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For example estradiol 2 mg with mastercard women's health center elmira ny, • General assessment factors include rate and character of caffeine is a xanthine and therefore has bronchodilating respiration trusted 1mg estradiol women's health hargreaves street bendigo, skin color purchase generic estradiol menopause 123, arterial blood gas analysis purchase estradiol with visa womens health york, and effects similar to, but weaker than, those of theophylline. Abnormal breathing patterns • Use mechanical measures for removing excessive respi- (eg, rate below 12 or above 24 per minute, dyspnea, ratory tract secretions and preventing their retention. For example, oxia include mental confusion, restlessness, anxiety, allergens may be removed from the home, school, or and increased blood pressure and pulse rate. Late signs work environment; cigarette smoke should be avoided include cyanosis and decreased blood pressure and pulse. When bronchospasm is precipitated by Hypoxemia is conﬁrmed if arterial blood gas analysis exercise, prophylaxis by prior inhalation of bronchodi- shows decreased partial pressure of oxygen (PO2). A charac- • Assist clients with asthma to identify early signs of difﬁ- teristic feature of bronchospasm is forceful expiration or culty, including increased need for beta-adrenergic ago- wheezing. This is an objec- between acute attacks, such as restrictions in activities of tive measure of airﬂow/airway obstruction and helps to daily living due to asthma. Clients with a and character of sputum, exercise tolerance (eg, dyspnea decreased PEFR may need treatment to prevent acute, se- on exertion, dyspnea at rest), medications, and nondrug vere respiratory distress. Nursing Diagnoses • Try to prevent or reduce anxiety, which may aggravate • Impaired Gas Exchange related to bronchoconstriction bronchospasm. Stay with the client during an acute asthma and excessive mucus production attack if feasible. Clients experiencing severe and pro- • Activity Intolerance related to impaired gas exchange and longed bronchospasm (status asthmaticus) should be ad- fatigue mitted or transferred to a hospital intensive care unit. Emphasize the health beneﬁts of • Deﬁcient Knowledge: Factors precipitating broncho- improved respiratory function. Evaluation • Deﬁcient Knowledge: Accurate self-administration of drugs, including use of inhalers • Observe for relief of symptoms and improved arterial blood gas values. Planning/Goals • Interview and observe for correct drug administration, in- the client will: cluding use of inhalers. General measures include those to prevent respira- Choice of drug and route of administration are determined tory disease or promote an adequate airway. Some guidelines include the following: CHAPTER 47 DRUGS FOR ASTHMA AND OTHER BRONCHOCONSTRICTIVE DISORDERS 707 CLIENT TEACHING GUIDELINES Antiasthmatic Drugs General Considerations ✔ Avoid tobacco smoke and other substances that irritate ✔ Asthma and other chronic lung diseases are character- breathing passages (eg, aerosol hair spray, antiperspi- ized by constant inﬂammation of the airways and periodic rants, cleaning products, and automobile exhaust) when or persistent labored breathing from constriction or nar- possible. Antiasthmatic drugs are often given ✔ Avoid excessive intake of caffeine-containing ﬂuids such in combination to combat these problems. These beverages may in- crease bronchodilation but also may increase heart rate tremely important to know the type and purpose of each and cause palpitations, nervousness, and insomnia with drug. This means they must be taken on a regular you are taking and do not take over-the-counter drugs or schedule and continued when symptom free. Some drugs can decrease beneficial effects shortness of breath, wheezing respirations, cough) oc- or increase adverse effects of antiasthmatic medica- curs, the only fast-acting, commonly used medication to tions. For example, over-the-counter nasal deconges- relieve these symptoms is an inhaled, short-acting bron- tants, asthma remedies, cold remedies, and antisleep chodilator (eg, albuterol). Other inhaled and oral drugs medications can increase the rapid heartbeat, palpitations, are not effective and should not be used. For example, respiratory infec- With herbal remedies, none are as effective as standard tions can precipitate difﬁculty in breathing. Avoiding in- antiasthmatic medication, and they may cause serious fections (eg, by good handwashing, avoiding people with or life-threatening adverse effects. Preparations con- infections, annual inﬂuenza vaccinations, and other mea- taining ephedra (also called ma huang or herbal ecstasy) sures) can prevent acute asthma attacks. If you are al- are especially dangerous and not recommended for use lergic to tobacco smoke, perfume, or ﬂowers, try to avoid by anyone, for any purpose. Better breathing with mini- to two thirds of clients with asthma do not comply with mal adverse effects depends on accurate use of pre- instructions for using their medications. If help is needed with metered-dose tribute to noncompliance with drug therapy include long- inhalers, consult a health care provider. If you have ✔ Use short-acting bronchodilator inhalers as needed, not difﬁculty taking medications as prescribed, discuss the sit- on a regular schedule. Cheaper medications or or if symptoms worsen, inform the prescribing physician. Overuse increases adverse drug effects and decreases ✔ If unable to prevent symptoms, early recognition and drug effectiveness. Signs of impending difﬁculty include increased inhaled bronchodilators, do not use more often than every needs for bronchodilator inhalers, activity limitations, 12 hours. If constricted breathing occurs, use a short- waking at night because of asthma symptoms, and vari- acting bronchodilator inhaler between doses of a long- ability in the peak expiratory flow rate (PEFR), if you use acting drug. The first treatment is to use a of breath because it takes approximately 20 minutes to short-acting, inhaled bronchodilator. If this does not im- start acting and 1 to 4 hours to achieve maximal bron- prove breathing, seek emergency care. Missing ✔ If taking an oral or inhaled corticosteroid, take on a reg- a few doses of long-term control or preventive medica- ular schedule, approximately the same time each day. They lead to more severe problems and the need for emer- are not effective unless taken regularly. Take long-acting preparations every 8 to ✔ Drinking 2 to 3 quarts of ﬂuids daily helps thin secretions 12 hours; do not chew or crush. While pressing down on the inhaler, take a slow, deep montelukast and zileuton may be taken with or without breath for 3 to 5 seconds, hold the breath for approx- food. Wait 3 to 5 min before taking a second inhalation of night and early morning, when asthma symptoms often the drug. With the inhaler in the upright position, place the inhaler that makes it easier to use). A selective, short-acting, inhaled beta2-adrenergic ag- used early in the disease process, often with a broncho- onist (eg, albuterol) is the initial drug of choice for dilator or mast cell stabilizer. Because aerosol products act directly on the airways, or IV for several days. Ipratropium, the anticholinergic bronchodilator, is doses of an oral corticosteroid. It administration are not clearly established, but more is ineffective in relieving acute bronchospasm by itself, frequent dosing (eg, every 6 hours) may be more but it adds to the bronchodilating effects of adrenergic effective than less frequent dosing (eg, every 12 hours), drugs. Theophylline is used less often than formerly and glucocorticoid therapy, the recommended dose is the is now considered a second-line drug. High it is usually given orally in an extended-release for- doses suppress adrenocortical function, but much less mulation for chronic disorders, such as COPD. Small doses may impair bone aminophylline is no longer used to treat acute asthma metabolism and predispose adults to osteoporosis by attacks. Cromolyn and nedocromil are used prophylactically; resorption from bone. In children, chronic administra- they are ineffective in acute bronchospasm. Because inﬂammation has been established as a major verse effects (oropharyngeal candidiasis, hoarseness) component of asthma, an inhaled corticosteroid is being can be decreased by reducing the dose, administering less often, rinsing the mouth after use, or using a spacer device. These measures decrease the amount of drug deposited in the oral cavity.
When a speciﬁc antigen attaches to cell Eosinophils increase during allergic reactions and para- membrane receptors to form an antigen–antibody complex purchase generic estradiol canada women's health libido issues, sitic infections quality 1mg estradiol women's health magazine big book of yoga. In parasitic infections cheap estradiol 2mg with amex breast cancer komen, they bind to and kill the complex activates the lymphocyte to form tremendous the parasites estradiol 1 mg low price breast cancer 60 mile 3 day. In hypersensitivity reactions, they produce en- numbers of duplicate lymphocytes (clones) that are exactly zymes that inactivate histamine and leukotrienes and may like the parent cell. Clones of a B lymphocyte eventually se- produce other enzymes that destroy antigen–antibody com- crete antibodies that circulate throughout the body. Despite these generally beneﬁcial effects, eosinophils a T lymphocyte are sensitized or activated T cells that are re- also may aggravate tissue damage by releasing cytotoxic leased into lymphatic ducts, carried to the blood, circulated substances. Basophils release histamine, a major chemical through all tissue ﬂuids, then returned to lymphatic ducts and mediator in inflammatory and immediate hypersensitivity recirculated. Monocytes are the largest WBCs, and their life span is much longer than that of the neutrophils. Monocytes can phagocytize larger sizes T Lymphocytes and amounts of foreign material than neutrophils. In addi- tion to their activity in the bloodstream, monocytes can leave T lymphocytes are the primary regulators of immune re- blood vessels and enter tissue spaces (and then are called sponses because they direct the activities of B cells and fixed tissue macrophages), although they can again become macrophages. They originate in pluripotential stem cells in mobile and reenter the bloodstream in some circumstances. When T olar macrophages in the lungs, others in the lymph nodes cells bind with an antigen, specific genes are activated to and spleen) and form the mononuclear phagocyte system. One such substance is IL-2, which stimulates tant in inflammatory processes and both can initiate the im- T-cell deoxyribonucleic acid replication and mitosis. They perform division is necessary for production of large numbers of this function as part of phagocytosis, in which they engulf antigen-reactive cells and for cellular changes associated a circulating antigen (eg, foreign material and cellular de- with the different subgroups of T cells. Specific types and bris), break it into fragments, and return antigenic fragments functions of T cells include the following: to the cell surface. The antigenic fragments are recognized • Helper T cells (also called TH or CD4+ cells), the largest as foreign material by circulating T and B lymphocytes, and subgroup, regulate virtually all immune functions by pro- an immune response is initiated. Because the monocytes ducing protein substances called cytokines (formerly prepare the antigen to interact with T and B lymphocytes, called lymphokines to denote cytokines produced by they are called antigen-processing and antigen-presenting lymphocytes). They also activate macrophages sues are in dynamic equilibrium with those in circulating and facilitate phagocytosis. These cells continuously travel through blood and IL-2, -3, -4, -5, and -6, GM-CSF, and interferon gamma. The the devastating effects of acquired immunodeﬁciency three types of lymphocytes are natural killer cells, T cells, syndrome (AIDS) result primarily from the ability and B cells. T cells are involved in both cell-mediated but differ in the other cytokines they secrete. The TH1 and humoral immunity and are especially able to combat in- subset is responsible for many cell-mediated functions tracellular infections (eg, virus-infected cells). B cells are (eg, delayed-type hypersensitivity reactions and acti- involved in humoral immunity; they secrete antibodies that vation of cytotoxic T cells) and for the production of can neutralize pathogens before their entry into host cells. These cells are also associated with they can fulfill their immune functions, and both have pro- excessive inﬂammation and tissue injury. The TH2 sub- teins on their cell membrane surfaces that act as receptors set stimulates the activation and differentiation of for antigens. There are five main classes of also associated with hypersensitivity reactions. Once activated by antigen and IL-2, cytotoxic with molecules of antigen, and the antigen–antibody T cells bind to antigens on the surfaces of target cells. Activated complement After binding to antigen, the T cells are thought to de- causes an inﬂammatory reaction, promotes phagocyto- stroy target cells by one or more of three mechanisms. IgG also One mechanism involves the formation of holes in the crosses the placenta to provide maternally acquired anti- target cell membrane that allow fluids to enter and bodies (passive immunity) to the infant. Another is the insertion of • IgA is the main immunoglobulin in mucous mem- enzymes that break down or digest the cell. It is found in saliva, breast mechanism is to induce apoptosis (programmed cell milk, and nasal, respiratory, prostatic and vaginal se- death). It protects against pathogens and other anti- target cells, they can detach themselves and attack gens that gain access to these areas. Cytotoxic T cells are especially lethal to virus-infected • IgM constitutes approximately 10% of serum antibodies. It acts only in the bloodstream because even after destruction of all the invaders that elicited the its large molecular size prevents its movement or trans- original cytotoxic activity. It activates complement to pecially important in killing body cells that have been in- destroy microorganisms. Cytotoxic T cells also play a role in body fluids and readily enters body tissues. It is in- the destruction of transplanted organs and delayed hyper- volved in parasitic infections and hypersensitivity re- sensitivity reactions. IgE sensitizes mast An additional type of T cells, called suppressor cells, which then release histamine and other chemical T cells, has been postulated to exist and to function by mediators that cause bronchoconstriction, edema, ur- stopping the immune response (ie, decreasing the ac- ticaria, and other manifestations of allergic reactions. This activity is considered impor- of IgE is stimulated by T lymphocytes and interleukins tant in preventing further tissue damage. Small in autoimmune disorders, suppressor T cell function is amounts of IgE are present in the serum of nonallergic impaired and extensive tissue damage may result. They also regulate the intensity and duration of in the bone marrow), and migrate to the spleen, lymph the immune response by stimulating or inhibiting the acti- nodes, or other lymphoid tissue. In lymphoid tissue, the vation, proliferation, and/or differentiation of various cells cells may be dormant until exposed to an antigen. In re- and by regulating the secretion of antibodies or other cy- sponse to an antigen and IL-2 from helper T cells, B cells tokines. Although the hematopoietic cytokines described in- multiply rapidly, enlarge, and differentiate into plasma clude the immune system cytokines, the emphasis here is on cells, which then produce antibodies (immunoglobulins those that affect immune cells. Immunoglobulins are secreted formed by activated macrophages enter the bone marrow, into lymph and transported to the bloodstream for circula- where they induce the synthesis and release of other cytokines 636 SECTION 7 DRUGS AFFECTING HEMATOPOIESIS AND THE IMMUNE SYSTEM Macrophage Antigen ILs 1, 6, 11, 12 IL8 G-CSF, GM-CSF, TNF alpha M-CSF, TNF RBCs ILs 1, 6, 8, 10, 12, 15 IFNs alpha and beta WBCs TNF alpha Stem cell Neutrophils Platelets Resting TH cell Activated TH cell ILs 4, 10 IL2 ILs 3, 6, 7 ILs 3, 4, 10 ILs 3, 5 ILs 2, 12, 15 GM-CSF Antigen Resting TH cells B cell IL12 Stem cells Activated B cell TC cells ILs 2, 4, 5, 13 IFN gamma ILs 3, 4, 10, 13 IFN alpha and beta Natural TNF beta Eosinophils killer cells RBCs WBCs Platelets Mast cells B cells IL 6 Macrophages Plasma cells Antibodies (Ig G, M, A, E, D) Figure 42–2 Macrophage and T cell cytokines, their target cells, and the products of target cells. IL, interleukin; IFN, interferon; TNF, tumor necrosis factor; TH, helper T cell; TC, cytotoxic T cells; CSF, colony- stimulating factor. CHAPTER 42 PHYSIOLOGY OF THE HEMATOPOIETIC AND IMMUNE SYSTEMS 637 that activate resting stem cells to produce more granulocytes crease over approximately 6 months as maternal antibodies and monocyte–macrophages. Although the infant does start producing and monocytes leave the bone marrow and enter the circulat- IgG, the rate of production is lower than the rate of break- ing blood in approximately 3 days. Cell-mediated immunity is Cytokine binding to target cells elicits wide-ranging ef- probably completely functional at birth.
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