睿学教育Wisdome Education

Dan Engelhard, M.D.

• Associate Professor
• Department of Pediatrics
• The Hebrew University Hadassah Medical School
• Chief
• Department of Pediatrics
• Hadassah University Hospital
• Jerusalem, Israel

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Duration of Therapy • For children blood pressure ranges for males purchase bisoprolol online, check x-ray reports of bone growth status ini- tially and approximately every 6 months while the drugs Drug therapy with androgens may be short or long term blood pressure chart on excel generic 5 mg bisoprolol, are being taken blood pressure zona plus purchase cheap bisoprolol. Nursing Diagnoses Effects of Androgens and Anabolic • Disturbed Body Image related to masculinizing effects Steroids on Other Drugs and menstrual irregularities • Deficient Knowledge: Physiologic and psychological Androgens may increase effects of cyclosporine and warfarin, consequences of overuse and abuse of the drugs to enhance apparently by slowing their metabolism and increasing their athletic performance concentrations in the blood. These combinations should be 430 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM CLIENT TEACHING GUIDELINES Androgens General Considerations ✔ Place the tablet between the cheek and gum and ✔ Take the drugs only if prescribed and as prescribed. Rotate sites, with 7 days between appli- ✔ Practice frequent and thorough skin cleansing to de- cations to a site. Wash hands after application and allow sites to ✔ For buccal preparations: dry before dressing. However, if required, serum creatinine and Use in Children cyclosporine levels should be monitored with cyclosporine and prothrombin time or international normalized ratio (INR) with the main indication for use of androgens is for boys with es- warfarin. Because the drugs cause epiphyseal Androgens also increase effects of sulfonylurea anti- closure, hands and wrists should be x-rayed every 6 months diabetic drugs. If required, smaller doses of sulfonylureas may be needed, Stimulation of skeletal growth continues for approximately blood glucose levels should be monitored closely, and clients 6 months after drug therapy is stopped. Danazol in- occurs (precocious sexual development, enlarged penis), the hibits metabolism of carbamazepine and increases risks of drug should be stopped. Scrupulous skin care and other antiacne treatment may be needed, especially in adolescent boys. Use in Older Adults Nursing Notes: Ethical/Legal Dilemma the main indication for use of androgens is a deficiency state in men. Older adults often have hypertension and other cardio- After you discussed the dangers of using anabolic steroids with the vascular disorders that may be aggravated by the sodium and wrestling team, one of the young second-string players comes to water retention associated with androgens and anabolic you to discuss his friend. In men, the drugs may increase prostate size and in- wrestlers on the team and he suspects that his dramatic athletic im- terfere with urination, increase risk of prostatic cancer, and provement over the last year has been because he has used ana- cause excessive sexual stimulation and priapism. Androgens and anabolic steroids are contraindicated in clients Reflect on: with preexisting liver disease. Drug-induced jaundice is reversible when the solve how he might handle the situation? CHAPTER 29 ANDROGENS AND ANABOLIC STEROIDS 431 NURSING Androgens and Anabolic Steroids ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Give intramuscular preparations of testosterone, other an- drogens and anabolic steroids deeply, preferably in the gluteal muscle. With transdermal systems: Correct site selection and application are necessary for therapeu- tic effects. Clients may prefer self-applica- abdomen, once daily, preferably in the morning. Skin should be clean, dry, and intact; hands should be washed after application; and showering and swimming should be avoided for at least 1 hour and preferably 4 to 6 hours after application. When the drug is given for hypogonadism, observe for mas- culinizing effects, such as growth of sexual organs, deepening of voice, growth of body hair, and acne. When the drug is given for anabolic effects, observe for in- creased appetite, euphoria, or statements of feeling better. Virilism or masculinizing effects: (1) In adult men with adequate secretion of testosterone— priapism, increased sexual desire, reduced sperm count, and prostate enlargement (2) In prepubertal boys—premature development of sex organs and secondary sexual characteristics, such as en- largement of the penis, priapism, pubic hair (3) In women—masculinizing effects include hirsutism, deepening of the voice, menstrual irregularities b. Edema More likely in clients who are elderly or who have heart or kidney disease d. Hypercalcemia More likely in women with advanced breast cancer (continued) 432 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM NURSING ACTIONS RATIONALE/EXPLANATION e. Difficulty voiding due to prostate enlargement More likely in middle-aged or elderly men f. Drugs that decrease effects of androgens (1) Barbiturates Increase enzyme induction and rate of metabolism (2) Calcitonin Decreases calcium retention and thus antagonizes calcium-retaining effects of androgens SELECTED REFERENCES Review and Application Exercises Drug facts and comparisons. What are the adverse effects of using large doses of ana- bolic steroids in body-building efforts? If your 14-year-old brother said some friends were telling him to take drugs to increase muscle development and ath- letic ability, how would you reply? Minimize complications of enteral and parenteral tions of fluid imbalances, undernutrition, and nutrition. Collaborate with nutritionists and physicians in develop and maintain a safe and realistic designing and implementing nutritional support weight loss program. Critical Thinking Scenario Jamie, 2 months of age, had a gastrostomy tube placed after surgical repair of his esophagus.

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Breast cancer is almost in multiple myeloma and other hematological malignan- double and lung cancer five times higher in the elderly (60 – cies which may blood pressure chart to keep track of readings cheap 10 mg bisoprolol free shipping, however arrhythmia in child order bisoprolol with amex, be considered as primary tu- 79 years) than in the middle-aged (40 – 59 years) hypertension while pregnant purchase bisoprolol pills in toronto. About 10% of the cancer patients are attained by though cancer is one of the major causes of morbidity and metastases located in the spine [23, 36] (incidence 1999, mortality, elderly persons are often excluded not only SEER and NPCR Registries, United States Cancer Statis- from clinical cancer studies but also from standard treat- tics; SEER Cancer Statistics Review 1975–2000, National ment, and generally also from cancer screening because Cancer Institute). Among adults 60% of spinal metastases comorbidity and frailty alter the risk benefit of screening are either from breast, lung, or prostate cancer. Renal and (World Health Organization report: Pain in the elderly gastrointestinal malignancies each account for about 5% with cancer, www. There is of spinal metastases, and thyroid carcinomas and melanomas clearly an underrepresentation of older persons in drug occurring with a lesser frequency [2, 24] (incidence 1999, studies, as documented by the United States Food and SEER and NPCR Registries, United States Cancer Statis- Drug Administration (http://cbsnewyork. Since these tumors are increasingly ac- derly because it usually affects the quality of life by re- cessible to treatment by surgery, radiation therapy, and ducing the endurance, the capacity to ambulate, and the chemotherapy, thus prolonging the survival of the affected ability for physical activity. Due to their age these patients patients, there is also an increased probability of them be- often have other diseases which already limit their quality ing affected by metastases, i. Metastatic disease involving the spine most often af- fects the vertebral bodies of the thoracic, lumbar, cervical, and sacral spine. Pathological anatomy and classification 5% of patients with cancer metastases develop cord com- pression. It is postulated that incidence 1999, SEER and NPCR Registries, United the venous blood return is shifted into the paravertebral States Cancer Statistics; SEER Cancer Statistics Review plexus via the intervertebral and basivertebral veins due to 1975–2000, National Cancer Institute; World Health Or- increased intra-abdominal and intrathoracic pressure. The average age of are seeded by this mechanism into the capillary network patients affected by secondary spinal tumors is 55 – 60 years of the vertebral bodies. Due to its avascular nature the [23] when considering all metastases; however, it is sig- disc is usually spared from tumor involvement: however, nificantly higher when considering tumors that are more the most frequently and severely affected part of the ver- tebra is the vertebral body (in about 80%) followed by the pedicles and the posterior elements. This constellation ex- plains why most of the spinal metastasis are located in Table1 Probability of developing invasive cancer (percentages) front of the spinal cord or dural sac ending up with an an- at selected ages with spinal metastasis (from [23]) terior epidural compression. More than 90% of spinal 40–59 years old 60–79 years old metastases are extradural and only 5% intradural and less than 1% intramedullar [45]. Finally there is also the Lung cancer option of direct spread through direct tumor infiltration Male 1. The system differentiates between intra- groups covering most of the possibilities of spinal metas- compartmental, extracompartmental, and multiple tumor tases appearance: involvement. The first two categories include types 1 – 3 and types 4 – 6, respectively, whereas multiple tumor in- – Class I: destruction without collapse but with pain. This scoring – Class II: the addition of moderate deformity and col- system found increasing application in recent years as a lapse with immune competence. This class is consid- baseline in publications to make the results comparable ered a good risk for surgery. This class is con- Clinical presentation and Imaging sidered a relative surgical emergency. This class is not considered a good dominantly pain, neurological deficit, progressive defor- operative risk. Pain may be localized to a This classification allows consideration of the tumor, po- certain structure and region of the spine and may be of tential instability, and patient physiology, which is a sen- radicular or medullary origin. The WBB Surgical Staging fibers, by a secondary instability due to the osteoligamen- System was been introduced in 1997 primarily for pri- tous destruction of parts of the axial skeleton, or by the in- mary bone tumors of the spine [9]. This can be applied for filtration of the dura or other neuroanatomical structures. Tokuhashi et to be influenced by the regulation of the physical activi- al. Generally speaking, slowly progressive, dull neck or evaluation of metastatic spine tumor prognosis that, in- back pain which occurs in a patient with a known cancer stead, allows a correlation of the tumor extent with the disease or which may become apparent in an elderly pa- 123 tient without a history of a tumor, should be considered as tebral body is weakened by the replacement of bone by tu- caused by a spinal metastases until proven otherwise [20]. Usually the posterior period between initial pain and neurological deficit is for elements are also involved to some extent at this point and the cervical and thoracic spine weeks to months but in the render the segment definitely unstable. The patients may metastases are prone to pathological fractures with frag- have motor or sensory deficit or both, whereas there is the ment displacements only if there is a certain mix with os- option of pure radicular and/or a medullary compression.

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The ten most common all medications are given heart attack neck pain purchase cheap bisoprolol line, flush the tube with 50 mL of water un- lethal medication errors in hospital patients blood pressure medication green pill purchase generic bisoprolol online. American Review and Application Exercises Journal of Nursing heart attack 80s song buy cheap bisoprolol 10mg on-line, 101(10), 26–32. When giving an oral medication, what are some interven- therapy, 7th ed. Teach clients and family members how to weight, health–illness status, and lifestyle use prescription and OTC drugs safely and habits likely to influence drug effects. When indicated, teach clients about the use of prescription, over-the-counter (OTC), potential effects of herbal and dietary and social drugs as well as herbal and dietary supplements. Identify nondrug interventions to prevent or plements, provide or assist them in obtaining decrease the need for drug therapy. Describe major considerations in drug ther- and decrease hazards of drug therapy. Discuss guidelines for rational choices of drugs, function or critical illness. Critical Thinking Scenario You are making the first home visit for an elderly client with arthritis and hypertension who is taking the following medications: Ibuprofen 800 mg every 4 hours Prednisone 5 mg daily Lasix 20 mg twice a day Captopril 25 mg twice a day Pepcid 20 mg at bedtime Look up each of these medications. What criteria will you use to determine therapeutic effects for each drug? Note any side effects that are likely for each drug and what assessment data will be important to collect. OVERVIEW knowledgeable about pharmacology (drugs and their effects on the body), physiology (normal body functions), and patho- Drug therapy involves the use of drugs to prevent or treat physiology (alterations in mental and physical functions due disease processes and manifestations. It may save lives, im- to disease processes), and must be adept at using all steps of prove the quality of life, and otherwise benefit recipients. Adverse effects and failure to Chapter 1 included general information about drugs and achieve therapeutic effects may occur with correct use, but suggested strategies for studying pharmacology. Physicians, described cellular physiology and concepts and processes es- pharmacists, clients, and nurses all have important roles to sential to understanding drug effects in humans. Although For the nurse, drug therapy is one of many responsibilities the importance of safe and accurate administration cannot be in client care. To fulfill this responsibility, the nurse must be overemphasized, this is only one aspect of the nursing process 47 48 SECTION 1 INTRODUCTION TO DRUG THERAPY in drug therapy. The nurse also must monitor responses to nicotine, cocaine, marijuana) drugs. A medication history drug therapy, both therapeutic and adverse, and teach clients (Box 4–1) is useful, or the information can be incorpo- about drugs, both prescribed and OTC. Is lines, principles and actions related to specific drug groups teaching needed? It also may be helpful to ask about nonprescription NURSING PROCESS IN drugs for headache, colds, indigestion, or constipation, DRUG THERAPY because some people do not think of these preparations as drugs. The nursing process is a systematic way of gathering and • Has the client ever had an allergic reaction to a drug? If using information to plan and provide individualized client so, what signs and symptoms occurred? It involves both tion is necessary because many people describe minor cognitive and psychomotor skills. Unless the nursing process are required for drug therapy, as in the reaction is further explored, the client may have other aspects of client care. Try to tablishing goals for nursing care, interventions, and evalu- obtain information to help assess whether the client ation. One might say that assessment and interventions are takes drugs freely or reluctantly, is likely to comply the action phases whereas analysis of assessment data with a prescribed drug regimen, or is likely to abuse and establishing nursing diagnoses and goals are thinking drugs. However, knowledge and informed, rational think- • If long-term drug therapy is likely, can the client afford ing should underlie all data collection, decision-making, to buy medications?

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However blood pressure chart readings for ages buy 10 mg bisoprolol amex, the autonomic nervous system does influence heart Endothelial Mediators That rate blood pressure medication chronic cough buy bisoprolol with visa. Sympathetic nerves increase heart rate (through the re- TABLE 50–1 Regulate Cardiovascular lease of epinephrine and norepinephrine); parasympathetic Function nerves (by way of the vagus nerve) decrease heart rate class 4 arrhythmia drugs cheap bisoprolol 5 mg on-line. Promoting Factors Inhibiting Factors Vasomotor Tone Blood Supply Vasodilators Vasoconstrictors Endothelial-derived hyper- Angiotensin II the heart receives its blood supply from the coronary arter- polarizing factor (EDHF) Endothelin ies. Coronary arteries branch off the aorta at the aortic valve Nitric oxide (also called Endothelium-derived constricting endothelial-derived factor and fill during diastole, the resting or filling phase of the car- relaxing factor, or EDRF) Platelet-derived growth factor diac cycle. Coronary arteries branch into smaller arteries that Prostacyclin (prostaglandin I2) Thromboxane A2 supply specific parts of the myocardium, without an over- Blood Coagulation lapping supply from other arterial branches. However, artery- Procoagulants Anticoagulants to-artery anastomoses occur between many adjacent vessels. Tissue factor Heparin sulfate These anastomotic arteries may not supply sufficient blood to Von Willebrand factor Thrombomodulin the heart if a major artery is suddenly occluded, but they may Platelet activators Platelet inhibitors dilate to considerable size when disease (usually coronary Platelet-activating factor Nitric oxide Von Willebrand factor Prostacyclin atherosclerosis) develops slowly. The resultant collateral cir- Profibrinolytic factors Antifibrinolytic factor culation may provide a sufficient blood supply for myocar- Tissue plasminogen Plasminogen activator inhibitor-1 dial function, at least during rest. Arteries and veins are similar in that they have three Platelet-derived growth factor Prostacyclin layers. The intima, the inner lining, is composed of a layer of Inflammation endothelial cells next to the blood (to provide a smooth sur- Proinflammatory factors Anti-inflammatory factors face for blood circulation) and an elastic layer that joins the Cellular and intercellular Nitric oxide media. The media is the middle layer of muscle and elastic tis- adhesion molecules Monocyte chemotactic sue. Vascular smooth CHAPTER 50 PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM 741 Arteries bolic wastes from tissues to the kidneys, skin, and lungs for excretion Arteries and arterioles contain a well-developed layer of • Transports hormones from endocrine glands to other smooth muscle (the media) and are sometimes called resis- parts of the body tance vessels. Their efficiency depends on their patency and • Transports leukocytes and antibodies to sites of injury, ability to constrict or dilate in response to various stimuli. They are sometimes called ca- • Plasma comprises approximately 55% of the total blood pacitance vessels, because blood may accumulate in various volume, and it is more than 90% water. Their efficiency depends on pa- ents are tency, competency of valves, and the pumping action of mus- • Serum albumin, which helps maintain blood volume cles around veins. They consist of a sin- • Solid particles or cells comprise approximately 45% of gle layer of connected endothelial cells and a few smooth total blood volume. Gases, nutrients, cells, and waste products are cells or RBCs); leukocytes (white blood cells or WBCs); exchanged between blood and extracellular fluid across cap- and thrombocytes (platelets). The endothelial lining acts as a semipermeable all RBCs, 60% to 70% of WBCs, and all platelets. Lym- membrane to regulate the exchange of plasma solutes with phatic tissues (spleen and lymph nodes) produce 20% extracellular fluid. Lipid-soluble materials diffuse directly to 30% of the WBCs, and reticuloendothelial tissues through the capillary cell membrane; water and water-soluble (spleen, liver, lymph nodes) produce 4% to 8% of WBCs. Almost all oxygen (95% to 97%) is transported in Lymphatics combination with hemoglobin; very little is dissolved in blood. The lifespan of a normal RBC is approxi- Lymphatic vessels, which are composed mainly of endothe- mately 120 days. They then stream to enter injured tissues and phagocytize the carry lymphocytes, large molecules of protein and fat, micro- injurious agent. For example, when a blood vessel is injured, platelets adhere to each other and Blood functions to nourish and oxygenate body cells, protect the edges of the injury to form a cluster of activated the body from invading microorganisms, and initiate hemo- platelets (ie, a platelet thrombus or plug) that sticks stasis when a blood vessel is injured. If cells to lungs for removal from the body not used, they circulate for approximately a week • Transports absorbed food products from the gastroin- before being removed by phagocytic cells of the testinal tract to tissues; at the same time, carries meta- spleen. In addition, these drugs may be given for pal- bidity and mortality, often stem from blood vessel abnormali- liation of symptoms without alteration of the underlying dis- ties. In turn, most vascular diseases result from the malfunction ease process. Dysfunctional endothelium is considered a major factor in atherosclerosis, acute coronary syndromes (symptomatic myocardial ischemia, asymptomatic myocardial infarction [MI], and MI with or Review and Application Exercises without ST-segment elevation), hypertension, and throm- boembolic disorders. In what circumstances do other parts of the heart take over forces and leads to vasospasm, thrombosis, growth of the in- as pacemaker?

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Several experiments have shown that the hippocampus is required in situa- tions where multiple and distinct pulse pressure of 80 discount 10 mg bisoprolol free shipping, but overlapping experiences must be combined into a larger representation that mediates expression of flexible pulmonary hypertension xanax buy bisoprolol discount, inferential memory blood pressure chart vaughns 1 pagers com discount 10 mg bisoprolol with visa. For example, in one experiment, rats initially learned a series of distinct but overlapping associations between odor stimuli (Bunsey and Eichenbaum, 1996; figure 5. Following training on two sets of overlapping odor-odor associations (A-B and X-Y, then B-C and Y-Z), subsequent probe tests were used to characterize the extent to which learned representations could be linked to support expression of inferential memory. The control rats learned paired associates rapidly and hippocampal damage did not a¤ect the acquisition rate on either of the two training sets. The intact rats also showed that they could link the information from overlapping experiences and employ this information to make in- ferential judgments in two ways. First, normal rats showed strong transitivity across odor pairings that contained a shared item. For example, having learned that odor A goes with odor B, and B goes with C, they could infer that A goes with C. For example, having learned that B goes with C, they could infer that C goes with B. By contrast, rats with selective hippocampal lesions were severely impaired, showing no evidence of transi- tivity or symmetry. A similar characterization accounts for the common observation of deficits in spatial learning and memory following hippocampal damage. For both tests a preference score was calculated as ða À bÞ=ða þ bÞ, where a and b were the digging times in the appropriate and alternate choices, respectively. Left: In the test for transitivity, rats are presented with one of two sample cues from the first training set (A or X) and then required to select the appropriately matched choice cue from the second set (C or Z, respectively), based on the shared associates of these items. It is important to note that training in the conventional version of the task involves an intermixing of four di¤erent kinds of trial episodes that di¤er in the starting point of the swim. Under this condition, animals with hippocampal damage typically fail to acquire the task (Morris et al. However, if the demand for synthesizing a solution from four di¤erent types of episodes is eliminated by allowing the animal to repeatedly start from the same position, animals with hippocampal damage acquire the task almost as readily as normal rats and use the same distant spatial clues in identifying the escape site (Eichenbaum et al. Nevertheless, even when rats with hippo- campal damage are successful in learning to locate the escape platform from a single start position, they are unable to use this information for expression of flexible, infer- ential memory. Thus, once trained to find the platform from a single start position, normal rats readily locate the platform from any of a set of novel start positions. However, under these same conditions, rats with hippocampal damage fail to readily locate the platform, often swimming endlessly and unsuccessfully in a highly familiar environment. The view that has emerged from these and many other studies is that the hippo- campus plays a central role in the creation of a broad range of memory networks, with their central organizing principle the linkage of episodic memories by their com- mon events and places, and a consequent capacity to move among related memories within the network. The scope of such a network reaches to various domains relevant to the lives of animals, from knowledge about spatial relations among stimuli in an environment, to categorizations of foods, to learned organizations of odor or visual stimuli or social relationships. The Elements: Memory-Coding Properties of Cortical and Hippocampal Neurons Parallel electrophysiological studies that involve recording from single cells through- out this brain system have provided a preliminary understanding of the neural coding mechanisms that underlie di¤erent aspects of memory performance that contribute to conscious recollection and explicit expression of memory. In particular, many studies have focused on simple recognition tasks, such as delayed nonmatch-to-sample, which allow analysis of the neural firing patterns associated with perception, maintenance of memory representations, and cognitive judgments and actions based on memory. These studies have examined the firing patterns of neurons in several cortical areas, including the prefrontal cortex, inferotemporal cortex, and parahippocampal region, as well as the hippocampus. In a variety of cortical areas, and in both monkeys and rats, three general responses have been observed (figure 5. First, many cells exhibited selec- tive tuning to sample stimuli during the initial perception of the stimulus, indicating that these areas encode specific stimulus representations. Second, some cells contin- ued firing in a stimulus-specific fashion during a memory period when the cue was no longer present, indicating the persistence of a representation of the sample. Third, many cells showed enhanced or suppressed responses to the familiar stimuli when they reappeared in the memory test phase of the task, indicating involvement in the match-nonmatch judgment. All three types of representations have been found in prefrontal areas and in the parahippocampal region, suggesting that information about all aspects of the task is shared among these areas. However, it is likely that each area makes a distinct contribution to the performance of the task. For example, in rats we found that more cells in the orbitofrontal area exhibited stimulus-selective match enhancement or suppression, whereas more cells in the parahippocampal region exhibited sustained stimulus-specific activity during the delay (figure 5. In monkeys, a greater proportion of cells in the lateral prefrontal region showed sustained responses during the delay and conveyed more information about the match-nonmatch status of the test stimuli than the perirhinal cortex in a task where the memory delay was filled with interpolated material (Miller et al.

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For example hypertension renal failure discount bisoprolol 10 mg with visa, in diabetic ketoacidosis blood pressure levels low cheap 10mg bisoprolol with amex, gases and careful titration to avoid inducing alkalosis arteria 4ch effective 5mg bisoprolol. In cardiac ar- losis makes the myocardium more sensitive to stimuli and in- rest, interventions to maintain circulation and ventilation are creases the occurrence of dysrhythmias. TABLE 32–2 Sodium Imbalances Causes Pathophysiology Signs and Symptoms Hyponatremia 1. Hypotension and tachycardia uretic drug therapy or when water only is output 3. Headache, dizziness, weakness, lethargy, (eg, excessive sweating) creased glomerular filtration rate, and de- restlessness, confusion, delirium, muscle 2. Excessive losses with vomiting, GI creased ability of kidneys to excrete water tremors, convulsions, ataxia, aphasia suction, diarrhea, excessive water 4. Anorexia, nausea, and vomiting are com- enemas, excessive perspiration, burn (cerebral edema). Leads to impaired neu- mon; abdominal cramps and paralytic wounds, and adrenal insufficiency states rologic and muscular functions. Lethargy, disorientation, hyperactive ciency results from lack of intake or ex- decreases fluid volume in extracellular reflexes, muscle rigidity, tremors and cessive losses (diarrhea, diuretic drugs, fluid and intracellular fluid compartments spasms, irritability, coma, cerebral excessive sweating). Hypotension mon cause of hypernatremia because the creases extracellular fluid volume and 4. Fever, dry skin, and dry mucous thirst mechanism is normally activated, decreases intracellular fluid volume as membranes and water intake is increased. CHAPTER 32 MINERALS AND ELECTROLYTES 473 TABLE 32–3 Potassium Imbalances Causes Pathophysiology Signs and Symptoms Hypokalemia 1. Decreased strength of myocardial con- pressed ST segment; flattened or in- free intravenous fluids for several days. Excessive losses from the gastrointesti- Decreased response to catecholamines P wave; prolonged P-R interval; prolonged nal tract (vomiting, gastric suction, diar- and other substances that normally raise QRS complex with normal shape and rhea, overuse of laxatives and enemas) blood pressure. Premature atrial and ventricular or urinary tract (polyuria from diuretic 4. Neurologic changes due to impaired con- beats or atrioventricular block may occur, drugs, renal disease, excessive duction of nerve impulses usually in people taking digoxin. Movement of potassium out of serum and cardiac muscle, most likely with 3. Confusion, memory impairment, lethargy, tration of insulin and glucose in treat- impulses are slowed until muscle con- apathy, drowsiness, irritability, delirium ment of diabetic ketoacidosis and in traction cannot occur. Slowed gastric emptying and decreased Weakness of leg muscles usually occurs intestinal motility, probably caused by first. Then weakness ascends to include muscle weakness respiratory muscles and cause respira- 7. Abdominal distention, constipation, para- glomerular filtration rate with prolonged lytic ileus potassium deficiency. Impaired carbohydrate metabolism and deficiency may increase serum creatinine decreased secretion of insulin and blood urea nitrogen 8. Impaired excretion due to renal insuffi- and muscle contraction respiratory insufficiency ciency, oliguria, potassium-saving diuret- 3. Cardiotoxicity, with arrhythmias or ics, aldosterone deficiency, or kalemia anesthetizes nerve and mus- cardiac arrest. Cardiac effects are not adrenocortical deficiency cle cells so electrical current cannot be usually severe until serum levels are 3. ECG changes include food sources of potassium include potas- tion) for an electrical impulse to be initi- a high, peaked T wave, prolonged P-R sium supplements, salt substitutes, ated and conducted. Movement of potassium from cells into serum with burns, crushing injuries, and acidosis ECG, electrocardiogram. Potassium is then eliminated from Alkalinization increases solubility of uric acid and sulfon- the body in the feces. Each gram of resin removes approxi- amide drugs and increases excretion of some acidic drugs mately 1 mEq of potassium. Because the resin requires sev- (eg, salicylates, phenobarbital) when taken in overdose.

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Milrinone has a long half-life of approxi- doses mately 80 hours and may accumulate with prolonged infusions heart attack high bride in a brothel order bisoprolol with amex. Rapid loading or digitalization heart attack 911 call buy bisoprolol 5mg otc, whether by one or more large doses or frequent administration of small doses 3 blood pressure omron buy discount bisoprolol 5 mg line. Impaired renal function, which delays excretion of Human Natriuretic Peptide B-type digoxin 4. Age extremes (young or old) Nesiritide (Natrecor) is the first in this new class of drugs to 5. Electrolyte imbalance (eg, hypokalemia, hypomagne- be used in the management of acute HF. Produced by recom- semia, hypercalcemia) binant DNA technology, nesiritide is identical to endogenous 6. Hypoxia due to heart or lung disease, which increases human B-type natriuretic peptide, which is secreted primarily myocardial sensitivity to digoxin by the ventricles in response to fluid and pressure overload. Hypothyroidism, which slows digoxin metabolism and This drug acts to compensate for deteriorating cardiac func- may cause accumulation tion by reducing preload and afterload, increasing diuresis and 8. Concurrent treatment with other drugs affecting the secretion of sodium, suppressing the renin–angiotensin– heart, such as quinidine, verapamil, or nifedipine aldosterone system, and decreasing secretion of the neuro- hormones endothelin and norepinephrine. Onset of action is immediate with peak effects attained in 15 minutes with a Phosphodiesterase Inhibitors bolus dose followed by continuous IV infusion. Administra- tion should be by a separate IV line because nesiritide is in- Inamrinone (Inocor), formerly amrinone, and milrinone IV compatible with many other drugs. Hemodynamic monitoring (Primacor) are cardiotonic-inotropic agents used in short- of pulmonary artery pressure is indicated to determine drug term management of acute, severe HF that is not controlled effectiveness. Clearance of the drug is proportional to body by digoxin, diuretics, and vasodilators. The drugs increase weight and partially by the kidneys; however, no adjustment levels of cyclic adenosine monophosphate (cAMP) in myo- in dosing is required for age, gender, race/ethnicity, or renal cardial cells by inhibiting phosphodiesterase, the enzyme that function impairment. They also relax vascular smooth ducted on the use of nesiritide for more than 48 hours. The effects of these drugs are additive to those Endothelin Receptor Antagonists This new class of drugs relaxes blood vessels and improves blood flow by targeting endothelin-1 (a neurohormone) that is produced in excess in heart failure. Endothelin-1 causes Nursing Notes: Apply Your Knowledge blood vessels to constrict, forcing the ailing heart to work harder to pump blood through the narrowed vessels. Studies Your assessment of Pamela Kindra reveals the following: indicate that endothelin antagonist drugs improve heart func- 118/92, 110, 32 and labored. Respiratory assessment reveals tion, as measured by cardiac index; animal studies indicate coarse rhonchi and wheezing bilaterally. Urine output has been that structural changes of heart failure (eg, hypertrophy) may less than 30 cc per hour and she has gained 12 pounds over the be reversed by the drugs. After examining her, he orders tration (FDA) approved but only for treatment of pulmonary digoxin 0. Discuss specific indications for these drugs in the management of the rationale for your answer. CHAPTER 51 DRUG THERAPY OF HEART FAILURE 749 Assess a baseline ECG before digoxin therapy when Nursing Process possible. If a client is in normal sinus rhythm, later ECGs may aid recognition of digitalis toxicity (ie, drug-induced Assessment dysrhythmias). If a client has an atrial tachydysrhythmia Assess clients for current or potential HF: and is receiving digoxin to slow the ventricular rate, later • Identify risk factors for HF: ECGs may aid recognition of therapeutic and adverse ef- • Cardiovascular disorders: atherosclerosis, hyper- fects. For clients who are already receiving digoxin at the tension, coronary artery disease, myocardial infarction, initial contact, a baseline ECG can still be valuable because cardiac dysrhythmias, and cardiac valvular disease. Within the clinical syndrome of HF, clinical mani- fluid accumulation in lungs festations vary from few and mild to many and severe, • Imbalanced Nutrition: Less Than Body Requirements re- including the following: lated to digoxin-induced anorexia, nausea, and vomiting • Mild HF. Common signs and symptoms of mild HF are • Noncompliance related to the need for long-term drug ankle edema, dyspnea on exertion, and fatigue with or- therapy and regular medical supervision dinary physical activity. Edema results from increased • Deficient Knowledge: Managing drug therapy regimen venous pressure, which allows fluids to leak into tissues; safely and effectively dyspnea and fatigue result from tissue hypoxia. More extensive edema, dysp- Planning/Goals nea, and fatigue at rest are likely to occur. Additional the client will: signs and symptoms include orthopnea, postnocturnal dyspnea, and cough (from congestion of the respiratory • Take digoxin and other medications safely and accurately tract with venous blood); mental confusion (from cere- • Experience improved breathing and less fatigue and edema bral hypoxia); oliguria and decreased renal function • Maintain serum digoxin levels within therapeutic ranges (from decreased blood flow to the kidneys); and anxiety. Acute pul- especially during digitalization, when dosage is being monary edema indicates acute HF and is a medical emer- changed, and when other drugs are added to or removed gency.

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Unfortunately arteria humeral buy bisoprolol 5mg with mastercard, while the notion of building wings was ingenious and the construction of them skilful blood pressure iphone buy bisoprolol 10mg amex, the theory was based on a major miscalculation: his wings were made of feathers and wax hypertension chart bisoprolol 5 mg without a prescription, and when he flew near to the sun the wax melted and he fell back to earth. Ideas the problem is usually having too many of them, rather than not having any at all (see rumination). Illness Many people find it helpful to write about the illness of themselves or of a loved one. Your chances of getting an article of this kind published increase considerably if you can draw out of the particular case some general message. Illustrations When writing for scientific papers, you will be expected to provide these, when appropriate. Take guidance from the Instructions to Authors and from the Vancouver group guidelines. If you are using pictures of patients, make sure that you have their written consent. When writing for magazines and newspapers, you will not normally be expected to provide photographs and illustrations: the editorial staff will organize these. The exception is if you have taken photographs, for instance on an expedition to the North Pole, that cannot be replicated. A useful principle when submitting illustrations, particularly valuable ones, is that anything that can be lost will be lost. This is now a huge enterprise, under- taken by the Institute for Scientific Information in its annual Journal Citation Reports. But despite the elegance of the idea, impact factors have had a baleful influence on medical writing. As a measure of quality, of course, the index is suspect because it modifies the human behaviour it tries to measure. Most of those involved with science publishing agree that the system favours US journals, and that individual editors from all over the world directly and indirectly encourage authors to cite from their own journal. The whole thing becomes self-fulfilling as those with high scores attract the best pieces, and those with a lower index start to struggle. As for writers, impact factors have encouraged them to choose publications on the basis of the points they are likely to get rather than because of the audience they would like to reach. It encourages them – and their co-authors – to hold out for a high impact journal, even though any rational view would tell them that the work in hand is simply not appropriate (see Icarus fallacy). Some departments now send their article routinely to the higher impact journals, rational- izing it by saying that at least they will get a high quality review. IMRAD structure the model was originally proposed by the British scientist Bradford Hill, and the idea was to help writers by using a simple four-part structure. This section usually consists of about six to seven paragraphs, though journals concentrating on pure research may often take longer. The descriptions should be full enough to allow someone else to replicate what you did. Sometimes there may be as many as seven to eight paragraphs, each dealing with a particular aspect. However, while IMRAD is a useful structure for authors to follow, it is not reader-friendly. The main message is at the end (if at all) which is not a logical place to put it. However, the last two or three genera- tions of scientists have become used to it, and therefore if you want to communicate with them then you must conform to that structure. Under no circumstances, however, should you use this structure for anything other than original scientific papers, and perhaps some papers for other professionals who are somehow expecting that you write this way. The trouble is that they end up writing to please themselves, not the reader (see false feedback loop). Instructions to Authors Most academic journals publish a wide range of specific rules on what contributions they seek and how they wish to have them presented (see style guide). Most of them go into considerable detail, with instructions on the size of paper, how to lay out the first page, copy- right and reprints, and the number and style of references.

Jorn, 45 years: The pathway of propriospinally mediated reciprocal inhibition has been omitted. Kim K, Suk K, Kim J, Lee S (2003) (1987) Paraplegia caused by vertebral 106. De-efferentation was achieved by complete nerve block with lignocaine proximal to recording site (horizontal double-headed dashed line in (a)). Modafinil may increase effects of clomipramine, person of 70 kg or 150 lbs) may cause myocardial irritability, phenytoin, tricyclic antidepressants, and warfarin.

Iomar, 22 years: This does not have to be an expensive gift or reward but instead may be time set aside for a particular activity that the child enjoys doing with their parent. Megaloblastic anemias, characterized by draw up and administer 5 mL of KCl IM to the patient. CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 61 Neonates, Infants, and Children: Physiologic Characteristics and TABLE 4–2 Pharmacokinetic Consequences Physiologic Characteristics Pharmacokinetic Consequences Increased thinness and permeability of skin in Increased absorption of topical drugs (eg, corticosteroids may be absorbed sufficiently to neonates and infants suppress adrenocortical function) Immature blood–brain barrier in neonates Increased distribution of drugs into the central nervous system because myelinization and infants (which creates the blood–brain barrier to the passage of drugs) is not mature until approximately 2 years of age Increased percentage of body water (70% Usually increased volume of distribution in infants and young children, compared with to 80% in neonates and infants, compared with adults. Activity-dependent learning contributes in human gait: Modulation of magnetically evoked to motor recovery.

Josh, 64 years: After the patient responds with the tar- combined with operant conditioning for the get words, the patient is asked to complete the global aphasic patient, but the efficacy was lim- story without benefit of having heard the tar- ited. A virtual reality-based exercise program matosensory cortex induced by motor activity. It is especially use- administration of colchicine prevents this effect. Clinical trials for phase 3 studies em- bias and complications as the clinician on a re- ploy the gold standard design of a randomized habilitation service imagines.

Hernando, 62 years: These find- Tonic contraction ings suggest that the re-appearance of presynaptic Heteronymous facilitation of the soleus H reflex was inhibition after its initial decrease is centrally pre- not significantly increased during relatively strong programmed, much as is the suppression of presy- tonic contractions of soleus at 20% of MVC (Meunier naptic inhibition and the degree of suppression. For ketoaci- ketotic coma, severe infections or dosis, regular insulin may be given other illnesses, major surgery, and by direct injection, intermittent infu- pregnancy sion, or continuous infusion. Spherical glia and neurons form weak adhesion with this complex surface within 15–30 min and flatten and extend short processes by 1– 2 hr. If you find yourself craving a particularly naughty food, reserve it for your cheat meal.

Rakus, 28 years: The suppression of the inhibition in ues correlated with the intensity of rigidity assessed patients with corticospinal lesions might suggest by the Webster scale: increased rigidity was associ- that there is normally tonic corticospinal facilitation ated, first, with a reduction of inhibition and, from ofIbinterneurones. In view of ing new frontier in the understanding and possible treat- their radiating processes that extend from the cell border ment of metabolic bone disorders such as osteoporosis. Adduct your wrist, that is bend it toward the forearm on the little finger side while keeping your fingers straight. The reason for the absence humanlowerlimbmighthaveevolvedtoprovidethe may be related to the role of the gastrocnemius- moreelaboratereflexassistancerequiredforbipedal soleus during plantigrade gait.

Kasim, 31 years: Your postoperative patient is hypotensive and has low urine out- PRINCIPLES OF THERAPY put. Liver, muscle, and fat cells have many insulin receptors is to lower blood glucose levels, primarily by the following and are primary tissues for insulin action. Infections caused by Salmonella or • Replacement of fluids and electrolytes (2 to 3 quarts daily). During postural co- the Ia excitatory connection that is not appropri- contractions of quadriceps and soleus, as occur in ate for a particular movement.

Finley, 33 years: Acetylcholine is released in the esophagus, stomach, or duodenum, areas of the gastro- by vagus nerve endings in response to stimuli, such as thinking 867 868 SECTION 10 DRUGS AFFECTING THE DIGESTIVE SYSTEM BOX 60–1 SELECTED UPPER GASTROINTESTINAL DISORDERS Gastritis sis, burns, acute respiratory distress syndrome, major surgical pro- Gastritis, a common disorder, is an acute or chronic inflammatory cedures, or other severe illnesses. Later manifestations may include jaundice, vomiting, and CNS stimulation with ex- Nursing Notes: Apply Your Knowledge citement and delirium, followed by vascular collapse, coma, and death. The referrer may only select COGNITIVE BEHAVIOUR THERAPY 283 those possible participants who they view as Bentall et al. Louis as the first recipient of the Malcolm Baldrige National Quality Award for Healthcare.

Norris, 21 years: When directly implanted into isch- emic tissue in a rat stroke model, however, no Human Studies effect was detected. For example, as rats performed a spatial DNMS task, some hippocampal cells were activated when the rat pressed one of two levers only during the sample phase or only during the test phase of the task (Hampson et al. Hydrochlorothiazide vocate this approach as preferable to supplemental 50 mg may also be used with furosemide and may be potassium or combination diuretic therapy, but its safer than metolazone because of its shorter duration effectiveness is not clearly established. Whenever you are asked your opinion on a piece of writing, first establish the audience for which is intended.

Cobryn, 54 years: If you want to give information, but not be linked to it (for valid reasons. THE ULTIMATE NEW YORK BODY PLAN EXERCISE PROGRAM 71 TLFeBOOK PLATYPUS WALK WITH MEDICINE BALL A. This claim is supported by circumstantial evidence garnered from electron microscopic, immuno- logic, and epidemiologic studies [56]. Subjects with 17 or 18 points are consid- Motor evoked potentials ered free of signs of cervical myelopathy.

Leon, 52 years: In the past two decades, methods have been developed that allow the growth of primary cultures, derived from a variety of dissociated central nervous system (CNS) tissues, on surfaces decorated with substrate-integrated microelectrodes. An indirect effect on osteoclast recruitment mediated toms; the former tends to respond better to surgical de- by cells of osteoclastic lineage that are capable of stim- compression [126]. Transmission through group II pathways background activity from peripheral or descend- ing sources (Lundberg, Malmgren & Schomburg, Transmission through group II interneurones is very 1987b, c). This implies only declaring differences as effect which will be estimated from the trial data statistically significant at the 100α% level if the by a comparison of all patients randomised to one observed p-value <α/k.

Tukash, 26 years: The significance of these findings with respect to developing a neural prosthesis for replacing cognitive functions is severalfold. This is the reason unreasonably at the time, as due to the mutual inhi- for its inclusion in the present chapter. Just allow the contents of your brain and your heart to spill out on the paper. This manner of standing may, for some, seem strange and uncomfortable at first, due to years of misalignment and injuries.

Nefarius, 37 years: She is recovering from a modified radical mastectomy when she comes to the clinic to dis- cuss additional treatment with chemotherapy with the oncologist. Overall survival in this patient cat- lowed by e anterior revision and restabilization after a previous embolization of the tumor and occlusion of one of the vertebral ar- egory is around 12 months [12, 15, 33, 48, 51, 54, 56]. Amsterdam: lesion: evidence for presynaptic inhibition of Ia transmis- Elsevier. Weissfeld JL, Ling BS, Schoen RE, Bresalier dose folinic acid, or both, as adjuvant chemother- RS, Riley T, Prorok PC.

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