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Internal Anal Sphincter This sphincter is a continuation of the circular muscle coat of the rectum and extends 8–12 mm below the dentate line purchase cefpodoxime 200 mg online antibiotics nursing considerations. In the normal living subject cefpodoxime 100mg overnight delivery antibiotic ointment infection, the internal anal sphincter is tonically contracted so that the anal canal is closed generic cefpodoxime 200mg with visa antibiotic resistance of staphylococcus aureus. The internal sphincter is supplied by autonomic nerve fibers and is not consid- ered to be under voluntary control (3). Thus, although it appears to contract 104 Rogers and Newton during a digital assessment of voluntary anal contraction, it is presumed to result from its compression by the surrounding external sphincter fibers (177). External Anal Sphincter This sphincter encircles the internal sphincter but extends below it, end- ing subcutaneously. The lower edges of the external and internal sphincters can be distinguished on digital palpation. Although this sphincter is tonically contracted in the resting state, this contraction can be overcome with firm pressure (177). If the patient is asked to contract the anus during a digital assessment, the external sphincter can be felt to ensure contraction and clos- ing of the anus tightly. However, because the muscle fibers are predominantly the slow-twitch type, a maximum contraction of the external sphincter can only be maintained for approx 1 minute(178). Fecal continence is maintained by several factors, the relative impor- tance of which has not been fully elucidated. Currently, the most important factor is the angulation between the rectum and the anal canal, which is main- tained at a mean of 92° by continuous contraction of the puborectalis muscles, located above the external sphincter. Both sphincters have supportive roles in maintaining fecal continence (175), and their disruption can result in inconti- nence (see Subheading 10. Forensic Evidence The presence of semen in the anus or rectum of a male complainant can be corroborative evidence of alleged anal intercourse in conjunction with the presented history and possible physical findings. The same is only true for a female complainant if no semen is detected in the vagina, because semen has been found on rectal and anal swabs taken from women who described vaginal intercourse only. It is postulated that the presence of semen in these cases results from vaginal drainage (49,179). Swabs should also be taken if a condom or lubricant was used during the sexual assault and if anilingus is alleged (see Subheading 7. Just as when sampling the skin elsewhere, if the perianal skin is moist, the stain should be retrieved on dry swabs. If there is no visible staining or the stain is dry, the double-swab technique should be used (28). The forensic practitioner should use as many swabs as are necessary to remove any visible stain (repeating moistened swab followed by dry swab). Although not specifically defined for forensic pur- Sexual Assualt Examination 105 poses, the perianal area should be considered as an area with a radius of 3 cm from the anus. Even though traditionally these swabs have been labeled “external anal swab,” they should be labeled as “perianal swab” to clearly indicate the site of sam- pling. The anal canal is then sampled by passing a wet swab and then a dry swab, sequentially, up to 3 cm through the anus. The proctoscope (anoscope) is then passed 2–3 cm into the anal canal, and the lower rectum is sampled using a dry swab. As the proctoscope is withdrawn, the anal canal can be sampled, again with a dry swab. As discussed previously, when examining female complainants of anal intercourse alone, swabs should also be obtained from the vagina. If doctors decide for clinical reasons to use a lubri- cant, they should apply the lubricant (from a single-use sachet or tube) sparingly, taking care not to contaminate the swabs, and must note its use on the forms returned to the forensic scientist. In the process of sampling the rectum/anal canal, the proctoscope may accumulate body fluids and trace evidence. Therefore, the used proctoscope should be retained, packaged separately, and stored in accordance with local policy. If the proctoscope is visibly wet on removal, swabbing may be con- ducted to retrieve visible material. If storage space is restricted, then the instrument should be swabbed and the swabs retained instead. Stool samples and toilet paper need not be collected routinely because the other samples described should be adequate for laboratory requirements. Persistence Data Under normal circumstances, the maximum recorded interval between the act of anal intercourse and the identification of spermatozoa on a rectal swab is 65 hours (181). However, in one exceptional case in which a female remained prone in the hospital for several days because of injuries sustained 106 Rogers and Newton during a sexual assault, semen was detected on anal swabs taken 113 hours after the act of anal intercourse (181). Medical Evidence When an allegation of anal penetration is made, the perianal skin, anal canal mucosa, and, when tolerated, the lower portion of the rectum should be examined with the aid of a proctoscope/anoscope. It is generally accepted that with gradual dilatation and lubrication, con- sensual penile anal intercourse can be performed without any resultant injury (80,182). Furthermore, it is important to emphasize that nonconsensual anal penetration can also occur in both children and adults without producing acute or chronic injury (3). Although anecdotal accounts have detailed the anal and rectal injuries that result from consensual penile/object anal penetration (121,175), few peer- reviewed articles have addressed this subject.

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This ontology leads Introducing the Theory: to research and practice on patterns (Rogers purchase cefpodoxime 100 mg otc infection under crown, 1992) cheap 100 mg cefpodoxime otc antibiotic resistant bacteria evolution, The Human Becoming lived experiences cefpodoxime 100 mg on line antibiotic guidelines 2014, and quality of life (Parse, 1981, School of Thought 1992, 1997a, 1998a). Because the ontologies of these paradigmatic perspectives lead to different re- Presently, nurse leaders in research, administration, search and practice modalities, they lead to differ- education, and practice are focusing attention on ent professional services to humankind. The goal of the discipline is to expand knowledge The profession of nursing consists of people edu- about human experiences through creative concep- cated according to nationally regulated, defined, and tualization and research. The standards and regulations are to preserve the safety of health care for members of society. The nursing regulations and standards are Knowledge of the discipline is the scientific specified predominantly in medical/scientific terms. This is according to tradition and is largely related to nursing’s early subservience to medicine. The the nurse leaders in health-care systems and in regu- discipline-specific knowledge is given birth and lating organizations have been developing standards fostered in academic settings where research and ed- (Mitchell, 1998) and regulations (Damgaard & ucation move the knowledge to new realms of un- Bunkers, 1998) consistent with discipline-specific derstanding. The goal of the profession is to provide knowledge as articulated in the theories and frame- service to humankind through living the art of the works of nursing. Members of the nursing profession are re- ment that will fortify the identity of nursing as a sponsible for regulating the standards of practice discipline with its own body of knowledge—one and education based on disciplinary knowledge that that specifies the service that society can expect from reflects safe health service to society in all settings. The totality paradigm frameworks and Human Becoming language is unique to nursing. Nurses living the beliefs of this nine concepts written in verbal form with “ing” paradigm are concerned with participation of per- endings to make clear the importance of the ongo- sons in health-care decisions but have specific ing process of change as basic to human-universe regimes and goals to bring about change for the emergence. Nurses living the simultaneity unitary beings, as specified in the ontology, pre- paradigm beliefs hold people’s perspectives of their cludes any use of terms such as physiological, bio- health situations and their desires to be primary. Human Becoming, a school of thought named such The assumptions of the human becoming school of because it encompasses on ontology, epistemology, thought are written at the philosophical level of and methodologies, emanates from the simultane- discourse (Parse, 1998a). When the term (Rogers, 1992) and from existential phenomeno- “mankind” was replaced with “male gender” in the logical thought (Parse, 1981, 1992, 1994a, 1995, dictionary definition of “man,” the name of the 1997a, 1998a). In the assumptions, the author sets theory was changed to “human becoming” (Parse, forth the view that unitary humans, in mutual 1992). With process with the universe, are cocreating a unique the 1998 publication of The Human Becoming becoming. The mutual process is the all-at- School of Thought, Parse expanded the original onceness of living freely chosen meanings that arise work to include descriptions of three research with multidimensional experiences. The chosen methodologies and a unique practice methodology, meanings are the value priorities cocreated in tran- thus classifying the science of Human Becoming as scending with the possibles in unitary emergence a school of thought (Parse, 1997c). The principles and the assumptions of the human Human Becoming is a basic human science that becoming school of thought make up the ontology. The principles of human becoming, which describe the central phenomenon of nursing (the human- Human Becoming is a basic human science universe-health process), arise from the three that has cocreated human experiences as major themes of the assumptions: meaning, rhyth- its central focus. The ontology—that is, the assumptions and explicates fundamental paradoxes of human be- principles—sets forth beliefs that are clearly differ- coming (Parse, 1998a, p. Discipline-specific knowledge is articulated in Paradoxes are not opposites or problems to be unique language specifying a position on the phe- solved but, rather, are ways humans live their cho- nomenon of concern for each discipline. The principles are the author explicates the idea that humans con- referred to as the Human Becoming Theory. The struct personal realities with unique choosings concepts, with the paradoxes, describe the human- from multidimensional realms of the universe. This ontological base gives Reality, the meaning given to the situation, is the rise to the epistemology and methodologies of individual human’s ever-changing seamless sym- Human Becoming. Consistent with the Human Becoming symphony is the unique story of the human as mys- School of Thought, the focus of inquiry is on tery emerging with the explicit–tacit knowings of humanly lived experiences. The second principle (Parse, 1981, 1998a) de- Sciencing Human Becoming is the process of com- scribes the rhythmical patterns of relating human ing to know; it is an ongoing inquiry to discover with universe. Not all is explicitly methods; two are basic research methods and the known or can be told in the unfolding mystery of other is an applied research method (Parse, 1998a, human becoming. The methods flow from the on- opportunities-restrictions present in all choosings tology of the school of thought. There are oppor- methods are the Parse Method (Parse, 1987, 1990, tunities and restrictions no matter what the choice. It is coming together two methods is to advance the science of Human and moving apart, and there is closeness in the sep- Becoming by studying lived experiences from par- aration and distance in the closeness. The phenomena for study changing; that is, moving beyond with the possibil- with the Parse Method are universal lived experi- ities, which are their intended hopes and dreams. Written texts from any lit- resist with powering in creating new ways of living erary source or any art form may be the subject of the conformity-nonconformity and certainty- research with the Human Becoming Hermeneutic uncertainty of originating, while shedding light on Method. The researcher in affirming being in light of nonbeing” (Parse, 1998a, the Parse Method is truly present as the participant p. The being-nonbeing rhythm is all-at-once moves through an unstructured discussion about living the ever-changing now moment as it melts the lived experience under study. Humans, in originating, seek to the Human Becoming Hermeneutic Method is conform–not conform; that is, to be like others and truly present to the emerging possibilities in the unique all-at-once, while living the ambiguity of horizon of meaning arising in dialogue with texts the certainty-uncertainty embedded in all change. True presence is an intense attentive- The changing diversity arises with transforming the ness to unfolding essences and emergent meanings.

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Chapter 7: It’s Skin Deep: The Integumentary System 121 Hair pigment (which is melanin buy cefpodoxime 100 mg lowest price bacteria gumball, just as in the skin) is produced by melanocytes in the follicle and transferred to the hair’s cortex and medulla cells discount cefpodoxime 200 mg mastercard bacteria 3 shapes. Three types of melanin — black cefpodoxime 200mg overnight delivery xifaxan antibiotic ibs, brown, and yellow — combine in different quantities for each individual to pro- duce different hair colors ranging from light blonde to black. Gray and white hairs grow in when melanin levels decrease and air pockets form where the pigment used to be. Hair becomes oily over time thanks to sebum, a mixture of cholesterol, fats, and other substances secreted from a sebaceous (or holocrine) gland found next to each follicle. Attached to each follicle is a smooth muscle called an arrector pili (literally “raised hair”) that both applies pressure to the sebaceous gland and straight- ens the hair shaft, depressing the skin in a pattern called goose bumps or goose pimples. Each hair is made up of three concentric layers of keratinized cells: A central core, called the medulla, consists of large cells containing eleidin that are separated by air spaces; in fine hair, the medulla may be small or entirely absent. A cortex surrounding the medulla forms the major part of the hair shaft with sev- eral layers of flattened cells. The cortex also has elongated pigment-bearing cells in dark hair and air pockets in white hair. The outermost cuticle is a single layer of overlapping cells with the free end pointing upward. The cuticle strengthens and compacts the inner layers, but abrasion tends to wear away the end of the shaft, exposing the medulla and cortex in a pattern known as split ends. Nailing the fingers and toes Human nails (which actually are vestigial claws) have three parts: a root bed at the nail base, a body that’s attached to the fingertip, and a free edge that grows beyond the end of the finger or toe. Heavily cornified tissue forms the nails from modified strata corneum and lucidum. A narrow fold of the stratum corneum turns back to form the eponychium, or cuticle. At the base of the nail, partially tucked under the cuticle, the strata thicken to form a whitish area called the lunula (literally “little moon”) that can be seen through the nail. Beneath the lunula is the nail matrix, a region of thickened strata where mitosis pushes previously formed cornified cells forward, making the nail grow. Under the free edge of the nail, the stratum corneum thickens to form the hypony- chium. Nails are pinkish in color because of hemoglobin in the underlying capillaries, which are visible through the translucent cells of the nail. Nails function as an aid to grasping, as a tool for manipulating small objects, and as protection against trauma to the ends of fingers and toes. Sweating the details Humans perspire over nearly every inch of skin, but anyone with sweaty palms or smelly feet can attest to the fact that sweat glands are most numerous in the palms and soles, with the forehead running a close third. Both are coiled tubules embedded in the dermis or subcutaneous layer composed of simple columnar cells. Eccrine glands are distributed widely over the body — an average adult has roughly 3 million of them — and produce the watery, salty secretion you know as sweat. The sympathetic division of the autonomic nervous system controls when and how much perspiration is secreted depending on how hot the body becomes. About 99 percent of eccrine-type sweat is water, but the remaining 1 percent is a mixture of sodium chlo- ride and other salts, uric acid, urea, amino acids, ammonia, sugar, lactic acid, and ascorbic acid. Apocrine sweat glands are located primarily in armpits (known as the axillary region) and the groin area. Usually associated with hair follicles, they produce a white, cloudy secretion that contains organic matter. Although apocrine-type sweat contains the same basic components as eccrine sweat and also is odorless when first secreted, bac- teria quickly begin to break down its additional fatty acids and proteins — explaining the post-exercise underarm stench. In addition to exercise, sexual and other emotional stimuli can cause contraction of cells around these glands, releasing sweat. Getting an earful The occasionally troublesome yellowish substance known as earwax is secreted in the outer part of the ear canal from modified sudoriferous glands called ceruminous glands (the Latin word cera means “wax”). Lying within the subcutaneous layer of the ear canal, these glands have ducts that either open directly into the ear canal or empty into the ducts of nearby sebaceous glands. Working with ear hairs, cerumen traps any foreign particles before they reach the eardrum. As the cerumen dries, it flakes and falls from the ear, carrying particles out of the ear canal. The muscle that straightens a hair and puts pressure on a gland causing it to secrete is the a. The bulb of the follicle of a hair contains epithelial cells (germinating cells) that are continu- ous with the a. This gland contains true sweat, fatty acids, and proteins, and acquires an unpleasant odor when bacteria breaks down the organic molecules it secretes. The gland that secretes an oily mixture of cholesterol, fats, and other substances into hair fol- licles to keep hair and skin soft, pliable, and waterproof is the a. Eccrine gland Chapter 7: It’s Skin Deep: The Integumentary System 125 Answers to Questions on the Skin The following are answers to the practice questions presented in this chapter.