Hypercoagulation (Thick Blood) - Causes, Symptoms and medicine

Hyper coagulation has come to be a base ailment these days. Therefore it's vital to know what causes this problem. It happens due to an anomaly in the coagulation system. Such anomaly arises due to problems in the clotting factors. Blood clotting can cause serious issues. This coagulation can be caused by genetically acquired problems in clotting. This disease does not have any singular treatment, but continuous problems of this kind guarantee a long term clarification for coagulation.

The most prevalent symptoms of this ailment are pulmonary embolism (Pe) and deep vein thrombosis (Dvt). The later occurs in legs and involves a lot of pain and inflammation of the limbs. The veins of the legs valves get destroyed due to heavy blood clotting which is responsible for clotting. This clot can also shift to legs. So, when blood clotting happens in lungs, it results in paucity of breath and huge pain in the chest.

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This implies a huge risk of heart charge and chances of a stroke. Now, other clotting disorder called purpura fulminans, which happens in babies, causes the destruction of tissues and bleeding in the vital organs and skin. This kind of hypercoagulation occurs due to a lack of protein C in the child. Eventually, it prevents medicine with anti coagulant drugs like warfarin. When pregnant mothers suffer from hyper coagulation it can cause miscarriage. Other complications can also effect while pregnancy apart from miscarriage like still birth, and intrauterine increase prohibition.

Hypercoagulation (Thick Blood) - Causes, Symptoms and medicine

There are discrete reasons behind the incidence of this ailment. The most base of them is any arresting of the body movement after an accident. This can increase chances of blood clotting. So, the shortage of muscle performance can cause the movement of blood to stop in veins. So, whatever who is prohibited to bed rest after a surgery can get blood clotting.

Since the body parts can swell due to a decreased body supply, they can also function at lower levels. The furnish of blood to the brain can also decrease which causes a stroke. There are many ways to treat this disorder. The blood clots in the arteries can be removed straight through surgeries. They can also be eliminated straight through medication like activase and tenecteplase. Now, a inpatient can also get cardiac catheterization so that the blood clot is opened.

Now, when the blood clots form in the deep veins of the leg they are more perilous as compared to superficial veins, as they can be transferred to lungs. Their transfer to lungs can cause a blocked furnish of oxygen to the heart which can cause death. So, its good that such clots are treated with enoxaparin straight through injections which can right away thin the coagulated blood. Warfarin can also be given straight through pills but it takes some time for it to fetch healing levels in the body. while that time, it is given straight through injectable and oral versions so that the symptoms of the ailment are reduced.

Hypercoagulation (Thick Blood) - Causes, Symptoms and medicine

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Cure Vomiting - The Surefire Way To Cure Vomiting Fast

If you think that vomiting is a disease, you cannot be supplementary from the truth. In fact, vomiting is not a disease in itself. Vomiting is something that goes along with other diseases. In this record I will tell you how to cure vomiting fast.

Vomiting is something that needs to be treated as soon as possible, because inordinate vomiting results in loss of water and electrolytes, which causes dehydration. When you vomit, all the undigested or semi-digested gift in your stomach are forcefully expelled out through the mouth. Persisting vomiting can make your body weak and you may suffer from varied separate illnesses. So, what is it that causes vomiting?

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Like I said before, there are any separate causes behind vomiting. There are medicines out there which cause vomiting as a side-effect. Particularly the medicines that are prescribed for cancer patients are notorious for causing vomiting and nausea. Alcohol can also cause vomiting. Note that when you drink alcohol, you may not vomit immediately. In fact, if you drink alcohol at night, the vomiting will start in the morning. This vomiting is known as 'hangover'. Similarly, vomiting can also occur during pregnancy. Vomiting normally occurs during the first few months of pregnancy but for some women vomiting may continue well for a longer time.

Cure Vomiting - The Surefire Way To Cure Vomiting Fast

Lots of population think that a someone vomits because he is suffering from indigestion. However, vomiting does not necessarily indicate an upset stomach. Vomiting can be caused for any psychological reasons as well. For example, if you are afraid or anxious about something, you are likely to contact vomiting tendencies.

So, is there admittedly any way to cure vomiting? There is. The number one way to get rid of vomiting is to start taking liquids and avoid solid foods for some time. Take clear liquids such as soup, lemon juice, etc. What do I mean by a 'clear' liquid? Well, if you are not sure either a liquid is clear or not, pour the liquid in a glass. Can you see through it? If not, then the liquid is not clear adequate and should be avoided.

You should also avoid milk and milk-related products. Any dairy product can irritate your stomach and you may suffer from vomiting.

Instead of eating foods which seem hard to absorb for you, try having soft foods such as gelatin, oatmeal, and yogurt. These foods can be admittedly digested and the quicker you absorb your food, the sooner you will be able to cure vomiting.

Cure Vomiting - The Surefire Way To Cure Vomiting Fast

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Size of Your Belly during pregnancy

Sometimes it seems for pregnant women that their belly is growing before their eyes, or, on the contrary, it's almost unnoticeable. Let's read experts comments on this question.

- Which factors sizes of belly during pregnancy depend on?

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- Height of belly, i.e. Height of uterus normally corresponds to the term of pregnancy. For example, on 32nd week of pregnancy it should be 32-33 cm. And volume of belly depends on a woman's personel peculiarities. Sometimes anatomic structure affects it: dinky women with slim pelvis have bigger belly, than tall women with full thighs have. But most of all increase of belly is associated with pregnant woman's normal weight gaining. This is the factor which a woman should always pay attention to.

Size of Your Belly during pregnancy

- Which weight gaining is thought about to be normal?

- Every woman has her own personel norm. It depends on index of body mass, which can be calculated according to a extra formula. Divide weight in kg on height in square meters. normal index is from 19,8 to 25,9. If you're expecting twins, add at least 2,3-4,6 kg to this figures.
Majority of women gain 40% of weight while the first half of pregnancy, 60% - while the second. If a woman had normal weight before pregnancy, then in the first term she may gain 1,5-2 kg, while the second - 0,5 kg a week, and for the whole 9th month - no more than 0,5-1 kg. Weight should be increased evenly and dinky by little. normal baby's improvement depends on this.

- What are the dangers of overweight?

- If a woman gained too much weight, both she and fetus may perceive troubles. Excessive weight gaining - is one of the symptoms of late toxicosis, unhealthy state of a pregnant woman. Late toxicosis may lead to improvement of miscarriage threat. Under such circumstances, a woman begins feeling pains in waist and lower part of belly. In highly serious cases premature delivery or premature placenta exfoliation may take place.

Moreover, overweight makes muscles work difficult. It also leads to edemas on feet, front abdominal wall, hands. Back and calf-leg muscles begin aching, blood circulation in legs' veins is gets broken, varicose disease becomes more intense. Pregnant woman gets tired more often and strong, becomes irritable. As for fetus, late toxicosis may cause lasting anoxaemia and even pre-natal death. Very full women's risk of such complications is higher.

- What can cause highly quick weight gaining during pregnancy?

- Sometimes those who like eating well gain weight quickly. However, moderation in eating still does not guarantee normal weight. Too much liquid may regain in some women's organisms - for example, when kidneys work not well enough. So, if a pregnant woman gains weight too quickly, she should check quantity of liquid she drinks and evolves for day-and-night. Salutary woman evolves more liquid, than she drinks. And accumulation of liquid in organism leads to overweight. Then not only external organs, but also internal come to be swollen. Placentas' edemas are especially dangerous: they break normal fetus development.

- How can a pregnant woman get rid of edemas?

- While visiting maternity welfare centre, she should pay faithful attention to recommendations with regard to regimen of nutrition, which a doctor will give to her. As a rule, doctors advice all pregnant women to limit salt, piquant, fried and fat products consumption. The matter is that these products conduce to liquid accumulation in organism and lead to edemas. Once in 10 days it is recommended to dispose fasting days. Of course, this does not mean a pregnant woman should go without food. Hunger is legitimately contra-indicated to a future mother. while fasting days a pregnant woman should restrict herself with determined products, for example, apples, cotton cheese, kefir, meat in strictly thought about quantities. Moreover, she should peruse confinement to bed - this improves liquid excretion out of organism. Diuretic herbs also help a lot. However, she should not restrict quantity of liquid drunken suddenly. She should drink no less than 1,2-1,5 liters per day-and-night.

- It turns out that it's rather simple to struggle with edemas?

- Unfortunately, not always. Weight gaining depends on kidneys' work in many aspects. Thus, for example, weight is gained speedily if a woman has lasting urolithiasis, lasting pyelonephritis. Sometimes pyelonephritis appears already during pregnancy. As hormonal background is changing while this period. Organism begins producing more of a hormone, contributing to urinary tracts dilation. And assorted infections come to kidneys through these open gates. That's why all pregnant women should pass bacteriological test of vagina's excretions, operate urine analyses constantly.

- What if a pregnant woman has too big fetus and this explains her overweight?

- Such thing happens sometimes. But this may testify of other problem. Very often women suffering from diabetes have big fetus. If a woman herself was born being big, then she needs to check sugar article in blood and urine, as diabetes can lope also in latent form. Sometimes diabetes appears already during pregnancy. Again because of hormonal background change. Such pregnant women are in a risk group - even if heightened sugar article was shown only on one of several tests. By the way, overweight during pregnancy often force obstetricians to use Cesarean section.

- On which terms sudden weight gaining is specially unwanted?

- Excess weight gaining is especially hazardous in the second half of pregnancy, to be more exact, since 20th week. And the earlier such complications happen, the more difficult confinement a woman will have.
That's why we advise women to take care of their weight, take arterial pressure on both hands and urine tests. If a woman has late toxicosis, as a rule, her blood pressure increases and albumen appears in urine. If all 3 symptoms are found - edemas, heightened blood pressure and albumen in urine - a woman is urgently hospitalized.

- Probably my demand will surprise you. Is it potential to "adjust" a size of fetus somehow?

- I think, yes. Balanced nutrition, along with products, rich in animal and vegetable proteins, vitamins, minerals, is requisite for this. A woman should take vitamin preparations for sure. Of course, these are copy-book truths, but a woman observes these rules not always, for this or that reason.

- Apparently, size of belly depends also on quantity of amniotic fluids? Does liquid a woman drinks sway them?

- No. Reasons of excess of amniotic fluids are quite other: diabetes, anomalies of fetus development, Rhesus-conflict, infectious complications. If a woman has dinky amniotic fluids, this quite often means she will give birth to a post-mature baby.

- Probably, too small belly is better, than too big?

- No, I would not say that. Insufficient weight gaining often leads to blemish of fetus development, giving birth to a very small baby, premature birth, and sometimes even to death of a new-born. Pregnant women should strive for "golden middle".
By the way, American scientists noticed that women with optimistic view on life give birth to babies of small weight less often. Experts justify that optimist women take care of their condition better: do exercising normally and eat well.

- Is there a right dependence in the middle of a pregnant woman's emotional state and excess kilograms?

- Probably, there is. You know, being under stress situation, some women begin eating any food they see and emptying fridge. Here goes excess weight. And, on the contrary, other women just cannot eat at all in stress situation. That's why it's so important for close population and future mom herself to take care of her stable, calm emotional mood.

Approximate budget of weight gained during pregnancy

Baby 3,5 kg

Placenta 0,675 kg

Amniotic fluid 0,8 kg

Increased uterus 0,9 kg

Breasts 0,45 kg

Volume of mother's blood 1,5 kg

Intracellular fluid of mom 1,4 kg

Adipose cellulose of mom 3,25 kg

General Weight increase 11,9 kg

Size of Your Belly during pregnancy

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Abortion Pros and Cons

Abortion pros and cons

When the topic of abortion comes up there is almost all the time a heated argument between both sides. There are pros and cons to abortion s some see it. In general, here are the pros and cons most often mentioned day those on both sides of the fence.

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Abortion Pros

Abortion Pros and Cons

It is a woman's right to choose to do what she wants to with her own body. Those who hold to this argument say no one should be able to make a decision on what a woman can do with her own body. Those on the abortion pro side look at it as an inalienable human right. Of course, those on the abortion con side would retort, "The life of the baby is an inalienable human right that cannot be discarded."

Those on the abortion con side might also argue that abortion takes care of the problem. Many on the abortion pro camp have been quoted as saying, "Once it is done it is done." Again, on the other side of the argument, they would say that nothing can be additional from the truth. Explore does in fact bear out what has even been formally diagnosed as Post Abortion Stress Syndrome (Pass). It is hard to deny that a woman is bound to go through gigantic emotional and physical stress after having undergone an abortion.

Abortion Cons

Those that are in the abortion con camp would say first and important that this is human life and it begins at conception. It is not an organism or unfeeling "fetus," but a living, breathing life. If in fact this is the case then abortion is murdering a human being. That is the primary assertion for those in this camp. The abortion pros would argue that life begins at distinct ordinarily suitable but arbitrary periods. In truth, this argument cannot hold up to real science.

Abortion cons would also say that organizations that perform abortions do so for the money and disguise this as a commitment to the welfare of the mom but a look behind the scenes does tell the real story. That is why pro life organizations encourage a woman to at least get an ultra sound before production the choice to have an abortion.

These are just a few of the many pros and cons of abortion. If you would like to learn more or may be inspecting having an abortion then you may want to check out the link below.

Abortion Pros and Cons

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The Causes and Risks of Salmonella in Babies

Every year more than 15.000 cases of salmonella in children under the age of 4 are reported in the Us. Infants are most likely to get infected with salmonella, compared to all other age groups.

There are several factors that make the discrepancy if a baby contracts salmonella or not:

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Breastfeeding protects against most infectious diseases and thus breastfed babies are much less likely to get salmonella. Breastfeeding is so much easier than bottle feeding - and much less work. Think how much more clean it is than all those dirty bottles left behind.

The Causes and Risks of Salmonella in Babies

Babies that are exposed to reptiles like turtles, snakes or lizards are more likely to compact salmonella. Please note, you should not have reptiles as pets in your home if you have children under the age of five. Go and visit a zoo if you are into reptiles.

If you put your child into a shopping cart next to raw meat and poultry, he is more likely to get infected. So remember always to carry with you disinfectant wipes and clean the area where your child will sit. Put the unsafe items away from your child.

Babies that drink concentrated liquid child method are more likely to get infected. There might be several reasons for that. For once, the method might not be sterile, or the enterprise did not use clean and boiled water. Whatever the reason, just remember to stick with powdered method or much better, breastfeed your baby.

A baby that attends a daycare center is more likely to get salmonella than if the child would stay at home. Point out to the caretakers that hygiene is very prominent to you. Check if they reinforce permissible hand washing and permissible diaper disposal.

Whatever the reasons, if your baby contracts salmonella, keep him dehydrated. The diarrhea he gets is not very dangerous. But it could get very risky if the bacterial infection gets into your baby's blood. That could then be potentially life-threatening. This can cause pneumonia, meningitis, septic arthritis or a bone infection. So whenever a very young child has severe diarrhea, get to an emergency room as soon as possible. The quicker you treat the much better chances you have for a quick recovery.

To sum up:

Breastfeeding is the estimate one thing you can do to safe your baby. Not only in connection with salmonella.

The next prominent tip is to avoid sense with any reptiles. (50% of all reptiles are carriers of salmonella bacterias.)

Always buy potential food, especially eggs. Serve the eggs completely cooked and never poached or sunny-side-up.

Always use disinfectant gel or wipes when you are out and about in the supermarket using a shopping cart. You just don't know what might have been in sense with the child's seat or in general with the cart.

Don't offer foods like raw cookie dough, chocolate mousse, ice cream that contains eggs,... To your infant.

One last thing, did you know that you cannot pass salmonella through breastfeeding to your child.

The Causes and Risks of Salmonella in Babies

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Andrea Yates and Post Partum Depression

Can postpartum depression become so invasive as to cause a mother to kill her children? Since this very rarely happens, many scoff at the prospect. Interestingly enough, postpartum psychosis was first recognized as a disorder as far back as 1850. According to Pregnancy Infonet, (2007), studies on the rates of the disorder have shown that the amount of women experiencing postpartum psychosis hasn't changed since the mid 1800s. Master psychologists, psychiatrists, and behavioral scientists are discovering that postpartum depression can, if not treated instantly and properly over an extended period of time most definitely can escalate to psychosis. Physician statements and evaluations, insufficient treatment, and failed suicides are things that must be considered in determining Andrea Yates thinking blemish at the time of her crime.

It has been argued that due to some of Yates' logical and thought out actions that these prove she was sane at the time of the incident. The fact that, on two occasions she refused medication and on another occasion she stopped taking her medication. The fact that she had done a "practice run" of filling up the bathtub and, individually tracked her children down and drug them to their death are all arguments that are being touted as evidence that she had full knowledge of what she was doing.

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To understand the thought of Postpartum depression and Postpartum psychosis, one must first realize that the two illnesses are not synonymous. Postpartum depression is described as something that can start at anytime within one year of birth. There is regularly sadness, coarse after such an ordeal as birth, and of course a loss of energy, also a coarse thing after giving birth. Sometimes there will be a bout with the inability to concentrate, especially for first time mothers and along with that, anxiety about motherhood. All these are symptoms of postpartum depression. Not every woman experiences these and some may touch only a few of them. However, these symptoms are quite different than those of postpartum psychosis. Catherine Roca, (April, 2005)

Andrea Yates and Post Partum Depression

Dr. Dan Williams, Psy.D., Pa-C, "Peace and Healing", (2006), describes post partum psychosis as "very rare". He goes on to say that "It is characterized by homicidal and suicidal impulses, hallucinations, delusions, disorganized and bizarre thinking." Dr. Williams goes on to added communicate some of the consistent characteristics of one who suffers postpartum psychosis.

"The dilemma is that these individuals regularly refuse treatment. This is a medical crisis situation. If post-partum psychosis is suspected, families need to call 911 as crisis intervention is necessary. Medication most likely will be prescribed. The greatest goal is to keep the baby and mother safe." "Peace and Healing", (2006)

Yates was first diagnosed July 21, 1999 as having severe major depression by Eileen Starbranch, Md. This diagnoses, came after her attempted suicides. During her week stay at Methodist Hospital Psychiatric Unit, she was diagnosed as having severe major depressive disorder, recurrent with psychotic features. added problems diagnosed were communal withdrawal and minimal verbal communications. It was During this psychological appraisal that Andrea Yates admitted to having thoughts of hurting herself or person else.

Eileen Starbranch, Md, Court Tv, Psychiatric appraisal July (1999) On August 5, 1999, Dr. Starbranch along with Dr. Arturo Rics, M.D., had a consultation about continued care of Andrea. The findings of this consultation revealed that the onset of her depression began about six week prior along with symptoms of psychosis. Much of the documentation that was reviewed by both physicians indicated that Andrea remained reclusive, guarded and still had a persistent, depressed mood. ultimately Andrea did acknowledge to some degree to her medication but was warned by Dr. Starbranch not to have another child as this could bring on another psychotic episode.

Dr. Arturo Rics, M.D., Dr. Starbranch, Md, Methodist Hospital Psychiatric Center July (1999) another psychiatrist, Dr. Melissa R. Ferguson, previous medical director of psychiatric services at the Harris County Jail, gave testimony that in her opinion, Yates was suffering from psychosis. According to Dr. Ferguson, Yates told her she believed that the cartoon characters on television were telling her how bad she was for giving her children "too much candy and cereal". Ferguson also testified that she believed that Andrea was incapable of comprehension the consequences of what she did. Dr. Milissa, previous Director, Harris County Jail.

Andrea Yates had all the classic symptoms of post partum psychosis. Even though medication was administered, there was limited administration to ensure that she followed doctor's orders. Her hospital stays were short and therefore not productive in a medically supervised environment assuring that at best the possibility of her harming herself or others was sufficiently minimized.

There is indubitably do doubt in anyone's mind that Andrea Yates did in fact drown her children in a bathtub. There is no doubt that the "how" was too horrible to fathom. Because of the rarity of this condition and its horrendous results if not treated, many Americans, particular women, will judge women like Andrea Yates without compassion for the suffer or the endeavor to learn and understand the illness. What those individuals should realize is that by comprehension this catastrophic illness, it in no way condones the actions done as a corollary of that illness.

In conclusion, the state of Texas is to be applauded in its efforts to identify this rare, yet debilitating and extremely hazardous illness. The Andrea Yates bill became affective September 3, 2003 and it states the following:

"Postpartum depression (Ppd) is a serious disorder, each year affecting 10% to 15% of women who have delivered children. This disorder, despite its high prevalence, often goes undetected and untreated. In an endeavor to address this communal condition problem, the State of Texas has enacted legislation, House Bill 341 (also known as the "Andrea Yates Bill"), which went into corollary on September 1, 2003. This law requires healthcare providers who treat pregnant women to furnish them with reserved supply data about counseling for postpartum depression and other emotional traumas related with pregnancy and parenting."
Blue Corss/Blue Shield of TexasPostpartum Depression and House Bill 341

References:

BlueCross BlueShield of Texas; Postpartum Depression and House Bill 341

(2007) Retrieved on September 9, 2007 from the World Wide Web:
http://www.bcbstx.com/provider/postpartum.htm

Ferguson, Dr. Melissa R. Former

Medical Director of Psychiatric Services at the Harris County Jail. Retrieved on September 8, 2007
from the World Wide Web: http://crime.about.com/b/a/257021.htm

Roca, Catherine , Chief, Women's Programs, (2005) Depression During and After Pregnancy

National manufacture of thinking Health, (April 2005). Retrieved on September 7, 2007 from the World
Wide Web: [http://www.4woman.gov/faq/postpartum.htm#5]

The Pregnancy-Info Team, Postpartum Psychosis (2007) Retrieved on September 7, 2007 from the World Wide Web:
http://www.pregnancy-info.net/postpartum_psychosis.html

Starbranch, Eileen, M.D. Court Tv

Retrieved on September 9, 2007 from the World Wide Web:
http://www.courttv.com/trials/yates/docs/gifs/psychiatric6.gif

Williams, Dan Psy.D., Pa-C, (2006) Peace and Healing.

Retrieved on September 7, 2007 from the World Wide Web:
http://www.peaceandhealing.com/psychosis/postpartum.asp

Andrea Yates and Post Partum Depression

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divergence between a Registered Nurse and Nurse Practitioner

Nurses have always played a vital role in the condition care industry. They spend their lives caring for people who are afflicted with illnesses and injuries. Two types of nurses that are extremely respected members of the curative community are Registered Nurses (Rn) and Nurse Practitioners (Np). There are a amount of differences between a Registered Nurse and Nurse Practitioner.

Registered Nurse (Rn)

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A Registered Nurse is a licensed curative expert who has completed a four-year nursing degree from a reputable nursing school. These nurses supply all types of nursing care to their patients and act as condition advocates for the patient. As well, they evaluate, plan, and implement nursing care treatment for the sick and injured in conjunction with physicians and other condition care providers. Registered nurses carry out a amount of curative tasks such as: explaining and educating patients about their curative conditions, dispensing treatments such as medications and fluids, performing superior curative procedures, monitoring a patient's vital signs, advising and supporting patients, maintaining outpatient condition records, and keeping families advised on a patient's condition status and progress. A registered nurse can work in most areas of the condition care field. With developed training and experience, registered nurses can specialize in a definite curative area such as surgical procedures.

divergence between a Registered Nurse and Nurse Practitioner

Nurse Practitioner (Np)

A Nurse Practitioner (Np) is a registered nurse who has ordinarily completed either a master's degree or doctoral degree and undergone training in the prognosis and management of tasteless curative conditions. The Nurse Practitioner degree schedule is explicit in its educational goals that consist of corporeal evaluation and screening, diagnosis, diagnostics, therapeutic treatment, pharmacology and drug interactions, assisting with outpatient emotional support and counseling, outpatient intake, referral and removal procedures, and case management practices.

In the Us, Nurse Practitioners are licensed by the state where they practice. They have national board certification which is ordinarily done through the American Nurses Credentialing Center or American Academy of Nurse Practitioners. The specialized training and educations allows a nurse practitioner to accomplish many curative tasks ordinarily performed by a doctor. Such tasks consist of diagnosing and treating illnesses and injuries. A few states permit nurse practitioners to write prescriptions. The nurse practitioner has developed understanding and clinical proficiency in assessment, diagnosis, treatment, and outpatient care practices. Nurse practitioners treat condition conditions within their range of practice through the utilization of corporeal exams, corporeal therapy, ordering tests, and implementing therapies for patients,

Nurses are the first curative professionals people see when faced with a condition problem. They can be found working in the community in such places as condition clinics, schools, doctors' offices, home care, family planning clinics, rehabilitation centers, and hospices. In a hospital, nurses can be found working in emergency, intensive care, operating room, maternity, cardiovascular (heart), oncology (cancer), psychiatry, pediatrics, palliative, and geriatrics.

They supply prominent and necessary support to doctors and other healthcare providers, patients, and families. A career as either a Registered Nurse or Nurse Practitioner is satisfying, lucrative, and meaningful.

divergence between a Registered Nurse and Nurse Practitioner

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