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While person- individualized education program under Public Law 94- al dispositions reflect the individual personality more ac- 142 buy cheap olanzapine 20 mg, the 1975 federal law aimed at insuring an adequate curately purchase 2.5mg olanzapine, one needs to use common traits to make any education for children with special needs quality 20mg olanzapine. Allport also claimed that about seven central traits dominated each individual personality (he described Baton Rouge Tourette’s Support Group. Allport was the cardinal trait—a quality so intense that it [Juvenile] governs virtually all of a person’s activities (Mother personal management styles in many American corpo- rations have been linked to the increase in workplace violence, nearly one-fourth of which end in the perpe- trator’s suicide. One type of violence that has received increased at- The high incidence of violence in the United tention in recent years is domestic violence, a crime for States is of great concern to citizens, lawmakers, and which statistics are difficult to compile because it is so law enforcement agencies alike. Between 1960 and heavily underreported—only about one in 270 incidents 1991, violent crime in the U. Estimates of the and over 600,000 Americans are victimized by hand- percentage of women who have been physically abused gun crimes annually. Violent acts committed by juve- by a spouse or partner range from 20 percent to as high niles are of particular concern: the number of Ameri- as 50 percent. Young African American males are partic- by women of all ages, races, ethnic groups, and social ularly at risk for becoming either perpetrators or vic- classes. For white males born in 1987, the ratio is Various explanations have been offered for the high one in 205. Workplace violence may television programs average 10 violent acts per hour, be divided into two types: external and internal. Exter- while children’s cartoons average 32 acts of violence nal workplace violence is committed by persons unfa- per hour. On-screen deaths in feature films such as miliar with the employer and employees, occurring at Robocop and Die Hard range from 80 to 264. It has also random or as an attempt at making a symbolic state- been argued that experiencing violence vicariously in ment to society at large. Internal workplace violence is these forms is not a significant determinant of violent generally committed by an individual involved in either behavior and that it may even have a beneficial cathartic a troubled spousal or personal relationship with a co- effect. However, experimental studies have found corre- worker, or as an attempt to seek revenge against an em- lations between the viewing of violence and increased ployer, usually for being released from employment. This introductory textbook is written specifically for qualified nurses who are working in intensive care units and also for those undertaking post-registration courses in the speciality. This accessible text is: ■ Comprehensive: it covers all the key aspects of intensive care nursing. Jane Roe is a Lecturer-Practitioner at St George’s Hospital Medical School and Kingston University, St George’s Hospital Intensive Therapy Unit. What the reviewers said: ‘An informed, well written and clinically focused text that has ably drawn together the central themes of intensive care course curricula and will therefore be around for many years…. Revision activities and clinical scenarios should encourage students to learn as they engage in analysing and reflecting on their everyday practice experiences. More experienced nurses will also find it a valuable reference source as a means of refreshing their ideas or in developing practice. It should find a place on the shelves of intensive care units, as well as in Higher Education institutions providing critical care courses. It will also be a welcome source of reference for nurses caring for critically ill patients outside of the intensive care unit. Woodrow provides a balance between pathophysiology oriented aspects of nursing practice and the relationship between patient/family and nurses that is the very essence of intensive care nursing. The text is helpfully punctuated with activities for the reader, whilst the extensive references also enable the reader to pursue specific aspects in greater depth. Main text © 2000 Philip Woodrow Clinical scenarios © 2000 Jane Roe Chapter 13 © 2000 Fidelma Murphy All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Woodrow, Philip, 1957– Intensive care nursing: a framework for practice/Philip Woodrow; clinical scenarios by Jane Roe. Intensive care nursing is a diverse speciality, and a text covering its every possible aspect would neither be affordable nor manageable to most clinical staff. This text, therefore, is necessarily selective, and will probably be most useful about 6 to 12 months into intensive care nursing careers. It assumes that readers are already qualified nurses, with experience of caring for ventilated patients, who wish to develop their knowledge and practice further. Knowledge develops and changes; controversy can, and should, surround most issues. But every aspect of knowledge and practice should be actively questioned and constantly reassessed. If this book encourages further debate among practising nurses it will have achieved its main purpose. Since a novice (Benner 1984) has little knowledge or experience, ‘basic’ nursing texts tend to explain almost everything. This book is for competent and advanced practitioners, however, whose knowledge and experience will vary. To help readers, ‘fundamental knowledge’ is listed at the start of many chapters, so that readers can pursue anything they are unsure about. Much ‘fundamental knowledge’ is related anatomy and physiology, and it would be a disservice to readers to displace other material for superficial summaries when there are many excellent anatomy and physiology texts available. Any book is necessarily a pragmatic balance between the author’s priorities and interests; this book represents mine. Many more topics could be covered (some were removed during writing), but this is not fundamentally a book about pathophysiology and the cost of comprehensiveness would be the book remaining largely unused and unread.

The individuality of pain experiences underlies McCaffery’s widely quoted definition: ‘pain is whatever the experiencing person says it is discount olanzapine 7.5 mg without a prescription, existing whenever the experiencing person says it does’ (McCaffery & Beebe 1994:15) cheap olanzapine 10 mg. However some patients may deny pain purchase 5 mg olanzapine otc, even if experiencing it (possibly due to social expectations—‘stiff upper lip’). McCaffery and Beebe (1994) add that nurses should not accept denial of pain, but explore reasons for that denial. Sternbach (1968) described pain in terms of ‘hurt’ and ‘tissue damage’, but ‘hurt’ merely replaces one word by another without clarifying concepts. Pain as a signal of tissue damage (defence mechanism) also ignores psychological stressors, individual interpretations, or powerlessness to prevent tissue degeneration causing chronic pain (e. Nerve fibres Pain is sensed by nociceptors which exist throughout almost all body tissue, especially the skin. A fibres are large; their thick myelin sheaths enable rapid conduction—up to 20 m/s (Grubb 1998). A- delta fibres are found mainly in skin, skeletal muscle and joints, producing sharp and well-localised impulses and defensive motor reflex withdrawal (Melzack & Wall 1988). C fibres transmit dull, poorly localised, deep and prolonged pain signals, resulting in guarded movements and immobility. Sharp impulses from the fast A-delta fibres are superseded by slower, dull and prolonged impulses from C fibres. Pain may be described in these or other terms, and descriptions may indicate the sources of pain (e. Pain management 63 Gate control theory Ancient associations of pain with the heart bequeathed linguistic concepts and images (e. Descartes’ description of direct pain pathways to the brain, although now recognised as grossly oversimplistic, influenced many subsequent theories. While pain mechanisms remain unproven, Melzack and Wall’s ‘gate control’ theory is widely accepted. Hopes that neuropeptide endorphins (endogenous morphines) would achieve better pain control than exogenous narcotics have been disappointed (McCaffery & Beebe 1994). Psychology The perception of signals received is influenced by various psychological factors, including culture anticipation (past experience, fear, misinterpretation) distraction. The word ‘pain’ derives from the Latin poena (punishment) (Schofield 1994), and the perception of pain as retribution may be partly a psychological coping mechanism, but it also encourages stoic attitudes of endurance that can be physiologically harmful. Cultures can also influence whether, when and how it is acceptable to admit to pain. Distraction may help people cope with pain (Puntillo 1988) by blocking the gate with other impulses and stimulating serotonin release. Stereotypes While recognising cultural influences (especially when pain is denied), stereotyping people is unhelpful and dehumanising; the examples below illustrate some of the dangers. Men are expected to tolerate more pain than women (McCaffery & Beebe 1994), and so are less likely to report it (Puntillo & Weiss 1994), but in fact pain tolerance is similar between the genders (Phillips 1997). Pain management 65 Children used to receive little analgesia, even though pain pathways are intact by 30 weeks gestation (Tatman & Ralston 1997); misconceptions may still prevent children receiving adequate analgesia (see Table 7. Even if pain impulses were comparable, pain experiences are unique to each individual necessitating individual assessment, which should be a nursing priority (Doverty 1994). Assessing pain Pain assessment, together with nursing knowledge and attitudes, is fraught with problems. Compared with patients’ own assessments, nurses consistently underestimate pain (Seers 1987; Ferguson et al. Since it is impossible to judge what others are experiencing, it is better to give too much analgesia rather than too little (McCaffery & Beebe 1994). Verbal assessment may be influenced by a nurse’s choice of words and so ‘hurt’, ‘discomfort’, ‘ache’ and ‘soreness’ may identify discomforts that would be denied as ‘painful’ (McCaffery & Beebe 1994). Pharmacological interventions Although the actions of drugs are often complex, including significant psychological/placebo components, analgesics can be divided between those with peripheral actions (e. Observe for skeletal muscle response (a) body movement immobility purposeless or inaccurate body movements protective movements include withdrawal reflex rhythmic movements (b) facial expression: clenched teeth wrinkled forehead biting of lower lip widely opened or tightly shut eyes 2. Autonomic nervous system response (a) sympathetic nervous system activation: increased pulse increased respiration increased diastolic and systolic blood pressure cold perspiration pallor dilated pupils nausea muscle tension (b) parasympathetic activation in some visceral pain low blood pressure slow pulse 3. Verbal report of pain Pain management 67 Questions to elicit from the patient location of pain intensity of pain (scale 1–10) onset and duration precipatating and aggravating factors nature of pain (i. Questions nurses should ask themselves (a) How long has it been since the fresh postoperative patient was medicated for pain? Most peripheral analgesics are anti-inflammatory, making them effective against musculoskeletal pain. Since prostaglandin inhibition impairs platelet aggregation, coagulopathies may be aggravated. Intensive care nursing 68 Opiates Opiates bind to receptors in the central nervous system; three types of receptors have been identified: mu, kappa and sigma. Since fats and fat soluble molecules readily cross the blood- brain barrier, lipid soluble (lipophilic) analgesics act quickly. Differences between opiates are relatively small and so choice largely depends on the personal preference of prescribers/users (Bergman & Yate 1997). Continuous infusions can cause accumulation if drugs have prolonged action or if renal or hepatic metabolism is impaired (renal failure, hepatic failure). It suppresses impulses from C fibres, but not A-delta fibres, and so relieves dull, prolonged pain. Its poor lipid solubility prolongs its effect and makes it unsuitable for epidural analgesia (McCaffery & Beebe 1994). Adverse effects include: ■ respiratory depression ■ histamine release (causing hypotension) (Viney 1996) ■ nausea (concurrent antiemetics may be needed) ■ euphoria Most other opiates also cause these effects. Morphine can be used with children; by the age of six, clearance and half-life have reached adult levels (Knight 1997).

Part of the left psoas major muscle has been removed to display the lumbar plexus buy olanzapine 20mg. Retroperitoneal Region: Autonomic Nervous System 335 56 Ganglia and plexus of the autonomic nervous system within the retroperitoneal space (anterior aspect) order 20mg olanzapine with amex. The penis includes the urethra and thus serves for both ejaculation and micturition olanzapine 5 mg otc. The internal (involun- 29 tary) and external (voluntary) urethral sphincters are widely 32 separated. The ureter, having crossed the ductus deferens, 33 enters the urinary bladder at its base. The peritoneum is 34 reflected off of the posterior surface of the bladder and Male urogenital system (schematic drawing). Male Genital Organs (isolated) 337 10 11 2 Male genital organs, isolated (right lateral aspect). Posterior half of male urethra and prostate in continuity with neck of bladder (anterior aspect). Male Genital Organs (isolated) 339 1 Apex of urinary bladder with urachus 2 Urinary bladder 3 Ureter 4 Ductus deferens 5 Ampulla of ductus deferens 6 Seminal vesicle 7 Prostate 8 Bulbo-urethral or Cowper’s gland 9 Bulb of penis 10 Crus penis 11 Corpus spongiosum of penis 12 Corpus cavernosum of penis 13 Testis and epididymis with coverings 14 Glans penis 15 Fundus of bladder 16 Head of epididymis 17 Testis 18 Mucous membrane of bladder 19 Trigone of bladder 20 Ureteric orifice 21 Internal urethral orifice 22 Seminal colliculus 23 Prostate 24 Prostatic urethra 25 Membranous urethra 26 Spongy (penile) urethra 27 Skin of penis 28 Deep dorsal vein of penis (unpaired) 29 Dorsal artery of penis (paired) 30 Tunica albuginea of corpora cavernosa 31 Septum of penis 32 Deep artery of penis 33 Tunica albuginea of corpus spongiosum 34 Deep fascia of penis Male genital organs, isolated (posterior aspect). The deep fascia of the penis has been opened to display the dorsal nerves and vessels. The corpus spongio- Sagittal section of the pelvic cavity with the male genital sum of the penis with the glans penis has been isolated and reflected. The left figure shows the testicular septa after removal of the seminiferous tubules. Pelvic Cavity in the Male: Coronal Sections 345 Coronal section through pelvic cavity at the level of prostate and hip joint (anterior aspect). Above = horizontal sections through the abdominal cavity, showing different contrast medium concentrations within the aorta and the aneurysm; below = 3-D reconstruction of the aneurysm; red = aorta; green = thrombotic areas; blue = vein (vena cava inferior, partly compressed). Pelvic Cavity in the Male: Vessels and Nerves of the Pelvic Organs 349 17 1 18 2 3 4 19 5 20 6 21 7 22 8 9 23 10 11 12 24 13 14 25 15 26 27 16 Vessels and nerves of the pelvic cavity in the male (medial aspect, midsagittal section). Urogenital and Pelvic Diaphragms in the Male 351 1 Right testis (reflected laterally and upward) 2 Bulbospongiosus muscle 3 Ischiocavernosus muscle 4 Adductor magnus muscle 5 Posterior scrotal nerves and superficial perineal arteries 6 Posterior scrotal artery and vein 7 Right artery of bulb of penis 8 Perineal body 9 Perineal branches of pudendal nerve 10 Pudendal nerve and internal pudendal artery 11 Inferior rectal arteries and nerves 12 Inferior cluneal nerve 13 Coccyx (location) 14 Penis 15 Left testis (reflected laterally) 16 Left posterior scrotal artery 17 Deep transverse perineal muscle 18 Left artery of bulb of penis 19 Posterior femoral cutaneous nerve 20 External anal sphincter muscle 21 Anus 22 Gluteus maximus muscle 23 Anococcygeal nerves 24 Acetabulum (femur removed) 25 Ligament of femoral head 26 Body of ischium (cut) 27 Sciatic nerve 28 Coccygeus muscle 29 Levator ani muscle a iliococcygeus muscle b pubococcygeus muscle c puborectalis muscle 30 Prostatic venous plexus 31 Body of pubis 32 Testis Urogenital diaphragm and external genital organs in the male with vessels and nerves (from below). The 21 right half of the pelvis including 20 14 the obturator internus muscle and femur have been removed to 32 display the right half of the levator ani muscle. The left crus penis has been isolated and reflected laterally together with the bulb of the penis. Urogenital and Pelvic Diaphragms in the Male 353 1 Right testis (reflected) 2 Corpus spongiosum of penis 3 Corpus cavernosum of penis 4 Perineal branch of posterior femoral cutaneous nerve 5 Posterior scrotal arteries and nerves 6 Deep artery of penis 7 Deep transverse perineal muscle 8 Right perineal nerves 9 Inferior rectal nerves 10 Inferior cluneal nerve 11 Anococcygeal nerves 12 Left spermatic cord 13 Left testis (cut surface) 14 Dorsal artery and nerve of penis 15 Deep dorsal vein of penis 16 Urethra (cut) 17 Artery of bulb of penis 18 Superficial transverse perineus muscle 19 Left artery of bulb of penis 20 Perineal branch of pudendal nerve 21 Anus 22 External anal sphincter muscle 23 Gluteus maximus muscle 24 Internal pudendal artery and pudendal nerve 25 Sacrotuberous ligament 26 Coccyx 27 Urogenital diaphragm (deep 22 transverse perineus muscle) 28 Tendinous center of perineum (perineal body) 29 Levator ani muscle 30 Anococcygeal ligament 31 Obturator internus muscle 32 Dorsal artery of penis Urogenital diaphragm and external genital organs in the male (from below). The urinary bladder 37 Infundibulum of uterine tube is empty, position and shape of the uterus are normal. Female Urogenital System 355 1 Muscular coat of urinary bladder 2 Folds of mucous membrane of urinary bladder 3 Right ureteric orifice 4 Interureteric fold 5 Internal urethral orifice 6 Vesico-uterine venous plexus 7 Urethra 8 Pubic bone (cut edge) 9 External urethral orifice 10 Vestibule of vagina 11 Left ureteric orifice 12 Trigone of bladder 13 Obturator internus muscle 14 Levator ani muscle 15 Bulb of the vestibule 16 Left labium minus 17 Psoas major muscle 18 Ampulla of rectum 19 Uterus 20 Urinary bladder 21 Promontory 22 Sigmoid colon 23 Uterine tube 24 Head of femur 25 Vagina Coronal section through the female urinary bladder and urethra (anterior aspect). During embryonal development, the 7 uterus and ovary remain within the 25 pelvic cavity where, after puberty, 16 the ovulation takes place. The anterior wall of the vagina has been opened to display the vaginal portion of the cervix. The fimbriae of the uterine tube have been reflected to show the abdominal ostium. Female Internal Genital Organs: Uterus and Related Organs 359 1 Ilio-inguinal nerve 2 Ureter 3 Psoas major muscle 4 Genitofemoral nerve 5 Common iliac vein 6 Common iliac artery 7 Ovary 8 Uterine tube 9 Peritoneum 10 Round ligament of uterus 11 Inferior vena cava 12 Abdominal aorta 13 Superior hypogastric plexus 14 Rectum 15 Recto-uterine pouch (of Douglas) 16 Uterus 17 Vesico-uterine pouch 18 Urinary bladder 19 Iliac crest 20 Pubic symphysis 21 Placenta 22 Amnion and chorion 23 Adnexa of uterus (uterine tube and ovaries) 24 Myometrium 25 Internal orifice of uterus 26 Cervix of uterus 27 Umbilical cord View of the female pelvis showing uterus and related organs (superior aspect). The anterior wall of the uterus has been removed to show the location of the placenta. Main drainage routes of lymph vessels of uterus and its adnexa (indicated by arrows). Female External Genital Organs 361 1 Glans of clitoris 2 Labium majus 3 Vestibule of vagina 4 Hymen 5 Posterior labial commissure 6 Body of clitoris 7 Labium minus 8 External orifice of urethra 9 Vaginal orifice 10 Ureter 11 Adnexa of uterus 12 Prepuce of clitoris 13 Crus of clitoris 14 Greater vestibular glands 15 Anus and internal anal sphincter muscle 16 Median umbilical ligament containing urachus 17 Urinary bladder 18 Infundibulum of uterine tube 19 Ovary 20 Ampulla of uterine tube 21 Suspensory ligament of the ovary 22 Bulbospongiosus muscle and bulb of vestibule 23 Central tendon of perineum (perineal body) 24 External anal sphincter muscle Female external genital organs (anterior aspect). Female external genital organs in relation to internal genital organs and urinary system, isolated (anterior aspect). Urogenital Diaphragm and External Genital Organs in the Female 365 1 Position of pubic symphysis 2 Body of clitoris 3 Prepuce of clitoris 4 Adductor longus and gracilis muscles 1 5 External orifice of vagina and labium minus 6 Posterior labial nerve 7 Perineal body 8 8 Deep artery of clitoris and dorsal nerve of clitoris 2 9 9 Adductor brevis muscle 10 Glans of clitoris 3 10 11 Crus of clitoris and 4 ischiocavernosus muscle 11 12 Bulb of vestibule and bulbospongiosus muscle 13 Anterior branch of obturator nerve 12 14 Labium minus 5 15 Vaginal orifice 16 Posterior labial nerves 13 17 Branches of pudendal nerve 6 18 External sphincter of anus 19 Anus 20 Bulb of vestibule (divided) 21 Dorsal artery of clitoris 22 Superficial transverse perineus muscle 7 23 Perineal branch of posterior femoral cutaneous nerve 24 Levator ani muscle External genital organs in the female (inferior aspect). The clitoris has been 25 Pudendal nerve and dissected and slightly reflected to the right. The prepuce of clitoris has been divided internal pudendal artery to display the glans. The bulb of vestibule has partly been removed; the left labium minus was cut away. The peritoneum at the left half of pelvic cavity has been 9 removed to display uterine tube, vessels, and nerves. Pelvic Cavity in the Female: Coronal and Horizontal Sections 367 1 Ilium 2 Rectum 3 Recto-uterine fold 4 Ovary 5 Uterine tube 6 Urinary bladder 7 Urethra 8 Labium minus 9 Recto-uterine pouch of Douglas 10 Uterus (uterovesical pouch) 11 Ligament of the head of the femur 12 Head of femur 13 Vestibule of vagina 14 Labium majus 15 Anal cleft 16 Coccyx 17 Rectum Coronal section through the pelvic cavity of the female (cf. Horizontal section through the pelvic cavity of the female at level of the urethral sphincter and vagina (from below). The two positions of the forearm essential to manual skills in the human, supination (right arm) and pronation (left arm), are shown. Skeleton of the Shoulder Girdle and Thorax 369 Vertebral column 1 Atlas 2 Axis 3 Third–seventh cervical vertebrae 4 First thoracic vertebra 5 Twelfth thoracic vertebra 6 First lumbar vertebra Ribs 7 First–third ribs True ribs 8 Fourth–seventh ribs 9 Eighth–tenth ribs False ribs 10 Eleventh and twelfth ribs (floating ribs) Clavicle 11 Sternal end 12 Articular facet for sternum 13 Acromial end 14 Articular facet for acromion 15 Impression for costoclavicular ligament 16 Conoid tubercle 17 Trapezoid line 18 Site of acromioclavicular joint 19 Site of sternoclavicular joint Scapula 20 Acromion 21 Coracoid process 22 Glenoid cavity 23 Costal surface Sternum 24 Manubrium 25 Body 26 Xiphoid process Skeleton of shoulder girdle and thorax (anterior aspect). Because of the human body’s upright posture, the upper limb has developed a high degree of mobility. The shoulder girdle is to a great extent movable in the thorax and is connected with the 16 trunk only by the sternoclavicular joint. Vertebral column Scapula 1 Atlas 12 Acromion 2 Axis 13 Spine of scapula 3 Third–sixth cervical vertebrae 14 Lateral angle 4 Seventh vertebra (vertebra prominens) 15 Posterior surface 5 First thoracic vertebra 16 Inferior angle 6 Sixth thoracic vertebra 17 Coracoid process 7 Twelfth thoracic vertebra 18 Supraglenoid tubercle 8 First lumbar vertebra 19 Glenoid cavity 20 Infraglenoid tubercle Clavicle 21 Lateral margin 9 Sternal end 10 Acromial end Thorax 11 Site of acromioclavicular joint 22 Body of sternum 23 Costal arch 24 Angle of ribs 25 Floating ribs Scapula 371 Right scapula (posterior aspect). Scapula A = superior border B = medial border C = lateral border D = superior angle E = inferior angle F = lateral angle 1 Acromion 2 Coracoid process 3 Scapular notch 4 Glenoid cavity 5 Infraglenoid tubercle 6 Supraspinous fossa 7 Spine 8 Infraspinous fossa 9 Articular facet for acromion 10 Neck 11 Supraglenoid tubercle 12 Costal (anterior) surface Right scapula (lateral aspect).

Base of the Skull 33 A pterygoid canal B foramen ovale C = internal carotid artery within carotid canal and internal jugular vein within the venous part of jugular foramen D stylomastoid foramen (facial nerve) E jugular foramen (glossopharyngeal discount olanzapine 10 mg overnight delivery, vagus and accessory nerves) F hypoglossal canal (hypoglossal nerve) 1 Incisive canal 2 Median palatine suture 3 Palatine process of maxilla 4 Palatomaxillary suture 5 Greater and lesser palatine foramina 6 Inferior orbital fissure 7 Middle concha (process of ethmoidal bone) 8 Vomer 9 Foramen ovale 10 Groove for auditory tube 11 Pterygoid canal 12 Styloid process 13 Carotid canal 14 Stylomastoid foramen 15 Jugular foramen 16 Groove for occipital artery 17 Occipital condyle 18 Condylar canal 19 Nuchal plane 20 External occipital protuberance 21 Zygomatic arch 22 Lateral pterygoid plate 23 Medial pterygoid plate 24 Mandibular fossa 25 Pharyngeal tubercle Base of the skull (from below) generic olanzapine 7.5mg with amex. Canals discount 7.5mg olanzapine fast delivery, fissures, and 17 Digitate impressions foramina of the base of the (frontal bone) skull 18 Lesser wing of sphenoidal 1 Superior orbital fissure bone 2 Foramen rotundum 19 Foramen lacerum 3 Optic canal 20 Hypophysial fossa 4 Foramen ovale (sella turcica) 5 Foramen spinosum 21 Anterior clinoid process 6 Internal acoustic meatus 22 Trigeminal impression 7 Jugular foramen 23 Petrous part of temporal 8 Foramen magnum bone 24 Groove for sigmoid sinus Bones 25 Dorsum sellae 9 Frontal bone (orange) (posterior clinoid process) 10 Ethmoidal bone (dark green) 26 Greater wing of sphenoidal 11 Sphenoidal bone (red) bone, groove for middle 12 Temporal bone (brown) meningeal artery 13 Parietal bone (yellow) 27 Hypoglossal canal 14 Occipital bone (blue) Details of bones 15 Crista galli 16 Cribriform plate Base of the skull (internal aspect, superior view). Skull of the Newborn 35 Cranial skeleton 1 Frontal tuber or eminence 2 Parietal tuber or eminence 3 Occipital tuber or eminence 4 Squamous part of temporal bone 5 Greater wing of sphenoidal bone Facial skeleton 6 Maxilla 7 Mandible 8 Zygomatic bone 9 Nasal bone Sutures and fontanelles 10 Frontal suture 11 Coronal suture 12 Sagittal suture 13 Lambdoid suture Skull of the newborn (anterior aspect). Bones (indicated by colors) 1 Frontal bone (yellow) 2 Nasal bone (white) 3 Ethmoidal bone (dark green) 4 Lacrimal bone (yellow) 5 Inferior nasal concha (pink) 6 Palatine bone (white) 7 Maxilla (violet) 8 Mandible (white) 9 Parietal bone (light green) 10 Temporal bone (brown) 11 Sphenoidal bone (red) 12 Petrous part of temporal bone (brown) 13 Occipital bone (blue) 14 Ala of vomer (light brown) Median section through the skull. Because of the upright posture that the human developed about 120° between the clivus and the cribriform plate (see in the course of evolution, the cranial cavity greatly drawing on page 19). The hypophysial fossa containing the increased in size, whereas the facial skeleton decreased. As pituitary gland lies at the angle formed between these two a result, the base of the skull developed an angulation of planes. The mosaic of the facial 29 Nasal crest bones [sphenoidal bone (green), ethmoidal bone (yellow), and 30 Incisive canal palatine bone (red)] is seen from the antero-lateral aspect. Palatine bone 31 Orbital process 32 Sphenopalatine notch 33 Sphenoidal process 34 Perpendicular plate 35 Conchal crest 36 Horizontal plate 37 Pyramidal process Frontal bone 38 Squamous part 39 Supra-orbital foramen 40 Frontal notch 41 Frontal spine Inferior nasal concha 42 Inferior nasal concha with maxillary process Left maxilla and palatine bone (medial aspect). Green = sphenoidal bone; yellow = ethmoidal bone; red = palatine bone; natural colored = left maxilla. Yellow = ethmoidal 29 Anterior nasal aperture bone; red = palatine bone; green = sphenoidal bone. The greater wing of sphenoidal 25 Maxillary hiatus bone (green) is shown as being transparent. Brown = temporal bone; 26 Pterygoid or Vidian canal 27 Lesser palatine canal yellow = ethmoidal bone; red = lacrimal bone; light red = inferior nasal concha; 28 Greater palatine canal violet = maxilla; red = palatine bone. The arrows indicate the locations of the lacrimal bone (11) and the nasal bone (17). Inferior concha and vomer 1 Ethmoidal process 2 Anterior part of concha 3 Inferior border 4 Ala of vomer 5 Posterior border of nasal septum 6 Lacrimal process 7 Posterior part of concha 8 Maxillary process Right inferior nasal concha (medial aspect). Septum and Cartilages of the Nose 49 1 Crista galli 2 Cribriform plate of ethmoidal bone 3 Perpendicular plate of ethmoidal bone 4 Vomer 5 Ala of the vomer 6 Palatine bone (perpendicular process) 7 Palatine bone (horizontal plate) 8 Mandible 9 Nasal bone 10 Sphenoidal sinus 11 Hypophysial fossa (sella turcica) 12 Grooves for the middle meningeal artery Cartilages of the nose 13 Lateral nasal cartilage 14 Greater alar cartilage 15 Lesser alar cartilages 16 Septal cartilage 17 Location of nasal bone Paramedian sagittal section through the skull including the nasal septum. The developing crowns of the permanent teeth are displayed in their crypts in the maxilla and mandible. Notice that the breadth of the alveolar arch of the child’s mandible and maxilla holding the deciduous teeth is nearly the same as the comparable portion in the jaws of the adult. Isolated teeth of the alveolar part of the maxilla (top row) and the mandible (lower row), labial surface of the teeth. Temporomandibular Joint and Masticatory Muscles 55 1 2 3 4 5 6 7 8 9 Muscles of mastication and temporomandibular joint. Masticatory Muscles: Pterygoid Muscles 57 1 2 3 4 5 6 7 8 9 10 11 Muscles of mastication. The zygomatic arch and part of the mandible have been removed to reveal the medial and lateral pterygoid muscles. Radially arranged muscles work as Left side: superficial layer, right side: deeper layer. Maxillary Artery 63 1 Galea aponeurotica 2 Superficial temporal artery and auriculo- temporal nerve 3 Occipital artery and greater occipital 1 12 nerve (C2) 4 Temporomandibular joint (opened) 5 External carotid artery 13 6 Mandible and inferior mandibular artery and 2 nerve 14 7 Accessory nerve (Var. I) pass the lamina cribrosa innervating the upper part of the nasal mucous membrane. Brain, brain stem, of the neck, the tongue, and the and cerebellum have been partly removed (from Lütjen-Drecoll, Rohen, Innenansichten des pharynx. V) Brain and Cranial Nerves 67 Brain stem and pharynx with cranial nerves (posterior aspect). Lateral wall of cranial cavity, lateral wall of orbit, zygomatic arch, and ramus of the mandible have been removed and the mandibular canal opened. V2) 2 Supra-orbital nerve pterygopalatine nerves 24 Trigeminal ganglion 3 Lacrimal nerve 13 Posterior superior alveolar 25 Mandibular nerve (n. V3) 4 Lacrimal gland nerves 26 Auriculotemporal nerve 5 Eyeball 14 Superior dental plexus 27 External acoustic meatus (divided) 6 Optic nerve and short ciliary nerves 15 Buccinator muscle and buccal nerve 28 Lingual nerve and chorda tympani 7 External nasal branch of 16 Inferior dental plexus 29 Mylohyoid nerve anterior ethmoidal nerve 17 Mental foramen and mental nerve 30 Medial pterygoid muscle 8 Ciliary ganglion 18 Anterior belly of digastric muscle 31 Inferior alveolar nerve 9 Zygomatic nerve 19 Ophthalmic nerve (n. V1) 32 Posterior belly of digastric muscle 10 Infra-orbital nerve 20 Oculomotor nerve (n. V3) 12 Posterior superior alveolar nerves 13 Tympanic cavity, external acoustic meatus, and tympanic membrane 14 Inferior alveolar nerve 15 Lingual nerve 16 Facial nerve (n. Facial canal and tympanic cavity opened, posterior wall of external acoustic meatus removed. Branches of facial nerve: a = temporal branch; b = zygomatic branches; c = buccal branches; d = marginal mandibular branch. The mandible has been divided and the muscles of mastication have been Facial nerve (schematic drawing of the dissection above). Brain and Cranial Nerves: Connection with the Brain Stem 71 1 1414 2 3 15 16 4 17 5 18 6 19 20 7 8 21 22 9 10 23 24 11 25 26 27 12 28 13 18 29 1 Optic tract 11 Lingual branch of hypoglossal nerve 22 Hypoglossal nerve (n. V) 27 Sympathetic trunk 7 Lingual nerve and inferior alveolar nerve 17 Fourth ventricle and rhomboid fossa 28 Branch of cervical plexus (ventral 8 Styloid process and stylohyoid muscle 18 Vagus nerve (n. V3) 7 23 26 External acoustic meatus 8 21 27 Pterygopalatine nerves 24 28 Deep temporal nerves 10 25 29 Buccal nerve 30 Masseteric nerve 11 31 Auriculotemporal nerve 32 Trochlea and superior oblique muscle 16 Cranial nerves innervating extra-ocular muscles (lateral aspect). Right side: superficial layer, left side: middle layer of the orbit (superior rectus muscle and frontal nerve divided and reflected). V1) 19 Optic chiasma and internal carotid artery 20 Trigeminal ganglion 21 Trigeminal nerve (n.