also communicates posteriorly with the central canal of the spinal cord. Cerebrospinal fluid exits from the fourth ventricle into the subarachnoid space (fig. Internal hydrocephalus (hi'dro-sef'a˘-lus) is a condition in which cerebrospinal fluid builds up within the ventricles of the Meningitis, an inflammation of the meninges, is usually caused brain (fig.
The on through the collecting ducts generic super p-force oral jelly 160mg with visa, three processes occur: fil- usual challenge is to remove excess acid super p-force oral jelly 160mg without a prescription. As we have tered HCO3 is reabsorbed, titratable acid is formed, and learned, strong acids produced by metabolism are first ammonia is added to the tubular urine. The involve H secretion (urinary acidification) by the tubular kidneys then must eliminate H in the urine and restore the epithelium. For example, if the urine has its lowest pH value shows ammonia movements in various nephron segments. With a typical daily urine output of 1 to 2 L, the amount of acid the body must Acidification in the Proximal Convoluted Tubule. The dispose of daily (about 70 mEq) obviously is not excreted pH of the glomerular ultrafiltrate, at the beginning of the in the free form. Most of the H combines with urinary proximal tubule, is identical to that of the plasma from buffers to be excreted as titratable acid and as NH4. H ions are secreted by the prox- Titratable acid is measured from the amount of strong imal tubule epithelium into the tubule lumen; about two base (NaOH) needed to bring the urine pH back to the thirds of this is accomplished by a Na /H exchanger and pH of the blood (usually, 7. It represents the amount about one third by H -ATPase in the brush border mem- of H ions that are excreted, combined with urinary brane. The largest component of titratable acid is normally The drop in pH is modest for two reasons: buffering of phosphate, that is, H2PO4. The glomerular filtrate and tubule bine with the free base NH3 and are excreted as NH4. The NH4 ) is produced by the kidney tubule cells and is se- proximal tubule epithelium is rather leaky to H , so that creted into the urine. Because the pKa for NH4 is high any gradient from urine to blood, established by H secre- (9. Urinary ammonia is measured Most of the H ions secreted by the nephron are se- by a separate, often chemical, method. Secreted Renal Net Acid Excretion Equals the H ions are also buffered by filtered phosphate to form titratable acid. Ammonia is produced by proximal tubule Sum of Urinary Titratable Acid and cells, mainly from glutamine. It is secreted into the tubular Ammonia Minus Urinary Bicarbonate urine by the diffusion of NH3, which then combines with a In stable acid-base balance, net acid excretion by the kid- secreted H to form NH4 , or via the brush border mem- neys equals the net rate of H addition to the body by me- brane Na /H exchanger, which can operate in a tabolism or other processes, assuming that other routes of Na /NH4 exchange mode. The distal nephron Glutamine Distal convoluted (distal convoluted tubule, connecting tubule, and collect- + Collecting ing duct) differs from the proximal portion of the nephron NH4 tubule duct pH = 6. It secretes far fewer H ions, H+ NH 3 and they are secreted primarily via an electrogenic H - + Na ATPase or an electroneutral H /K -ATPase. The distal nephron is also lined by “tight” epithelia, so little secreted + + H + NH3 NH H diffuses out of the tubule lumen, making steep urine-to- 4 blood pH gradients possible (see Fig. Na+ NH + The distal nephron usually almost completely reabsorbs Proximal 4 pH = 7. Considerable titratable tubule H + NH3 + acid forms as the urine is acidified. Ammonia, which was re- Na NH absorbed by the ascending limb of the Henle loop and has + 3 NH4 accumulated in the medullary interstitial space, diffuses as NH + NH + lipid-soluble NH3 into collecting duct urine and combines 4 4 H++ NH with secreted H to form NH4.
The muscle of the ciliary body has primarily a Optic disc parasympathetic innervation generic super p-force oral jelly 160mg with visa, although some sympathetic Fovea (blind spot) innervation is present 160mg super p-force oral jelly otc. When it is fully relaxed, the lens is at its flattest and the eye is focused at infinity (actually, at Retina anything more than 6 meters away) (Fig. When the Choroid Optic nerve ciliary muscle is fully contracted, the lens is at its most Sclera curved and the eye is focused at its nearest point of distinct vision (Fig. The near point of vision for view from above, showing the relative positions the eye of a young adult is about 10 cm. This con- dition is called presbyopia; supplemental refractive power, fluid. This liquid is continuously secreted by the epithelium of the ciliary processes, located behind the iris. As the fluid accumulates, it is drained through the canal of Schlemm into the venous circulation. If too much pressure builds up in the anterior cham- ber, the internal structures are compressed and glaucoma, a condition that can cause blindness, results. The vitreous humor (or vitreous body), a clear gelatinous substance, fills the large cavity between the rear of the lens and the front sur- face of the retina. The innermost layer of the eyeball is the retina, where the optical image is formed. This tissue contains the pho- toreceptor cells, called rods and cones, and a complex mul- tilayered network of nerve fibers and cells that function in the early stages of image processing. The rear of the retina is supplied with blood from the choroid, while the front is supplied by the central artery and vein that enter the eye- ball with the optic nerve, the fiber bundle that connects the retina with structures in the brain. The vascular supply to the front of the retina, which ramifies and spreads over the retinal surface, is visible through the lens and affords a direct view of the microcirculation; this window is useful for diagnostic purposes, even for conditions not directly re- lated to ocular function. At the optical center of the retina, where the image falls when one is looking straight ahead (i. During fixation macula is the fovea centralis, a depressed region about 0. With the lens flattened, parallel rays from a distant object are Slightly off to the nasal side of the retina is the optic disc, brought to a sharp focus. B, Lens curvature increases with accom- where the optic nerve leaves the retina. CHAPTER 4 Sensory Physiology 73 in the form of external lenses (reading glasses), is required The iris, which has both sympathetic and parasympa- for distinct near vision. They can be capable of a 30-fold change in area and in the amount of corrected with external lenses (eyeglasses or contact light admitted to the eye. Farsightedness or hyperopia is caused by an eyeball flex control, and bright light entering just one eye will that is physically too short to focus on distant objects. In effect, the converging power of the eye is too great; close Eye Movements. The extraocular muscles move the vision is clear, but the eye cannot focus on distant objects. These six muscles, which originate on the bone of the A negative (diverging) lens corrects this defect. If the cur- orbit (the eye socket) and insert on the sclera, are arranged vature of the cornea is not symmetric, astigmatism results.
Whereas physicians define the stomach as a specific organ cheap 160 mg super p-force oral jelly with amex, patients complaining of a “stomach ache” might be referring to an indefinite area from the ribs to the pubis generic super p-force oral jelly 160 mg free shipping. When you describe a procedure, choose words that do not produce anxiety. For example, “excise” might be misunderstood, whereas “cut- ting it out” sounds painful. Repetition Various studies have shown that the average patient retains only 35% of what he or she is told. To improve retention, summarize the essential points of your message at the end of the consultation or examination. Request Written Questions A visit to the doctor can cause anxiety that makes patients forget important questions or information until they have left the office. Encourage patients to write down questions and to bring a list on their next visit. If your patient already has a list, then do not, by word or body language, express impatience about answering the questions. In the event of an unfavorable outcome, the time you spent answering questions may avert a malpractice claim. Body Language Body language is as important when speaking as when listening. Starting with the first friendly handshake, nonverbal communication is important for establishing and maintaining patient confidence. In speaking, as in listening, eye contact is critical and holds the patient’s attention. A patient’s facial expressions and frequent nods indicate how effectively you are getting your message across. The anxieties of sick or injured people often act as a lens that greatly magnifies the physician’s body language. In some cases, an inno- 70 Gorney cent sigh, a raised eyebrow, or a look of skepticism when evaluating a colleague’s results has triggered a patient’s visit to an attorney. Likewise, remember that a reassuring smile, a comforting touch, and a confident and caring attitude are indispensable ingredients for the development of solid doctor–patient relationships. PROBLEMS OF NURSE–PHYSICIAN COMMUNICATION Case 1 A 39-year-old man was brought to the emergency room (ER) of a large hospital shortly after being struck in the head with a baseball bat. Eleven days later, he returned to the ER because of increasing lethargy. He was hospitalized, and a computed tomography (CT) scan raised the question of a subdural hematoma. It was late in the evening when the CT scan was interpreted, and the patient was alert, so his physician decided to wait until morning to perform further studies. When the patient’s doctor left the hospital at 10 PM, he wrote orders for the nurses to check the patient’s vital signs hourly. However, the doctor did not give specific direction to note the state of the patient’s pupils or his state of consciousness or to call the doctor if any alteration occurred. He later said he felt it was unnecessary to leave such detailed directions because the nurses should have understood their duty in this regard.