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This helps promote respiratory and cardiovascular • Assess for risk factors for complications of anesthesia and function and decreases anxiety combivent 100mcg sale medications for high blood pressure. Postoperatively discount combivent 100 mcg overnight delivery medicine 014, the major focus is on maintaining a safe en- vironment and vital functions combivent 100mcg with visa medications venlafaxine er 75mg. Speciﬁc interventions include: Postoperative Assessment • Observe and record vital signs cheap combivent 100 mcg with mastercard medicine expiration dates, level of consciousness, res- • During the immediate postoperative period, assess vital piratory and cardiovascular status, wound status, and elim- signs and respiratory and cardiovascular function every ination frequently until sensory and motor functions return, 5 to 15 minutes until reactive and stabilizing. If potential problems are identiﬁed (eg, hypo- • Continue to assess vital signs, ﬂuid balance, and laboratory volemia or hypervolemia), intervene to prevent them and other data. This combination should not be given IV or in exces- fever or other signs of infection). This combination should not be used with inhalation ing before injecting the local anesthetic solution. If anesthetic agents that increase myocardial sensitiv- blood is aspirated into the syringe, another injection ity to catecholamines. These drugs should not be used in clients with se- and may depress muscle strength, muscle tone, and root- vere cardiovascular disease or hyperthyroidism. If excessive amounts are used (eg, in paracervi- rine should be no greater than 1:200,000 because of cal block), local anesthetics may cause fetal bradycar- the danger of producing vasoconstriction in uterine dia, increased movement, and expulsion of meconium blood vessels. Such vasoconstriction may cause de- before birth and marked depression after birth. Dosage creased placental circulation, decreased intensity of used for spinal anesthesia during labor is too small to uterine contractions, and prolonged labor. For spinal or epidural anesthesia, use only local anes- thetic solutions that have been speciﬁcally prepared for spinal anesthesia and are in single-dose containers. Topical Anesthesia Multiple-dose containers are not used because of the of Mucous Membranes risk of injecting contaminated solutions. Epinephrine is often added to local anesthetic solutions When used to anesthetize nasal, oral, pharyngeal, laryngeal, to prolong anesthetic effects. Such solutions require tracheal, bronchial, or urethral mucosa, local anesthetics special safety precautions, such as the following: should be given in the lowest effective dosage. This combination of drugs should not be used for well absorbed through mucous membranes and may cause nerve blocks in areas supplied by end arteries (ﬁn- systemic adverse reactions. CLIENT TEACHING GUIDELINES Perioperative Medications ✔ When anticipating a surgical procedure and a general ✔ With preanesthetic, sedative-type medications, stay in anesthetic, be sure to inform health care providers about bed with the siderails up and use the call light if help is any herbal or other dietary supplements you take. You may fall or otherwise injure yourself if you American Society of Anesthesiologists recommends that get out of bed without assistance. Most of the com- alert from general anesthesia, sedation, or pain med- monly used herbal products (eg, echinacea, ephedra, fever- ication. Because few studies and little testing you will receive pain medication by injection (often intra- have been done, some products have unknown effects venously) for 2 or 3 days, then by mouth. CHAPTER 14 ANESTHETICS 229 CLIENT TEACHING GUIDELINES Topical Anesthetics ✔ Use the drug preparation only on the part of the body for ✔ With spray preparations, do not inhale vapors, spray near which it was prescribed. If the condition for which it is being used persists, report ✔ Use the drug only for the condition for which it was pre- the condition to the physician. For example, a local anesthetic prescribed to re- ✔ Inform dentists or other physicians if allergic to any local lieve itching may aggravate an open wound. Allergic reactions are rare, but if they ✔ Apply local anesthetics to clean areas. For the drugs to have occurred, another type of local anesthetic can usu- be effective, they must have direct contact with the af- ally be substituted safely. Use in Children Adverse effects include respiratory depression, hypo- tension, and pain with injection. Slow titration of dosage, Compared with adults, children are at greater risk of compli- a large-bore IV catheter, adding lidocaine, and slow cations (eg, laryngospasm, bronchospasm, aspiration) and drug injection into a rapidly ﬂowing IV can minimize death from anesthesia. In addition, the formulation now contains to children should be knowledgeable about anesthetics and an antimicrobial agent, which should reduce risks of their effects in children. In general, infants and children have a higher anes- require anesthesia or sedation must be skilled in using the thetic requirement, relative to size and weight, than nursing process with children. Some agencies allow parents to be present during in- chodilation and does not irritate respiratory mucosa, duction of general anesthesia. This seems to reduce features that make it especially useful for children with anxiety for both parents and children. However, the drug dilates blood vessels in the of surgery and anesthesia, contraindications to a par- brain and increases intracranial pressure, so it may not ticular agent, the presence of client conditions that af- be indicated in clients who already have increased fect or preclude use of a particular drug, and the intracranial pressure or mass lesions. For short surgical also sensitize the myocardium to epinephrine, although procedures, intermediate-acting nondepolarizing agents children are less likely than adults to have ventricular (eg, atracurium, mivacurium) are commonly used. Sevoﬂurane, a newer agent, may have some advan- contraindicated for routine, elective surgery in children tages over halothane in pediatric anesthesia. This precaution stems from reports of a faster induction and emergence, does not stimulate several deaths associated with the use of succinylcholine the sympathetic nervous system or potentiate cardiac in children with previously undiagnosed skeletal mus- dysrhythmias, and produces a minimal increase in in- cle myopathy. However, it is much more expen- cated in children who require emergency intubation or sive than halothane. Propofol is approved for use in children 3 years of age stomach) and for intramuscular administration when a and older. It has a rapid onset; a rapid metabolism rate; suitable vein is unavailable. Children are more likely to have postoperative nausea sedation, or nausea. In addition, propofol is widely used for cautions, and adverse effects in children as in adults. Propofol caine have not been established in children younger than may be given by injection for induction and an IV infu- 12 years of age. Benzocaine should not be used in in- sion pump for maintenance of anesthesia or sedation. Dosages in children 230 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM should be reduced according to age, body weight, and renal impairment may lead to accumulation of neuromuscular physical condition. The drugs should be used With topical applications to intact skin, there is greater very cautiously in clients with renal impairment. A mix- ture of lidocaine and prilocaine (Eutectic Mixture of Local Anesthetics [EMLA]) was formulated to penetrate Use in Hepatic Impairment intact skin, provide local anesthesia, and decrease pain of vaccinations and venipuncture. The cream is applied Most inhalation general anesthetics are minimally metabo- at the injection site with an occlusive dressing at least lized in the liver and therefore are unlikely to accumulate 60 minutes before vaccination or venipuncture. Propofol is metabolized EMLA cream should not be used on mucous mem- mainly in the liver to inactive metabolites, which are then ex- branes (or abraded skin). Propofol clearance may be slower be- sorbed through mucous membranes and may cause cause of decreased hepatic blood ﬂow. Neuromuscular blocking agents vary in the extent to which they are metabolized in the liver. For example, atracurium, rocuronium, and vecuronium are eliminated mainly by the Use in Older Adults liver.
Some ACE inhibitors ever buy combivent 100 mcg on line medicine rocks state park, metolazone combivent 100mcg low cost symptoms 8dpo, a thiazide-related drug order combivent line medicine remix, may be used (eg discount combivent 100mcg with amex symptoms ectopic pregnancy, lisinopril, ramipril, quinapril, moexipril) or their and relatively large doses may be required. Loop di- active metabolites produce higher plasma concentra- uretics, such as furosemide, are more often used, and tions in older adults than in younger ones. Additional guidelines include: effective in clients with renal impairment, but responses a. The goal of drug therapy for systolic-diastolic may vary and the following factors should be considered. When a client with renal impairment is started on an 140 mm Hg and a diastolic below 90 mm Hg in ACE inhibitor, careful monitoring is required, espe- clients with no other complications. For those with cially during the ﬁrst few weeks of therapy, to pre- diabetes or renal failure, the goal is a systolic pres- vent irreversible renal failure. For some clients, it sure below 130 mm Hg and a diastolic below 85 mm may not be possible to normalize blood pressure and Hg. However, the latter goal may be difﬁcult for most maintain adequate renal perfusion. In clients with severe atherosclerosis, especially those during blood pressure reduction in most clients; and with unilateral or bilateral stenosis of renal arteries, they are mainly eliminated by hepatic metabolism. ACE inhibitors can impair renal blood flow and However, cautious use is still recommended because worsen renal impairment (ie, increase blood urea ni- several agents produce active metabolites that are trogen [BUN] and serum creatinine). This may re- excreted by the kidneys (see section on Use in Renal quire stopping the drug. Although these are usually minor and transient, the drug may Use in Hepatic Impairment need to be discontinued or reduced in dosage. Approximately 25% of clients taking an ACE in- Little information is available about the use of antihyperten- hibitor for heart failure experience an increase in sive drugs in clients with impaired hepatic function. These clients usu- many of the drugs are metabolized in the liver and hepatic im- ally do not require drug discontinuation unless they pairment can increase and prolong plasma concentrations. Angiotensin-converting enzyme inhibitors have occa- with severe heart failure, whose renal function may sionally been associated with a syndrome that started depend on the activity of the renin–angiotensin– with cholestatic jaundice and progressed to hepatic aldosterone system, management with an ACE in- necrosis and sometimes death. The mechanisms are unclear, but ACE inhibitors also ACE inhibitor should have the drug discontinued. In ad- have renal protective effects in hypertensive clients dition, therapeutic effects can be decreased with several with some renal impairment and clients with diabetic of the drugs (eg, fosinopril, quinapril, ramipril) because nephropathy. A possible mechanism is less damage to less of a given dose is converted to an active metabolite. Angiotensin II receptor blockers should be used cau- their active metabolites is prolonged in clients with tiously in clients with biliary tract obstruction or hepatic renal impairment. For some of these drugs (eg, candesartan, with benazepril, lisinopril, quinapril, and ramipril. Angiotensin II receptor blockers also inhibit the However, a lower starting dose is recommended for renin–angiotensin–aldosterone system and may pro- losartan because plasma concentrations of the drug and duce effects similar to those of the ACE inhibitors. As its active metabolite are increased and clearance is de- with ACE inhibitors, some clients with severe heart creased approximately 50%. With telmisartan, plasma failure have had oliguria or worsened renal impair- concentrations are increased and bioavailability ap- ment. In addition, the drug is eliminated serum creatinine in clients with stenosis of one or both mainly by biliary excretion and clients with biliary tract renal arteries. The drug should be used with caution, but dosage clients with renal impairment. However, ﬂuid volume forms that allow dosage reduction below 40 mg are not deﬁcits (eg, from diuretic therapy) should be corrected available. Thus, an alternative drug should probably be before starting the drug, and blood pressure should be considered for clients with hepatic impairment. Beta blockers that normally undergo extensive ﬁrst- modialysis may have orthostatic hypotension with pass hepatic metabolism (eg, acebutolol, metoprolol, telmisartan and possibly other drugs of this group. Most beta blockers are eliminated primarily by the kid- levels in clients with cirrhosis because the blood con- neys and serum half-life is prolonged in clients with taining the drug is shunted around the liver into the sys- renal impairment. An additional con- bisoprolol and pindolol should also be reduced in sideration is that cardiac output and blood pressure clients with cirrhosis or other hepatic impairment. Calcium channel blockers should be used with caution, ﬂow and aggravate renal impairment. Calcium channel blockers are often used in clients with should be monitored periodically, and clients should be renal impairment because, in general, they are effective closely monitored for drug effects (see section on Use and well tolerated; they maintain renal blood ﬂow even in Hepatic Impairment, Chap. The infusion Antihypertensive drugs are frequently prescribed for clients should be stopped after 72 hours if the serum thiocyanate with critical illness and must be used cautiously, usually with level is more than 12 mg/dL; it should be stopped at 48 hours reduced dosages and careful monitoring of responses. Symptoms of thiocyanate many cases, the drugs are continued during critical illnesses toxicity (eg, nausea, vomiting, muscle twitching or spasm, caused by both cardiovascular and noncardiovascular dis- and seizures) can be reversed with hemodialysis. If the client cannot take oral drugs, drug choices are that may be used include IV hydralazine, labetalol, and narrowed because many commonly used drugs are not avail- nicardipine; see Drugs at a Glance: Antihypertensive Drugs. In one Herbal and Dietary Supplements way, this may be more difﬁcult, because critically ill clients are often unstable in their conditions and responses to drug Use of nonprescription herbal and dietary supplements is fre- therapy. In another way, it may be easier in a critical care unit, quently not reported by the client even though one third of the where hemodynamic monitoring is commonly used. Signiﬁcant inter- of management is usually to maintain adequate tissue perfu- actions can occur between herbs and dietary supplements sion while avoiding both hypotension and hypertension. Many nonprescription Antihypertensive drugs are also used to treat hypertensive medications such as antihistamine, cold/cough preparations, urgencies and emergencies, which involve dangerously high and weight loss products can decrease the effectiveness of blood pressures and actual or potential damage to target or- antihypertensive drugs or worsen hypertension. Although there are risks with severe hypertension, its stimulating effects, may increase blood pressure. Ephedra there are also risks associated with lowering blood pressure (ma huang), used to suppress appetite, treat colds, nasal con- excessively or too rapidly, including stroke, myocardial in- gestion and asthma, and increase energy, increases blood farction, and acute renal failure. This product should be ment is usually to lower blood pressure over several minutes avoided by anyone with hypertension; it is not recommended to several hours, with careful titration of drug dosage to for therapeutic use by anyone. Home Care A hypertensive emergency, deﬁned as a diastolic pressure of 120 mm Hg or higher and target organ damage, requires Antihypertensive drugs are commonly self-administered in an IV drug. The home care nurse is most likely to be in- astolic pressure to 100 to 110 mm Hg and maintain it there volved when making home visits for other reasons. Whether for several days to allow adjustment of the physiologic mech- the client or another member of the household is taking anti- anisms that normally regulate blood pressure. Then, the hypertensive medications, the home care nurse may be help- blood pressure can be lowered to normotensive levels. Fenoldopam is a fast-acting drug indicated only for (pharmacologic and lifestyle modiﬁcations). Dosage is Noncompliance with prescribed antihypertensive drug calculated according to body weight and desired effects on therapy is a major problem, and consequences may be cata- blood pressure. The home care nurse is well situated to assess for frequent monitoring of blood pressure.
Your publisher will have been involved in many more books than you have and will be better attuned to the target audience purchase 100 mcg combivent with mastercard symptoms multiple myeloma. If you think every proposed change is an insult to your great talent purchase genuine combivent on line symptoms in early pregnancy, you are either being unrealistic or are with the wrong publisher purchase 100mcg combivent visa symptoms zithromax. You then have a simple decision to take: do you negotiate 100 mcg combivent free shipping symptoms sleep apnea, or do you end the relationship and try to find another publisher? After about six months the book will be published – and there will probably be an anticlimax. Your friends will say (to your face) that the book is wonderful (and then drop hints about a free signed copy); letters of 13 THE A–Z OF MEDICAL WRITING praise from unknown admirers are less likely. The real point about writing books is that, like mountains, they are there. Books, writing of chapters in One of the great advan- tages of multi-authored books is that they meet the huge demand for authorship. Be flattered by the invitation to contribute, and then consider whether you really want (or need) to invest the time. Saying no at this stage will be appre- ciated: publishers say that their biggest problem in multi-authored books is dealing with the delays caused by those who keep insisting that they want to contribute, but never get around to doing so. Approach the project as you would any other writing task (see process of writing). Divide the chapter into manageable chunks of 1000 words or so, and use the structure of a feature article for each section. You are unlikely to get paid, and if so it will rarely be above £200 a chapter. You should be offered a free copy of the book; make sure you display it prominently. Bosses Some are marvellously helpful when it comes to giving balanced feedback on what we write. Remember that bosses can turn into a powerful false feedback loop, and that throughout the writing 14 BOSSES process our duty is to argue – tactfully – for the interests of our target readers (see negotiating over copy). Brainstorming Throughout the writing process our tendency to criticize can overwhelm our capacity to be creative. Brainstorming techniques try to circumvent that in the planning stage by encouraging us to put down our thoughts on paper – as they come and without stopping to criticize them. A development of this is branching (see below) where we allow our thoughts to spill out all over the page in a much freer way. A sophisticated version of this is mindmapping, a system developed by Tony Buzan (see process of writing booklist). Branching Branching techniques, such as spidercharts and mindmapping, play an important part in the writing process – in particular, at the stage when you have decided on your message and need to collect and arrange the information needed to prove it. All you need is the message, a large piece of paper with at least one pen or pencil (some say more) and 5–10 minutes. Each question should lead to others, and when you come to the end of one train of thought you should go back to the message in the middle and start again. Within minutes you will have a page covered with words, all coming out from the message in the middle. The advantage of this, as one course participant once put it, is that the mess in your head is now the mess on a piece of paper. You will, for instance, be able to distinguish between matters of substance that must be included, and detail that could be included if space permits. Breaks Locking yourself in a room for three hours at a time is unlikely to boost your creativity. Try to write in short bursts of, say, 10–15 minutes, and make sure that you really are writing and not worrying about what you have just written (see free writing). Brief setting One of the great mistakes we make when writing is to start too early, without really knowing where we want to end up. Some people start by writing lists; others go straight to a word processor and start writing down what comes into their heads. By all means let your writing be a voyage of discovery, but look at the existing navigation charts before you set out. You may be able to do it in less than a minute; with more difficult pieces of writing you may need days or even weeks. As long as it remains rumination, not procrastination, you should not worry. As for what you need to think about, these are contained in the following five points. Work out the most important thing you want your readers to take away from your writing. This is the message, and should take the form of a simple sentence of about 10 words. Do not settle for a question: if you do not yet have the answer, do more research or more thinking or both. Decide for whom this message is intended (audience) and how you intend to get it to them. Be specific: the more tightly defined your audience, the greater your chances of success. If you want to write an article, define which journal (The Lancet, for instance, or Country Life? If you are writing a report justifying the purchase of an expensive piece of equipment, write for the main player in the decision-making committee. If it looks as though you will have to please two separate audiences at the same time – such as a report 16 BRIEF SETTING on the latest research for members of a patient group and inter- ested doctors – then write two different reports. Decide on the length of the piece of writing, measured in words or paragraphs. This should not be determined by how you rate the importance of the topic (or happen to know about it), but on what the market should bear. Then work backwards, inserting second-level deadlines for the major steps you need to take on the way. Too often we judge it in terms of half-remembered notions of literary criticism (see English teachers; examinations). Now we are established in our careers, we should regard writing as a tool not a test, and therefore judge success not by the details, but by whether our writing has enabled us to achieve what we set out to do. For instance, if we are trying to attract a £1 million grant, and we manage to do so, our writing has succeeded, irrespective of whether we have split the odd infinitive. Similarly, if we are trying to get a paper published in a prestigious journal and it is accepted, we have also succeeded (and subsequent gripes from rivals should be seen in this context). You may not believe it at the time, but having a clear idea on the above five questions will make all the difference to what you are setting out to do. This will be based on the multicentre SOLE trial and will comprise 500 words. The article will be written by August 1, revised by August 15, sent out to co-authors on September 1 and submitted on September 21.
Intra-arterial blood pressure should be moni- alternative drugs buy combivent visa medications causing pancreatitis, the nurse may be able to identify resources tored during the infusion 100mcg combivent sale symptoms you need glasses. CHAPTER 55 ANTIHYPERTENSIVE DRUGS 815 NURSING Antihypertensive Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1 buy 100 mcg combivent otc medications just for anxiety. Give oral captopril and moexipril on an empty stomach order combivent once a day illness and treatment, 1 h Food decreases drug absorption. Give most other oral antihypertensives with or after food in- To decrease gastric irritation take. For intravenous injection of propranolol or labetalol, the For early detection and management of excessive myocardial de- client should be attached to a cardiac monitor. Atropine may be used to treat excessive enteral atropine and isoproterenol (Isuprel) must be readily bradycardia. Give the ﬁrst dose and the ﬁrst increased dose of prazosin, To prevent orthostatic hypotension and syncope doxazosin, and terazosin at bedtime. They also have speciﬁc requirements for preparation and of use, and monitoring of blood pressure during infusion. A protocol established beforehand can save valu- able time in an emergency situation. Observe for therapeutic effects the choice of drugs and drug dosages often requires adjustment to maximize beneﬁcial effects and minimize adverse effects. The usual goal is a normal blood optimal therapeutic effects may not occur immediately after drug pressure (ie, below 140/90). Observe for adverse effects Adverse effects are most likely to occur in clients who are elderly, have impaired renal function, and are receiving multiple anti- hypertensive drugs or large doses of antihypertensive drugs. Orthostatic hypotension, dizziness, weakness This is an extension of the expected pharmacologic action. Ortho- static hypotension results from drug blockage of compensatory re- ﬂexes (vasoconstriction, decreased venous pooling in extremities and increased venous return to the heart) that normally maintain blood pressure in the upright position. This adverse reaction may be aggravated by other conditions that cause vasodilation (eg, exercise, heat or hot weather, and alcohol consumption). Orthostatic hy- potension is more likely to occur with guanethidine and methyldopa. Sodium and water retention, increased plasma volume, per- These effects result from decreased renal perfusion. This reaction haps edema and weight gain can be prevented or minimized by concurrent administration of a diuretic. Prolonged atrioventricular conduction, bradycardia Due to increased vagal tone and stimulation d. Gastrointestinal disturbances, including nausea, vomiting, These effects are more likely to occur with hydralazine, methyl- and diarrhea dopa, propranolol, and captopril. Mental depression (with reserpine) Apparently caused by decreased levels of catecholamines and serotonin in the brain f. Bronchospasm (with nonselective beta blockers) the drugs may cause bronchoconstriction and are contraindicated in patients with asthma and other bronchoconstrictive lung disorders. Hypertensive crisis (with abrupt withdrawal of clonidine or This may be prevented by tapering dosage over several days be- guanabenz). Cough and hyperkalemia with angiotensin-converting en- A chronic, nonproductive cough is a relatively common adverse zyme (ACE) inhibitors effect; hyperkalemia occurs in 1%–4% of clients. Drugs that increase effects of antihypertensives: (1) Other antihypertensive agents Combinations of two or three drugs with different mechanisms of action are often given for their additive effects and efﬁcacy in con- trolling blood pressure when a single drug is ineffective. Drugs that decrease effects of antihypertensives: (1) Adrenergics These drugs stimulate the sympathetic nervous system and raise blood pressure. They include over-the-counter nasal decongestants, cold remedies, bronchodilators, and appetite suppressants. What are adverse effects of each group of antihyperten- How Can You Avoid This Medication Error? For a client newly diagnosed with hypertension, outline tions may not be safely taken at this time. Crushing the medica- a teaching plan for lifestyle and pharmacologic inter- tions is also not indicated because Cardizem SR and Slow-K are sustained-release products. List interventions by health care providers that may help ministration, you will see a signiﬁcant hypotensive effect because hypertensive clients adhere to their management regi- all the medication will be absorbed. List at least two major considerations in using anti- slowly, which might cause it to be excreted by the diuretic effects hypertensive drugs in children, older adults, and clients of the Lasix, which is not affected by crushing. Mentally rehearse your assessment and interventions for a client with a hypertensive urgency or emergency. How would you assess a client being treated for hyper- Review and Application Exercises tension for compliance with the prescribed lifestyle and drug therapy regimen? What are the potential consequences of untreated or in- Pharmacotherapy: A pathophysiologic approach, 5th ed. Alterations in blood pressure: Hypertension direct vasodilators lower blood pressure? Porth, Pathophysiology: Concepts CHAPTER 55 ANTIHYPERTENSIVE DRUGS 817 of altered health states, 6th ed. Angiotensin-II receptor antagonists: Their place in ther- Williams & Wilkins. Endothelial dysfunction and the promise of ACE Advance for Nurse Practitioners, 8(4), 28–33, 92. Joint National Committee on Detection, Evaluation, and Treatment of High Saunders, C. The sixth report of the Joint National Committee for the Nurse Practitioner, 3(4), 60–80. The World Health Organization and the International Society of Hypertension Karch, A. Discuss the rationale for using combination anism of action, indications for use, principles of products containing a potassium-losing and a therapy, and nursing process implications. Discuss the rationale for concomitant use of a loop, and potassium-sparing diuretics. Teach clients to manage diuretic therapy effec- reactions to diuretic administration. Discuss important elements of diuretic therapy and potassium-sparing diuretics. Critical Thinking Scenario Jennie Masury, an 82-year-old widow, is started on a thiazide diuretic to control her hypertension. She lives alone with her two cats and manages independently with only a lit- tle help from her neighbors.