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NURSING Nasal Decongestants buy discount duloxetine 40 mg anxiety symptoms and causes, Antitussives cheap 40mg duloxetine with mastercard anxiety ocd, and Cold Remedies ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1 cheap duloxetine 40 mg free shipping anxiety high blood pressure. With topical nasal decongestants: (1) Use only preparations labeled for intranasal use purchase 60mg duloxetine with visa anxiety symptoms eyesight. Intranasal preparations are usually dilute, aqueous solutions pre- pared speciﬁcally for intranasal use. Some agents (eg, phenyle- phrine) are available in ophthalmic solutions as well. If necessary, secretions may be cleared and a second tip to the nares, and rinse the spray tip after each use. Administer cough syrups undiluted and instruct the client Part of the therapeutic benefit of cough syrups stems from sooth- to avoid eating and drinking for approximately 30 min. Observe for therapeutic effects Therapeutic effects depend on the reason for use. When nasal decongestants are given, observe for decreased the goal of antitussive therapy is to suppress nonpurposeful nasal obstruction and drainage. With cold and allergy remedies, observe for decreased nasal congestion, rhinitis, muscle aches, and other symptoms. With nasal decongestants, observe for: (1) Tachycardia, cardiac dysrhythmias, hypertension These effects may occur with any of the adrenergic drugs (see Chap. When adrenergic drugs are used as nasal decongestants, cardiovascular effects are more likely to occur with oral agents. However, topically applied drugs also may be systemically ab- sorbed through the nasal mucosa or by being swallowed and ab- sorbed through the gastrointestinal tract. With antitussives, observe for: (1) Excessive suppression of the cough reﬂex (inability to This is a potentially serious adverse effect because retained secre- cough effectively when secretions are present) tions may lead to atelectasis, pneumonia, hypoxia, hypercarbia, and respiratory failure. When narcotics are given for antitussive effects, how- ever, they are given in relatively small doses and are unlikely to cause adverse reactions. With combination products (eg, cold remedies), observe for Adverse effects are rarely signiﬁcant when the products are used adverse effects of individual ingredients (ie, antihistamines, as prescribed. There may be subtherapeutic doses of one or more adrenergics, analgesics, and others) component drugs, especially in over-the-counter formulations. Also, the drowsiness associated with antihistamines may be offset by stimulating effects of adrenergics. Ephedrine, for example, has central nervous system (CNS)–stimulating effects. Drugs that increase effects of nasal decongestants: These interactions are more likely to occur with oral decongestants than topically applied drugs. Drugs that increase antitussive effects of codeine: (1) CNS depressants (alcohol, antianxiety agents, barbitu- Additive CNS depression. Codeine is given in small doses for anti- rates, and other sedative-hypnotics) tussive effects, and risks of signiﬁcant interactions are minimal. Drugs that alter effects of dextromethorphan: (1) MAO inhibitors This combination is contraindicated. Apnea, muscular rigidity, hyperpyrexia, laryngospasm, and death may occur. Drugs that may alter effects of combination products for Interactions depend on the individual drug components of each coughs, colds, and allergies: formulation. Risks of clinically significant drug interactions are increased with use of combination products. Review and Application Exercises Answer: Sudafed is an adrenergic agent whose use is contraindi- cated in hypertensive clients because it signiﬁcantly increases 1. Who should usually avoid OTC nasal decongestants and traindications to any medication she or he administers. When re- questing an order from a physician who does not know the patient cold remedies? What are advantages and disadvantages of multi-ingredient medications that may interact. Given a client who uses echinacea, vitamin C, or zinc lozenges and asks you what you think about the products as cold remedies, how would you reply? Nursing Notes: Apply Your Knowledge SELECTED REFERENCES Answer: Joan has the symptoms of a cold. Pathophysiology: Concepts of altered health getting adequate rest and drinking lots of ﬂuids. List cardiovascular disorders for which drug vessels, and blood in supplying oxygen and therapy is a major treatment modality. Describe the role of vascular endothelium in manage cardiovascular disorders. Discuss atherosclerosis as the basic disorder causing many cardiovascular disorders for which drug therapy is required. The right ventricle sends deoxygenated blood the cardiovascular or circulatory system is composed of the through the pulmonary circulation. The general functions of the because it contracts against minimal pressure. The left ventri- system are to carry oxygen, nutrients, hormones, antibodies, cle pumps oxygenated blood through the systemic circuit. It is and other substances to all body cells and to remove waste much more muscular and thick walled because it contracts products of cell metabolism (carbon dioxide and others). A muscular wall called the septum separates the right the quality and quantity of blood. HEART Layers the heart is a hollow, muscular organ that functions as a two- the layers of the heart are the endocardium, myocardium, and sided pump to circulate ﬁve to six liters of blood through the epicardium. It is continuous with the endothelial lining of blood described in the following sections. The myocardium is the strong muscular layer of the heart that provides the pumping power for circulation of blood. The right atrium receives de- oxygenated blood from the upper part of the body by way of Valves the superior vena cava, from the lower part of the body by way of the inferior vena cava, and from veins and sinuses within the Heart valves function to maintain the one-way ﬂow of blood heart itself. The mitral valve separates the left 739 740 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM atrium and left ventricle. The tricuspid valve separates the muscle functions to maintain blood pressure and blood ﬂow. The pulmonic valve separates It contracts and relaxes in response to numerous stimuli, in- the right ventricle and pulmonary artery. Overall, regulation of tone in vascular smooth muscle depends on the intracellular con- Conduction System centration of calcium ions. There are several mecha- the heart contains special cells that can carry electrical im- nisms by which calcium ions can enter the cell. This Endothelial cells, once thought to be passive conduits for special conduction system consists of the sinoatrial (SA) blood ﬂow, are now known to perform two extremely impor- node, the atrioventricular node, bundle of His, right and left tant functions in maintaining homeostatic processes. The SA node, the nor- function is structural, in which the cells act as a permeability mal pacemaker of the heart, generates a burst of electrical barrier and regulate passage of molecules and cells across the energy approximately 60 to 100 times each minute under nor- blood vessel wall. The electrical current ﬂows over the heart the cells secrete opposing mediators that maintain a balance in an orderly way to produce contraction of both atria, then between bleeding and clotting of blood (including activation both ventricles.
Diagnostic standards and classiﬁcation of tuberculosis in adults and United States generic 20 mg duloxetine free shipping anxiety symptoms or heart problems. American Thoracic Society order duloxetine now anxiety symptoms weak legs, Centers for Disease Control and Prevention Philadelphia: Saunders buy duloxetine 20 mg fast delivery anxiety symptoms 8 weeks. Targeted tuberculin testing and treatment of latent tuberculosis in- Zeind buy generic duloxetine from india anxiety symptoms pictures, C. Discuss difﬁculties in developing and using and nursing process implications. Identify clients at risk for development of drugs in treating HIV infection. Teach clients techniques to prevent viral virus (HIV) infections, inﬂuenza A, and respira- infections. Critical Thinking Scenario Mark, a 32-year-old bisexual man, was recently diagnosed with human immunodeﬁciency virus (HIV) infection with a CD4+ cell count of less than 200. He is started on aggressive drug therapy with Combivir, a reverse transcriptase inhibitor combination, and nelﬁnavir, a protease inhibitor. Reﬂect on: What is the expected outcome of antiviral therapy in a person infected with HIV? Is the HIV-infected person still able to spread the infection to others while on antiviral treatment? Who should be responsible for the cost of treatment if private insurance lapses when Mark is no longer able to work? OVERVIEW characteristics of viruses and viral infections are described in the following paragraphs; selected infections are de- Viruses produce many diseases, including acquired immuno- scribed in Box 39–1. Viruses are intracellular parasites that can live and re- other disorders that affect almost every body system. For example, more entry to human host cells by binding to receptors on than 150 viruses infect the human respiratory tract, includ- cell membranes. All human cells do not have receptors ing approximately 100 types of rhinovirus that cause the for all viruses; cells that lack receptors for a particular common cold. Viruses can be spread by secretions from in- virus are resistant to infection by that virus. Thus, the fected people, ingestion of contaminated food or water, locations and numbers of the receptors determine which breaks in skin or mucous membrane, blood transfusions, host cells can be infected by a virus. For example, the sexual contact, pregnancy, breast-feeding, and organ trans- mucous membranes lining the tracheobronchial tree plantation. Viral infections vary from mild, localized dis- have receptors for the inﬂuenza A virus, and certain ease with few symptoms to severe systemic illness and death. Re- Cytomegalovirus Disease and Retinitis covery from the primary infection leaves latent infection in nerve Cytomegalovirus (CMV) infection is extremely common, and most cells. Reactivation of the latent infection (usually later in life) people become infected by adulthood. Infection is usually causes herpes zoster (more commonly known as shingles), a lo- asymptomatic in healthy, immunocompetent adults. Like other her- calized cluster of painful, blister-like skin eruptions. The skin le- pesviruses, CMV can cause a primary infection, then remain latent sions have the same appearance as those of chickenpox and in body tissues, probably for life. Over several days, the vesicles become pustules, in secretions of an asymptomatic host and spread to others by con- then rupture and heal. Because the virus remains in sensory nerve tact with infected saliva, blood, urine, semen, breast milk, and cer- cells, pain can persist for months after the skin lesions heal. It also means the virus may lead to an opportunistic cases of herpes zoster infection occur among the elderly and the infection when the host becomes immunosuppressed. Two types of HIV virus have been identiﬁed, HIV-1 and congenital CMV infection. Most infections in the United States are caused by HIV-1; in saliva or urine, while adolescents and adults transmit the virus HIV-2 infections occur mainly in Africa. The binding of HIV to CD4+ cells and are patients with cancer who receive immunosuppressant drugs; its impending replication will eventually result in cell death. The destruction of CD4+ cells eventually results those with advanced human immunodeﬁciency virus (HIV) infec- in impairment of the immune system and resultant acquisition of tion. Systemic CMV infection occurs mainly from reactivation of opportunistic infections. Progression of HIV-1 infection to acquired immunodeﬁciency Active CMV infection may cause cellular necrosis and inﬂamma- syndrome (AIDS) occurs in phases of disease development. Common manifestations of disease in- initial phase of infection is characterized by inﬂuenza-like symp- clude pneumonitis, hepatitis, encephalitis, adrenal insufﬁciency, toms (eg, fever, chills, muscle aches) that may last several weeks. During this time, the virus undergoes rapid and signiﬁcant repli- In the eye, CMV infection produces retinitis, usually charac- cation. The next phase is characterized by a dramatic decline in the terized by blurred vision and decreased visual acuity. Visual im- rate of viral replication, attributed to a partially effective immune pairment is progressive and irreversible and, if untreated, may response. During this phase no visible manifestations of HIV in- result in blindness. Despite the lack of symptoms, replication CMV infection or may be entirely asymptomatic. During this period, which may last 10 years, the Genital herpes infection is caused by the herpes simplex virus person is seropositive (HIV+) and infectious but asymptomatic. The virus is usually transmitted from rate of viral reproduction accelerates. When viral load and im- person to person by direct contact with open lesions or secretions, munodeﬁciency reach signiﬁcant levels, the illness is termed including genital secretions. This phase is characterized by decreased CD4+ cell counts, viral entry, where the virus infects epithelial cells, produces prog- loss of immune responses, and onset of opportunistic infections eny viruses, and eventually causes cell death. In response to various stimuli, such as intense sunlight, emotional the virus is most commonly spread by sexual intercourse, injec- stress, febrile illness, or menstruation, this latent virus may become tion of intravenous drugs with contaminated needles, mucous reactivated and lead to viral reproduction and shedding. Although the virus is found in most and neonatal herpes is a serious complication of maternal genital her- body ﬂuids, infection has primarily been associated with exposure pes. Neonatal herpes usually becomes evident within the ﬁrst week to blood, semen, or vaginal secretions. The virus is not spread of life and may be manifested by the typical clusters of blister- through casual contact. Health care workers have been infected by like lesions on skin or mucous membranes. Irritability, lethargy, needlestick injuries and should be aware that postexposure pro- jaundice, altered blood clotting, respiratory distress, seizures, or phylaxis is available and may signiﬁcantly reduce the risk of trans- coma may also occur. In immunosuppressed patients, HSV infection may result in the respiratory syncytial virus (RSV) is a highly contagious virus severe, systemic disease.
Lung and lular structures and interfere with cell replication and regulation discount duloxetine 20mg otc anxiety symptoms 6 dpo. Industrial carcinogens include benzene (bladder cancer) purchase generic duloxetine anxiety 7 reasons, Geography and ethnicity are more environmental than heredi- hydrocarbons (lung and skin cancer) buy duloxetine overnight delivery anxiety job interview, polyvinyl chloride (liver tary or racial discount duloxetine 40 mg on-line anxiety high blood pressure. Immigrants who adopt dietary and lifestyle cancer), and other substances used in the production of various habits of natives have similar risks and people who live in products. Workers who manufacture the products and people who cities have greater risks because of greater exposure to air live in the plant vicinity are most likely to be affected. In the United States, products contain numerous carcinogens and are associated with African Americans have higher rates of multiple myeloma cancers of the lungs, mouth, pharynx, larynx, esophagus, and blad- and cancers of the lung, prostate, esophagus, and pancreas than white people. In some families, there is a strong tendency toward smokers and other people exposed to cigarette smoke. For example, close relatives of pre- whose parents smoke have an increased risk of brain cancer, lym- menopausal women with breast cancer are at high risk for phomas, and acute lymphocytic leukemia. Immunosuppression, whether caused by disease or drug ther- Therapeutic drugs are associated with both hematologic and apy, is associated with an increased risk of cancer. The alkylating antineoplastic drugs are associated ample, clients with acquired immunodeﬁciency syndrome with leukemia, lymphoma, and other cancers. At the organ transplantation and receive immunosuppressant drugs same time, they may damage the DNA of normal cells and trans- are at risk for lymphomas and skin cancers. Clients who are given Obesity has been associated with increased risks of developing these drugs and survive their illness have an increased risk of de- cancer of the breast, colon, endometrium, esophagus, liver, veloping leukemia for 15 to 20 years. Other clients on immunosuppressant drugs are who received radiation may develop bone and soft tissue sar- at risk for lymphomas, squamous cell carcinoma of skin, and soft comas; those who received radiation to the neck area may de- tissue sarcomas, but at lower rates than transplant recipients. For velop thyroid cancer; and patients who received radiation to example, leukemia and solid tumors have been reported in clients the head may develop brain tumors). ANTINEOPLASTIC DRUGS Lymphomas are tumors of lymphoid tissue characterized by abnormal proliferation of the white blood cells normally General Characteristics found in lymphoid tissue. They usually develop within lymph nodes and may occur anywhere, because virtually all body 1. Most drugs kill malignant cells by interfering with tissues contain lymphoid structures. Multiple (eg, amino acids, purines, pyrimidines), or with the myeloma is a tumor of the bone marrow in which abnormal genetic materials in the cell nucleus (DNA or RNA). As the ma- during speciﬁc phases such as DNA synthesis or forma- lignant cells expand, they crowd out normal cells, interfere tion of the mitotic spindle. Others act during any phase with other bone marrow functions, inﬁltrate and destroy of the cell cycle and are called cell cycle nonspeciﬁc. Cytotoxic drugs are most active against rapidly divid- spleen, liver, and lymph nodes. Commonly dam- Solid neoplasms are composed of a mass of malignant aged normal cells are those of the bone marrow, the cells (parenchyma) and a supporting structure of connective lining of the gastrointestinal tract, and the hair follicles. Antineoplastic drugs may induce drug-resistant malig- classified by cell type, such as adenocarcinoma or basal cell nant cells. Sarcomas are derived from connective tissue take or activation, increasing the rate of drug inactivation, (muscle, bone, cartilage, fibrous tissue, fat, blood vessels). Most cytotoxic antineoplastic drugs are potential ter- Grading and Staging of atogens. Most antineoplastic drugs are given orally or intra- Malignant Neoplasms venously (IV); some are given topically, intrathecally, or by instillation into a body cavity. Grades 1 and 2 are similar to the malignant tissues and decrease concentration in nor- normal tissue of origin and show cellular differentiation; mal tissues, thereby increasing effectiveness while grades 3 and 4 are unlike the normal tissue of origin, less dif- decreasing toxicity. These characteristics assist in treatment (eg, localized tumors are usually amenable to surgical or radiation therapy; metastatic disease requires systemic therapy). Cell Cycle Phases of Cell Cycle Nonspecific Cell Cycle Specific Effects of Cancer on the Host Alkylating agents G0 Effects vary according to the location and extent of the dis- Antibiotics G1 Steroids ease process. As the neoplasm grows, effects occur when the tumor becomes large enough Nitrosoureas S Antimetabolites to cause pressure, distortion, or deﬁcient blood supply in sur- rounding tissues; interfere with organ function; obstruct ducts G Podophyllotoxins 2 and organs; and impair nutrition of normal tissues. More M Taxanes or taxoids speciﬁc effects include anemia, malnutrition, pain, infection, hemorrhagic tendencies, thromboembolism, hypercalcemia, Vinca alkaloids cachexia, and various symptoms related to impaired function of affected organs and tissues. CHAPTER 64 DRUGS USED IN ONCOLOGIC DISORDERS 917 Indications for Use approved in 2002 for treatment of colorectal cancer in patients whose disease has recurred or worsened following standard Cytotoxic antineoplastic drugs are used in the treatment of therapy. It is used with 5-ﬂuorouracil and leucovorin and given malignant neoplasms to cure the disease, relieve symptoms, every 2 weeks by injection. Adverse effects include peripheral or induce or maintain remissions (symptom-free periods that neuropathy, vomiting, diarrhea, and anemia. Antimetabolites are substances that are structurally similar to In hematologic neoplasms, drug therapy is the treatment normal metabolites. They are allowed to enter cancer cells of choice because the disease is systemic rather than local- because they are similar to nutrients needed by the cells for ized. Once inside the cell, the drugs may compete after surgery or radiation therapy. These ac- Antineoplastic drugs are sometimes used in the treatment tions deprive the cell of substances needed for formation of of nonmalignant conditions. The drugs are methotrexate (MTX) are used for rheumatoid arthritis and cell cycle speciﬁc because they exert their cytotoxic effects psoriasis. This group includes a folic acid antagonist (eg, methotrex- Classiﬁcations ate), purine antagonists (eg, mercaptopurine), and pyrimidine antagonists (eg, ﬂuorouracil). These drugs have been used to Cytotoxic antineoplastic drugs are usually classiﬁed in terms treat many types of cancers, but they are most effective against of their mechanisms of action (alkylating agents and anti- rapidly growing tumors, and individual drugs vary in their metabolites) or their sources (plant alkaloids, antibiotics). Toxic effects Other drugs used in chemotherapy are immunostimulants (see include bone marrow depression, mucositis and ulceration of Chap. Alkylating Agents Antitumor Antibiotics Alkylating agents include nitrogen mustard derivatives, ni- These drugs (eg, doxorubicin) are active in all phases of the trosoureas, and platinum compounds. Nitrogen mustard de- cell cycle and their cytotoxic effects are similar to those of rivatives (eg, cyclophosphamide) interfere with cell division the alkylating agents. They bind to DNA so that DNA and and the structure of DNA during all phases of the malignant RNA transcription is blocked. As a result, they have a broad spectrum of activ- row depression and GI upset. They are most effective in hematologic malignancies but also cause cardiotoxicity and tissue necrosis if extravasation also are used to treat breast, lung, and ovarian tumors. Nitrosoureas also interfere with DNA replication and RNA synthesis and may inhibit essential enzymatic reactions of can- Plant Alkaloids cer cells. They are cell cycle nonspeciﬁc and have been used in clients with gastrointestinal (GI), lung, and brain tumors.
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