Soar Throat And Bumpy Lips

PROTECTED AREA WHOSE

The ministry of environment in the process of country's land that will determine the best use of water, soil and subsoil. To do this the manager to regional governments to make air boundaries, which has generated controversy in some sectors such as mining production and gained the support of the agricultural sector.

is to determine the use of land according to its potential and limitations. For two years it has instructed regional governments and municipalities to determine the Ecological Economic Zoning (EEZ), which is the location of all activities and resources that have the territories, the first step towards the land. are four regions that already have lists their EEZ: Cusco, San Martin, Amazonas and Madre de Dios.

the land will be used to give sustainability to our soil, an area that should be appropriately exploited.

An Opening Prayer To Begin A Program

Another curious point of view of this original structure, as seen here before, four tickets behind.

Short Skirt No Nickers

contrapicado angihumanist

After hearing about the style of Lomography I decided to try this image somewhat bland but all usable I've shot this morning, and give some of that special air. High contrast, saturation much, much vignetting, long grain and, in principle, that should be enough to take the hit, because the real Lomography is done with film cameras with certain specific characteristics and I think if the film is expired, even better.

Clear Blister On Inside Lip Of Mouth

BLOOD PRESSURE

Blood pressure is the pressure exerted by blood against artery walls.

depends on the following factors: systolic Debit
(volume of left ventricular ejection)
distensibility of the aorta and major arteries .
peripheral vascular resistance, particularly at the arteriolar, which is controlled by the autonomic nervous system.
blood volume (volume of blood within the arterial system).

is distinguished systolic pressure and a diastolic.

Systolic pressure is the maximum pressure is reached in the systole. This depends mainly on the debit systolic blood volume and distensibility of the aorta and major arteries.

Diastolic pressure is the minimum pressure of blood against the arteries occurs during diastole. Depends mainly on the peripheral vascular resistance.
Pulse pressure is the difference between systolic and diastolic pressure.
Blood pressure changes in individuals over 24 hours. Factors influencing the emotions, physical activity, the presence of pain, stimulants such as coffee, snuff, some drugs, etc.

blood pressure measurement.

is usually done with a sphygmomanometer. The most commonly used with mercury and aneroid type. They consist of a system to put pressure around the arm and a scale to find out the pressure.
mercury sphygmomanometers are more reliable calibration. The aneroid, which record the pressure in a clock, are lighter and easier to carry, but over time can mis.
blood pressure should be measured in the arm, with the patient sitting or lying position, comfortable and relaxed. Must have rested for 5 minutes and not having drunk coffee or smoking in the previous 30 minutes. Usually the measurement is made at the end of the examination, at which time the patient should be more relaxed. If you suspect a difference in the measurement of both sides should take the measurement in both arms (eg vasculitis or atherosclerosis of large arteries). Faced with the possibility of orthostatic (low pressure when the person to be standing), the measurement must be performed with the patient lying to standing (or sitting with feet hanging). In some cases, is useful to measure the pressure at the upper extremities as in the lower. Normally the pressure in the legs is a little more than arms, but pictures of coarctation of the aorta or in very advanced atherosclerosis, the pressure is lower in the legs. The cuff is applied in the middle of the arm (the lower edge is about 2 to 3 cm above the cubital crease.) Should be well implemented and not loose (because the latter would favor falsely elevated readings.) The arm should be bare, without clothes interfere with the placement of the cuff. It is desirable that the arm is resting on a table or hanging relaxed at sides. The rubber bag should be located so that just half of it is over the brachial artery. Also, the cuff should be at heart level. If located below, are recorded falsely elevated pressures (these errors occur more frequently when using compressed digital gauges the wrist and not care is that the cuff is at heart level during measurement). Systolic pressure (by the palpatory method): You inflate the cuff while palpating the radial pulse. The disappearance of the pulse, inflate a bit more and after deflating the cuff slowly. The pressure it turns again to feel the pulse corresponds to the systolic pressure (by palpatory method).
This is a good method to locate at what level is the systolic pressure, without having to inflate the cuff more than necessary. Register
Blood Pressure: Snack
cuff systolic pressure (by the auscultatory method): the cuff is inflated again, but this time the capsule is placed the stethoscope in the crease of the forearm, about where the pulse is palpable brachii. Inflates the cuff to just above the systolic pressure obtained by the palpation method and then slowly deflated. The pressure is starting to hear a noise related to the beating of the heart corresponds to the systolic pressure determined by the method auscultatorio.
Tanto el registro obtenido por el método palpatorio como por el auscultatorio deben ser parecidos. De no ser así, se registra como presión sistólica, el valor más elevado.
Presión diastólica: Después de identificar la presión sistólica auscultatoria, se sigue desinflando el manguito hasta que desaparecen los ruidos. Este momento corresponde a la presión diastólica. En ocasiones, primero los ruidos se atenúan y luego desaparecen. En general se considera como la presión diastólica el momento en que los ruidos desaparecen. Si ocurre que los ruidos se atenúan, pero nunca se dejan de escuchar, incluso con el manguito desinflado, la presión diastólica corresponde the time when the noise is attenuated. Registered sometimes leave both times: when attenuate noise and when they disappear.
Blood pressure is expressed as the systolic and diastolic. For example, a pressure of 120/80 mm Hg, mean systolic pressure of 120 mm Hg and diastolic 80 mm Hg. In addition to numerical register, you must specify where in the body pressure was taken and in what position was the patient. A record of 120/80/70 mm Hg mean of 80 mm Hg noise is attenuated and at 70 mm Hg were allowed to listen, the latter being the diastolic pressure value. Hole
auscultatory Korotkoff.
pressure when taken with the auscultatory method may be that after having heard the first noise pulse (systolic pressure), presents a silent phase noise and then come back and finally decrease and disappear completely (diastolic pressure). This period of silence is called Korotkoff auscultatory hole. The existence of this phenomenon makes it advisable to have determined systolic pressure first palpatory method, as it may happen that if you only used the auscultatory method and not enough up the cuff pressure, can be taken as the systolic time comes then auscultatory Korotkoff hole and have missed the true systolic pressure.
If pressure is measured directly with the auscultatory method, without first making palpation procedure could occur:
that the cuff is inflated more than necessary with the consequent discomfort for the patient to register
bad systolic pressure in the case that was not sufficiently inflated cuff
and had fallen into the hole auscultatory Korotkoff. Notwithstanding the foregoing, especially in people who quite possibly have normal blood pressure may be sufficient to make only the auscultatory method and rest assured if the identification of noise is clear.
Relationship between cuff size and arm.

must have a proper relationship between cuff size and arm (or segment of the limb where registration is taking place). Therefore, in obese people should use a larger cuff (if not, be registered falsely elevated pressures). Similarly, in children should have smaller sleeves.
Normal values \u200b\u200bof blood pressure: Systolic
: between 90 and 139 mm Hg (ideally have a systolic pressure did not exceed 120 mm Hg, or, at most, the 130 mm Hg). Diastolic pressure: 60 to 89mm Hg (ideally have a diastolic pressure below 90 mm Hg).
is considered that a patient is beginning to be hypertensive when their record is equal to or greater than 140/90 mm Hg. Some people, especially young women, have pressures that are normally low (100/60 mm Hg or less). In other situations, low pressure is an expression of shock or circulatory collapse, but in these cases, there are signs of poor tissue perfusion (impaired consciousness, cold extremities, low diuresis).
When there is a marked arrhythmia, such as atrial fibrillation the determination of blood pressure is a little harder. In these cases, it should slowly deflate the cuff and, if necessary, repeat the measurement to see how consistent are the results obtained. In atrial fibrillation, automatic digital gauges can record values \u200b\u200bwrong.
Glossary: \u200b\u200b

pulse pressure, systolic pressure palpation, systolic auscultatory, auscultatory Korotkoff hole.
Questions: How should
pressure cuff according to the characteristics of the patient's arm?
How is the systolic pressure and diastolic pressure?
Why should take palpatory systolic pressure before the auscultatory method do?
When can consider that a person has hypertension?

M Graham Alkyd Walnut Medium

BLOOD PRESSURE HEALTH TEAM - WORKING WITH QUALITY IN PRACTICE

HEALTH TEAM

I - DEFINITION:

Pritchard: define the team as a group of people performing different tasks contribute to the achievement of an objective and común.Davis Newstrom: define the task force as a small group whose members work together and are in contact and engaged in a coordinated, responsible and enthusiastically responding Polliack tarea.Para to as organizational model that is, the team can be considered as a working system that allows several people from different professions and skills to coordinate their activities, in which everyone contributes their knowledge to achieve común.Bajo purpose this perspective, a team must fulfill the basic principles of organizational theory, namely: Because each team member has different skills, there should be no duplication of funciones.Un member can not replace other so it is expected that each plays its role corresponda.La need for coordination requires the existence of adequate channels of communication that favors work eficiente.Como whole and each member must contribute their expertise, presumably also assume its responsibility and address the aspects of their area.The essential that all team members agree on common objectives and agree, as a group responsibility to achieve these overall equipment objetivos.La must be greater than the sum of its componentes.Finalmente, the team is not a goal in itself but a means to achieve the objectives propuesto.Hemos past, therefore, the team concept to describe the conditions that must be met for the work done by a group of people is truly a team effort, I might add that there is no hierarchical functioning of the equipment, should be the absence of a specific professional domain. This involves the recognition at an equal level of technical competence of all team members and that the actions of each are driven by them and not by orders of another, for a team or group to be efficient, members of the same should have a supportive environment, clarity of roles, goals and appropriate superior leadership, supportive environment based on organizational climate, trust and support that its members have had the opportunity to know and understand the roles and functions those with whom there are higher goals trabajando.La help keep the teams more focused, to unify efforts and promote group cohesion, team members need time to meet, but then is customary to close the new ways of analyzing problems as they is isolated from its environment. To prevent this deadlock, it may be convenient entry of new members as well as a careful combination of leadership with the new environment creado.Para De la Revilla, is summarized in four main characteristics that define a good operation of any group organization: A good interpersonal skills.

The correct classification of professional roles; The existence common goals and their relationship, knowledge of the functions themselves and others; Finally, good communication between members of equipo.Las formula of teamwork with a range of advantages both for the professionals of the same , and for users of the system salud.El ill get better care, reduce the prevalence of diseases in the community, encourages education for health in a coordinated way and provides greater job satisfaction for team members; The care provided by the team is greater than the sum of the individual care of their members to address the challenges both from many causes, but keeping unity of action for resolution; unifies concepts and techniques, and avoid contradictions between the various professionals, prevents duplication of effort, making profitable use of both local and materials, and even professionals themselves, it allows to cohesion health programs in its different facets, achieving greater efficiency thereof; The joint work with other professionals in the same discipline allows the exchange of knowledge and action guidelines and keep up more easily work with other types of professionals (nurses, social workers, health personnel, etc.) provides a perspective very different, making the biopsychosocial approach and allowing the team to perform all the functions intrinsic to primary care: promotion, prevention, care and rehabilitation of the population adscrita.Es obvious that in the reality of each day the teams do not always work as a coordinated and teamwork has all the features that have been described, in addition, it would be naive to assume that several people with different professional backgrounds and interests can work together without friction.

TEAMWORK CHALLENGES-

limited experience Lack of incentives, too rigid in some members, lack of interest- Difficulty in management control in times of study and research

II - HEALTH TEAM

The Royal College of General Pratitioners, in 1970, to make an assessment of current status and future needs of general practice, and was pronounced as follows: the concept of integrated community care, family-oriented, requires a multidisciplinary approach and involves communication and cooperation between various health professionals within a framework of allowing work to focus on total health needs of the patient. Within this context, these needs can not be satisfied by a doctor working in isolation, but require the formation of a Primary Care Team, whose members provide each one a different perspective on knowledge, attitudes and habilidades.El health team is defined by WHO in 1973 as a non-hierarchical association of people with different professional disciplines, but with a common goal is to provide in any field to patients and families the most comprehensive health care posible.De the Revilla based on the definition of team Pritchard, the team defines health as a group of health professionals and non health professionals involved in various activities aimed at achieving an elevation health community that is affected.

team composition PRIMARY (EAP)

The composition of an EAP is to suit the specific community it serves. Therefore there are no universal models that allow us to define a composition which is valid for all computers and circunstancias.Los factors that influence the composition of the EAP are summarized in Table 1, taken from Martin Zurro and we have added the field ( urban or rural) where the center sits 1Factores saludTabla influencing the composition of primary care teams. Political and economic situation country .. Existing health infrastructure .. Health problems and needs .. Availability of health and non health professionals .. Professional structure .. General Organization of the country's health system .. Functions assigned to EPA professionals .. Urban or rural area where it will be at the health center.

Source: Martin Zurro

equipment operating PRIMARY

have a clear role and priority over others and that there is another to promote qualitative changes in attitudes and habits of the population all fields that have a direct or indirect relationship to health.

Composition

Primary Care Team

basic EAP Core Family Physicians and pediatras.Enfermeras / os and nursing assistants. Workers

sociales.Personal especializadoTécnicos support administrativo.Celadores.Elementos radiology / radiologists.

laboratory technicians.

Odontólogos.ginecólogos consultants.

Midwives.

mental health team. Technical

public health.

Pharmacists. Veterinary

.

Source: Zurro Zurro Martín Martín et al.

distinguish, as the composition of the EAP is concerned, between the core and specialty items to support EAP equipo.El basic core is formed by those professionals necessary for the performance of its functions, such as doctors, nurses and social workers. The other professional, technical and non-health care, which can integrate into it, act as elements of infrastructure or specialized support, such is the case for specialists in Public Health and Community Medicine, as well as the dental, holistic health , obstetrics and gynecology, laboratory, radiology, pharmacy and veterinary medicine, etc..


Making health diagnosis community.

direct care functions:

_ Health Promotion.

_Prevención of the disease.

_Asistencia or curative.

_Rehabilitación.

salud.Funciones _Educación for this database.

_Docencia and research.

_Administrativa.

_Organización and management.

_Coordinación with other levels of care.

Source: Martin Zurro, as amended

distinguish, therefore, the following functions to fulfill the primary care teams:

1 - HEALTH PROMOTION Ideally it should be the first important function, but in practice this is not always the case, may be common, for example, that the implementation of a health center, by faulty planning, EAP is a large mass that forces you to care arise, assistance and role. It is obvious that the activities of health promotion should be developed both in the population enferma.Sus sound as the instruments are adequate healthcare, environmental performance and promoting community participation in solving health problems.

2 - DISEASE PREVENTION: The activities related to this function is aimed at specific problems and methodology for each of them, unlike the role of health promotion is more general and nonspecific. Examples: program of childhood immunizations, influenza vaccination campaign to control risk groups and healthy child.

3 - ATTENDANCE: The role care or EAP Healing is for those users who, given the deterioration of his health, decided to sue the health services. It aims to detect and treat disease, as well as track this enfermo.La assistance will be a primary function of physicians and nurses of CAS and will be held both on an outpatient (clinic) and home .}

4 - REHABILITATION: This function is completed the range that defines integrated care: promotion, prevention, care and rehabilitation. It is aimed at that group of people after an illness has been a loss or reduction of their physical, psychological or social.

5 - EDUCATION for HEALTH:

must always be present in all health activities, with the purpose of acquiring knowledge, developing healthy habits by the population, changing habits and negative attitudes to health, promoting ongoing, conscious and responsible people in solving their problems salud.Existen also other functions to be developed by the EAP, and that some authors grouped as the support functions or complementary. Among them include the siguientes.Docencia and investigación.Formación gestión.Coordinación continuada.Administrativas.Organización and with other levels of the network relationship salud.La sanitaria.Diagnóstico of diagnosis of the health of the community is an activity prior to any other. Its purpose is to know what are the specific health problems of the community, which involves measuring the health status of our population and the study of the factors that determine the level of health. The information obtained will allow to raise consistent targets to improve health status while that offers some valuable tools to assess progress in achieving such objetivos.Él doctor as a member health care team must fully understand that working together means having common goals, to accept the agreed standards of operation and sharing of roles and tasks, acknowledged in an equal level technical skills of other team members, since their contribution should be beneficial for achieving the above objectives the team.

WHY TEAMWORK?

is assumed that the professional groups most involved in providing health services are those who communicate more closely and effectively. In fact, many times that communication existe.Por other hand, multidimensional challenges social and health affects adolescents and reduction of human affection (chronic diseases, accidents, alcoholism, etc..) are not problems that can be managed by primary care professionals in health well-intentioned, not even for institutions high complexity health disciplinario.La experience working in isolation of medical schools, as well as other professions, is obsolete for this: the health professionals generally lack an essential preparation for work as a team. However, health services require increased collaboration with experts from various disciplines working together, sharing information, knowledge and skills, so these interdisciplinary skills are important as m {nunca.Sin however, few professionals, health care or social service agencies that are prepared to work effectively and use appropriate resources to provide services necessary, comprehensive and integrated, to provide quality care to these patients.

Nomenclature ·

collaboration between disciplines can be done in multiple ways. Interdisciplinary teamwork is just one of these modes: conscious in a group of people have different abilities that depend on each other to function efficiently, to achieve common goals and objectives.

In the primary health care ATS this translates into a group of people who contribute skills, talents and diverse skills in a coordinated manner, and depend on each other to work efficiently to achieve a common goal in caring health. These targets determine and justify the very existence of the team.

INTERACTION BETWEEN DISCIPLINES

Elichiry emphasizes that the problems are not disciplinary boundaries, the rigid disciplinary boundaries are fixed and unproductive. Multidisciplinary and Interdisciplinary terms are often used synonymously in the description of collaborative efforts. But these concepts are not interchangeable and the distinction is crucial. Multidisciplinary work is comparable to a web formed with patches or patches, while the interdisciplinary would be a seamless garment, or in chemical terms, is the difference between a body and a compuesto.El school curriculum tends to fragment knowledge isolated and compartmentalized disciplines, and more particularly to excessive specialization that prevents understanding of the plurality and complexity of the multidisciplinary approach realidad.En each discipline individual is engaged in his specialty area without any need to coordinate efforts with other disciplines, nor any evidence of modifications or changes in it. The work can be done by individuals from different disciplines, working separately, not necessarily in the same place you, or with more trade outside a referral or interconsultation. The results can be integrated by someone other than mismos.Por professionals across the interdisciplinary approach is the result of social demand, faced with increasingly complex problems and the internal evolution of the basic ciencias.La Interdisciplinary collaboration is guided by the problem and performs level of convergence problems. Recognizing the potential to ease the integration and production of knowledge, it is important that the problem itself, not the individual disciplines, contribute to the starting point.

JOINT INTERDISCIPLINARY:

Each discipline is important in its function as specified and individuality, and more interdisciplinary creates a link that leads to processing and cross-fertilization that determines a whole early mayor.Los joint based on joint correspondence, at intersections and links between disciplines, particularly on interdependence. All this enables the exchange of instruments, procedures or techniques, and facilitates the cremation of shared conceptual frameworks. The border issue or point of contact between two disciplines is not mentioned that interdisciplinary interdisciplinaridad.Elichiry achieved its best when participants are experts in their respective disciplines, affirmed in their identity and disciplinary specificity. "The system works if each of the disciplines performing its role individually but not independently. This integration, together with the creation of a new conceptual framework common to all disciplines, transdisciplinary ORIENTATION allows

BASIC DIMENSIONS

1. Interaction : Based on the development of cooperative behaviors and attitudes.

2. Recurrent Cooperation (iterative): requires "continuity of cooperation between disciplines."

3. Intentionality The relationship between the disciplines are brought.

4. Flexibility: Avoid dogmatic attitudes, allowing the exploration and use of models, working methods, new techniques. Explore their differences through dialogue.

5. Reciprocity and diversity: determined by the interactions between disciplines, sharing and / or modifying methods, conceptualizations, etc..

6. Institutional insertion / environment

7. Participation of members and other participants

The aspects of this joint interdisciplinary highlight the need for continuity, interdependence, flexibility to make the most of the participants.

This conceptualization makes clear that casual contact does not constitute or free basic integrative approaches interdisciplina.Los contributions different disciplines include various mechanisms such as.

a) The common group learning: the group shares the global understanding, exchange components or methodologies and produces a bump or a single product.

b) The modeling: there is an explicit model that links the various contributions.

c) Negotiation: Between experts or members whose responsibilities intersect efforts, discuss their work in detail but retain their unique expertise and

d) The integration of the leader: that is completely in charge of integration, what appears to be the least effective.

INTERDISCIPLINARY TEAM - LIFESPAN

EtapaCaracterísticasTarea of \u200b\u200bMiembrosTarea of \u200b\u200bEquipoResultados1. Orientation (position on the institution and circumstances) Definition of the situation. Exploration. Aprendizaje.Entender expectations and relate with each other. Addressing the lack of familiarity, anxiety, lack of confidence, estrés.Definir limits. Provide apoyo.Conocer colleagues. Understand the system. Top of confidence. Top of participation and identification.

2. Accommodation (adaptation and arrangements leading to a unit) handling. Moving and changing positions. Power struggles. Rearrangement todo.Hallar parties and an appropriate place for you, both personally and profesionalmente.Proporcionar structure and environment for maximum freedom. Facilitate the process of language and communication adaptación.Desarrollar common. Develop values \u200b\u200band norms. Affiliation with team development.

3. Bargaining (transaction and concluded by mutual agreement) Bargaining and conclusion. Setting limits and content of expertise in relation to other especializaciones.Usarse himself as a team member able to communicate, defer, to compare, using colaboración.Definir conflict and limits of purposes and expertise. Establish contracts. Designate targets, tasks, roles.Establecer dependence and differentiation. Development unit. Completion of work arrangements.

4. Operation (action purposes) gestalt.Relacionarse Achieving complementarity with the team and its members. Using knowledge and expertise. Scope of individual decisions. Relationship of balance and vitality tareas.Mantenimiento of internal and external. Decision making, planning and execution of trabajo.Aumentar collaboration towards the achievement of goals and implementation of propósitos.5. Solution (component separation) Evolution of the process, problems, opportunities and achievements in relation to the purpose and objective metas.Evaluación individual performance and equipo.Apoyo open and critical assessment and review of personnel and equipment resultados.Cambio. Awareness of success / failure and appropriate use of such información.Deben address the problems created by the need to coordinate their work: · need to set goals · You need to make plans · You need to join · You need to talk "to accomplish the work, it requires efforts combination of two or more people?

you are a team not a team Uds.son IF NOT

Do We Need Training? miembrosdel is important that the team raised the need for training in teamwork.
Training areas include: Leadership
:

Setting goals and objectives

Troubleshooting:

decision-making process

Conflict management and dispute

clarification and negotiation

roles

Communication skills

then discusses some of the topics to be developed further in the training sessions using specific exercises for each

LEADERSHIP:

Leadership is defined by the tasks and functions required by the team. Stimulation of the responsibility and authority of team members is essential for career development and job satisfaction, and contributes to enriching the experience of teamwork. Effective teams are headless, but show many "acts of leadership" by its members, and is characterized by shared leadership in which the computer's role is determined by the tarea.El leadership must be understood and practiced by all team members as a temporary, dynamic. Changes as it changes the predominant care needs. The focus should be the patient, not the individual disciplines, the academic degrees to the administrative hierarchy.

PROBLEM RESOLUTION PROCESS

Stage Critical Roles

Locks

1.DEFINITIONS the problem:

ClarificaciónResumen

abstraction PruebaUso

unclear

Goals broad generalizations

problem Census

Role playing

Problem Formulation

2. Collection

information

Inquiry data

Survey

Posted timetest necessary

Letard

premature decisions

baseless

Options

investigatory teams

Person / Member resource

Special Subcomitpes

3. Identification of alternative solutions

Tips: Getting

data

Customizing ideas

arguments or fights Brainstorming

Role playing

4. Alternative test.

Posted experienciaPrácticaRealidad pruebaRealidadesClarificaciónSugerenciasArmonizaciónFalta of practice

5. Determination of the action (s) and responsibilities

This may manifest as lack of clarity or information required for the development of intra-group communication problems (critical climate, competitive) premature closure of the section or implementation strategies, lack of proper motivation, lack skills for investigation and resolution of problemas.La decision making includes the following steps:

1. Assessing the problem (which is defining the problem);

2. Analysis (explore alternatives for action);

3. Selection (choosing the "best" alternative);

4. Action (implementation of the solution deciding who does what, then do it);

5. Re-evaluation (ensuring that the solution is implemented, and assess whether it is effective). The screening of the decision important to define exactly: • What is the the team tries to decide and at what stage of the resolution of the problem is. This requires defining for each stage: · Who should attend · How to participate? (Directly, is consulted, it is reported), and • When to do it. • Finally, it is necessary to identify who will be responsible for ensuring that tasks are performed.

main factors that can block the decision-making and the quality of these are:

1. Lack of clarity in defining the problem and / or designation of responsibilities.

2. Myopia (see the first alternative as the only possible).

3. Hasty decisions.

4. Decisions without rationale or adequate data.

5. Lack of commitment to action.

6. Allocation of responsibility for decision-making in very high levels in the organization.

7. Allowing a person in a position of power / authority to express their opinions or positions in very early stages of decision-making process.

8. Inability to experiment with alternative solutions. Fear of failure.

9. Confusion between generating ideas with the task of examining ideas.

10. Size inadequate decisiones.El group taking the process of negotiating roles can be triggered by a "feeling" or "uneasiness" that indicates the existence of a problem in this area.

The model consists of five phases:

1. list of role expectations (producing the most valid, sharing mutual expectations, exchanging "messages roles");

2. identify conflicts and ambiguity in roles, expectations analyzing and identifying problems - ambiguity and conflict;

3. production solutions alternatives and negotiation (give and take to find the "best" alternative: a realistic solution accepted by all);

4. implementation of a contract roles (developing a "contract" between the participants stating the expectations agreed by them, including a commitment to evaluate its usefulness in a given date, and review the contract if warranted) and

5. renegotiation if necessary.

CONCLUSIONS:

work in interdisciplinary teams of health should be considered as a form within a range of collaborative practices. Important to recognize the benefits that this method provides not only patients but also to team members. Periodically, the team should focus not only on specific tasks, but also devote time and effort to ask "How are we working together?" And "What areas need training to improve our effectiveness?"



REFERENCES: · De la Revilla L. The family doctor's office, the organization in daily practice. Ed Jarpyo, Madrid, 1992: 91-100. · Martin Suresh A, Palet Ferrero x, Sola Bas C. The Primary Care Team. In Martin Zurro A and Cano JE Pérez Primary Care Manual, 2nd ed. Ed Doyma, Barcelona, \u200b\u200b1989: 29-39. · EDISA: UBA. Kellogg Foundation. Distance Education

Canada;s Food Guide Game

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY EMERGENCY IN PRACTICE:
Introduction:
The intent of this writing, is not to create a new manual rather not clarify whether those concepts to my students mainly emergency leave their practices and are pressed against the EKG reading.
how?
Therefore to truly learn electrocardiography should study the texts created for that purpose (as Punto Dubin heading, is a simple and very practical manual)

1 .- What do I do with an EKG in hand? Seeing
when done.
If there is bad art (baseline vibration, disconnection of an electrode, ...) should be repeated. Always follow a systematic
for interpretation.
At the head of the EKG should include the patient's name and date and time of completion and whether or not symptoms.
not hesitate to consult.
not write to the measure on the path electrocardiográfico.Ni marking pencil. The electrocardiogram generalmemte

edit the EKG in the following format:
I aVR V1 V4II aVL aVF V3 V6 V2 V5III rhythm strip (II)
EKG's role should be "run" at a speed of 25 mm / s, with a look to see when we see changes in HR that "we do not add up."
The paper is separated by "squares" smaller than 1 mm each and every 5 mm, there is a thicker line.
The distance between each line is 5 mm thick, and corresponds to 0.2 seconds (200msec), so that a second corresponds to 25 mm.ONDAS, COMPLEX, CLASS AND SEGMENT OF EKG first thing we do is "take a look "them, which, while not have to llevarnosmucho time we begin to focus on the pathological that could have EKG before us.
2.-There
P wave? Atrial contraction.
3.-There
QRS complex? Ventricular contraction.
4.-There
T wave? Ventricular repolarization.

PR interval (from the beginning of the p to the beginning of the QRS). Should be 0.2 sec: first degree AV block (see if you take drugs that lower conducciónpor NAV). If 0.12 sg: QRSancho. Check

is sinus rhythm (or SV): Bundle branch block.
Go to V1.
If QS: BRI.
If R: BRD. Important

see previous EKG (pre-BR) and BR assess frequency-dependent aberrancy (Sonbre displayed at high frequencies, and frequencies disappear "low").

If tachycardia or bradycardia and QRS width, see section bradicardias.El QRS tachycardia and in which we look at is the QRS of the derivation in which more ancho.QT: Since the beginning of QRS to the end of the T (U?). Should be 500 msec, risk of torsade de pointes, especially if bradicardia.El QT in which we look at is the QT of the derivation in which the longest.

WHERE DO I START?

1. heart rate (ventricular rate): Go to strip ritmo.Contar the number of QRS complexes of all rhythm strip and multiply by FC seis.Si regular, you can see the distance between two adjacent complexes, if 5 mm: FC300 bpm, if 10 mm: HR 150 bpm, if 15 mm: HR 100 bpm, if 20 mm FC 75 bpm if 25mm: FC 60 lpm, if 30 mm FC 50 mm.Si 100 bpm tachycardia. In this case the important thing is objectively the case detaquicardia QRS QRS wide or narrow. In case of narrow QRS in mayoríade try cases supraventricular tachycardia (SVT). If we QRS width, this should get very alert, and in these first we must ask Councilof guards immediately, as may be due to ventricular tachycardia (VT). Tenemosque look if it is regular or irregular tachycardia (irregular is extremely rare if it is TV, except AF with WPW). The first thing is to know if the patient has had previous BR or not (EKG or previous reports). There are some criteria for the identification of wide QRS tachycardia, you can see in texts EKG. Anyway
with wide QRS tachycardia, we must discard urgent question of TV, yaque they can degenerate into ventricular fibrillation (VF) and death.

2. Rate:
ritmo.Observar Go to strip if the QRS are separated by the same distance from each other. Nap at the same distance is a regular ventricular rate or rhythm. If not Loest is said to be irregular or wave arrítmico.Buscar "p" (? Atrial contraction). Where better is identified ENV1 and II. Study its relation to the QRS (if regular distance atodos precedes the QRS, usually RS). The sinus
p is positive in inferior (II, III and aVF) and negative p aVR.Si not see any leads: AVB 2 or 3rd grade.
Observe what is the pacemaker of the heart: sinus node, focus (AF, Flutter, Atrial Tachycardia: TA), AV node (narrow QRS, not observaactividad handset before each QRS, can be seen waves "p" after QRS decade: p backward, which are negative in bottom). Focus
ventricular (QRS width can be observed independent atrial activity laventricular: AV dissociation or retrograde p times).

3. Shaft:
In the emergency setting has little practical value, especially in our primerasguardias. Should be calculated both in RS, such as tachycardia, because the location of ejepuede help us identify the origin of certain tachycardias (VT). To calcularlode is approx., We should only look at I and aVF. If the QRS is positive (R> S or Q) R aVF yen, it said that the axis is normal (between 0 º and 90 º). If R is positive, but negative enaVF, the axis is izdo (between - 90 º and 0 º). If R is negative (no matter how seaen aVF), the shaft will dcho (> 90 °).

4. Hypertrophy:
is important in the overall context of the EKG as well as in emergency management administration drugs, as certain drugs, especially antiarrhythmic agents, should not be administered to patients with structural heart disease, and monitoring electrocardiographic signs suggestive of hypertrophy is a relatively reliable indicator of structural heart disease.
We look at V2 and V5. If the sum of voltages V2 S plus R in V5 is 35mm, we can say that there is LV hypertrophy. Anyway, looking at high R izdas precordial (V4-V6), and / or deep enprecordiales dchas S (V1-V3), let us also think VI.5 hypertrophy.
Alterations of repolarization:
First of all we know the relationship between the leads of the EKG and cardiac anatomy, mainly VI. V1 and V2
correspond to the interventricular septum.
V2, V3 yV4 correspond to the front.
V5 and V6 lateral.
I and aVL high lateral.
II, III and aVF inferior.
We must look to the orientation of the T (positive, flat or negative) and the ST segment changes.
We should try to know if the electrocardiographic alteration is acute or chronic corresponds to something.

SCA (ACUTE CORONARY SYNDROME :

In cases of suspected acute coronary Sd, it is important to note that to observe "changes in the EKG," we have more of a patient's EKG, EKG although the first seems "normal." (Example: If a patient arrives with chest pain and EKG bland, we administer NTG SL and gives pain, we must repeat the EKG, that seemed quite normal for the first EKG). ST
Promotions: To be meaningful must be 1mm.

is important to note the location (consistent with anatomical areas), since, for example, simultaneous
ST elevation in V1 and aVL is meaningless because it does not correspond to the same anatomical area; whereas if the lift is in V5 and V6, targets an caralateral process.
also important to note whether the ST elevation is localized or generalized (in leads for various anatomic areas).
The morphology of the ST elevation is another aspect to consider. A elevaciónconvexa up is suggestive of disease, while if it is concave upward (hanging) is more suggestive of pericardial process or early repolarization (low probability of ischemic).
Of all the ways it is important to know that the morphology can "fool" as we sometimes see low elevations suggestive of ischemic sufriendoeventos in patients with coronary disease. ST
Drops: Also remember the anatomical areas. Importantly, LV overload can lead ST depression in lateral and valvular disease (stress). Q Waves

: Depending on the size of the Q wave, it will be significant or not, is usually a Q wave decirque significant when more than 1 mm wide and at least 1 / 3 "high" that the RS of the same complex. In the emergency setting, the observation of Q waves do not mean an acute phenomenon, although us towards the possibility of an ischemic patient setrate (Former AMI).
Also remember that Q waves are not only in ischemic patients, but also seen in ventricular overloads and other cardiomyopathy (HCM).
negative T waves: They are a warning sign on, as can be seen encardiopatía ischemic, reperfused myocardial infarction (open cup), unstable angina and pulmonary embolism.
To discriminate if indeed they are of acute nature, we observe "the evolution in time", since a patient with positive T and chest pain, after removing the pain, negative the T, is very suggestive of being ischemic (pseudonormalization T wave), while if these negative T waves is a casual event, and already presented in previous EKG, may be "something" chronic, which is less a matter of urgency.
However, the observation of negative T we must rule out ischemic heart disease (most often) and PET.

In patients with implanted pacemakers, the observation of negative T waves in the fasesde no ventricular stimulation, may have no pathological significance, as the most frequent question last eléctrica.Como memory "recommendation" in this section changes repolarization, it would be good to convey, we can not remain calm with a single EKG. This means that if we suspect an ischemic event (through clinical risk factors, previous episodes, ...), we should never dismiss because the ECG or EKG `s are normal, as is ischemic heart disease patients with pacemakers traicionera.En implemented, it is very difficult to assess changes in repolarization, as well as in patients with LBBB base.

As a final summary, here is a table of the aspects we look at an EKG, for this or any other order.
1. Frequently (rhythm strip).
2. Rhythm (rhythm strip).
3. Watching the PR, QRS width and morphology, and QT.
4. Axis (in I and aVF).
5. Hipretrofias (in V2 and V5).
6. Alterations of repolarization (T wave, Q wave, ST).

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