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Q. Umbrak. School of the Visual Arts.

The function of calcitonin is to lower serum calcium renal tubules and less urinary excretion order provigil 100 mg fast delivery insomnia side effects. The opposite effects in the presence of hypercalcemia order provigil 200 mg visa sleep aid kirkland review, which it does by decreasing occur with phosphate (ie, PTH decreases serum phosphate movement of calcium from bone to serum and increasing uri- and increases urinary phosphate excretion). Thus, it has little effect on long-term calcium production of PTH (hypoparathyroidism) or excessive pro- metabolism. Hypoparathyroidism is most often caused by removal of or damage to the parathyroid glands during neck surgery. Hyperparathyroidism is most Vitamin D (Calciferol) often caused by a tumor or hyperplasia of a parathyroid gland. It also may result from ectopic secretion of PTH by malignant Vitamin D is a fat-soluble vitamin that includes both ergo- tumors (eg, carcinomas of the lung, pancreas, kidney, ovary, calciferol (obtained from foods) and cholecalciferol (formed prostate gland, or bladder). It functions as a hormone ment of hypoparathyroidism are the same as those of hypocal- and plays an important role in calcium and bone metabo- cemia; clinical manifestations of hyperparathyroidism are lism. The main action of vitamin D is to raise serum cal- those of hypercalcemia. It also promotes bone formation by providing adequate serum concentrations of Calcitonin minerals. It must be converted to an intermediate metabolite in Calcitonin is a hormone from the thyroid gland whose secre- the liver, then to an active metabolite (1,25-dihydroxyvita- tion is controlled by the concentration of ionized calcium in the min D or calcitriol) in the kidneys. PTH and adequate he- 368 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM patic and renal function are required to produce the active used to treat hypocalcemia and to prevent and treat osteo- metabolite. These agents are described in the following sec- Deficiency of vitamin D causes inadequate absorption of tions; names and dosages of individual drug preparations calcium and phosphorus. This, in turn, leads to low levels of are listed in Drugs at a Glance: Calcium and Vitamin D serum calcium and stimulation of PTH secretion. Drugs used for hypercalcemia include bis- this sequence of events produces inadequate mineralization phosphonates, calcitonin, corticosteroids, 0. Those used adults, vitamin D deficiency causes osteomalacia, a condition for osteoporosis inhibit bone breakdown and demineraliza- characterized by decreased bone density and strength. These drugs are described in the following sections; indications for use and dosages are listed in Drugs Calcium and Phosphorus at a Glance: Drugs Used in Hypercalcemia and Selected Bone Disorders. Calcium and phosphorus are discussed together because they are closely related physiologically. These mineral nutrients are found in many of the same foods, from which they are ab- Bisphosphonates sorbed together. They are both required in cellular struc- Alendronate (Fosamax), etidronate (Didronel), pamidronate ture and function and, as calcium phosphate, in formation and (Aredia), risedronate (Actonel), tiludronate (Skelid), and maintenance of bones and teeth. Their characteristics and zoledronate (Zometa) are drugs that bind to bone and inhibit functions are summarized in Box 26–1. Although indications for use vary among the drugs, they are used mainly in the treatment of hypercalcemia and osteoporosis. Etidronate also inhibits Bone Metabolism bone mineralization and may cause osteomalacia. Bone is mineralized connective tissue that functions as struc- These drugs are poorly absorbed from the intestinal tract tural support and a reservoir for calcium, phosphorus, magne- and must be taken on an empty stomach, with water, at least sium, sodium, and carbonate. The role of bone in maintaining 30 minutes before any other fluid, food, or medication. The serum calcium levels takes precedence over its structural func- drugs are not metabolized. The drug bound to bone is slowly tion (that is, bone may be weakened or destroyed as calcium released into the bloodstream; most of the drug that is not leaves bone and enters serum). Bone tissue is constantly being formed and broken down Calcitonin-salmon (Calcimar, Miacalcin) is used in the in a process called remodeling. In hypercalcemia, calcitonin lowers serum calcium down (resorption) as the person attains adult height and peak levels by inhibiting bone resorption. After approximately 35 years of age, resorption is effective in hypercalcemia caused by hyperparathyroidism, greater than formation.

Its active ingredi- at a Glance: Topical Corticosteroids provigil 100mg on-line sleep aid 25mg, and Drugs at a Glance: ents are unknown discount provigil 100 mg online insomnia on period. Wound healing is attributed to moisturizing Miscellaneous Dermatologic Agents. Benzoyl peroxide Acne To affected areas, after cleansing, 1–3 times daily Clindamycin (Cleocin T) Acne vulgaris To affected areas, twice daily Erythromycin (Aknemycin) Acne vulgaris To affected areas, after cleansing, twice daily, morning and evening Gentamicin (Garamycin) Skin infections caused by susceptible strains of To infected areas, 3–4 times daily. Cover with streptococci, staphylococci, and gram-negative dressing if desired. Eradication of nasal colonization with methicillin- Other skin lesions: Cream, 3 times daily for resistant S. Eradication of nasal colonization: Ointment from single-use tube, one half in each nostril, morning and evening for 5 d Neomycin (Myciguent) Bacterial skin infections To affected area, after cleansing, 1–3 times daily, small, fingertip-size amount. Silver sulfadiazine (Silvadene) Prevent or treat infection in burn wounds caused by To affected area, after cleansing, once or twice Pseudomonas and many other organisms daily, using sterile technique Sulfacetamide sodium Bacterial skin infections Skin infections: 2–4 times daily until infection clears (Sebizon) Seborrheic dermatitis Seborrhea: to scalp and adjacent skin areas, at bedtime Tetracycline (Topicycline) Acne vulgaris To affected areas, twice daily, morning and evening Combination Products Bacitracin and polymyxin B Bacterial skin infections To lesions, 2–3 times daily (Polysporin) Erythromycin/benzoyl Acne To affected areas, after cleansing, twice daily, peroxide (Benzamycin) morning and evening Neomycin, polymyxin B and Bacterial skin infections To lesions, 2–3 times daily bacitracin (Neosporin) (continued) 954 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS Drugs at a Glance: Topical Antimicrobial Agents (continued) Generic/Trade Name Indications for Use Application Antifungal Agents Amphotericin B (Fungizone) Cutaneous candidiasis To affected areas, 2–4 times daily Butenafine (Mentax) Tinea pedis To affected area, once daily for 4 wk Ciclopirox (Loprox) Tinea infections To affected area, twice daily for 2–4 wk Cutaneous candidiasis Clioquinol (Vioform) Fungal skin infection and inflammation To affected areas, 2–3 times daily. Clotrimazole (Lotrimin, Tinea infections To affected areas, twice daily, morning and evening Mycelex) Cutaneous candidiasis Econazole (Spectazole) Tinea infections Tinea infections: To affected areas, once daily Cutaneous candidiasis Cutaneous candidiasis: To affected areas, twice daily Haloprogin (Halotex) Tinea infections To affected area, twice daily for 2–4 wk Ketoconazole (Nizoral) Tinea infections Tinea infections and cutaneous candidiasis: To Cutaneous candidiasis affected areas, once daily for 2–4 wk Seborrheic dermatitis Seborrheic dermatitis: To affected areas twice daily for 4 wk or until clinical clearing Miconazole (Micatin) Tinea infections To affected areas, twice daily for 2–4 wk Cutaneous candidiasis Naftifine (Naftin) Tinea infections To affected areas, once daily with cream, twice daily with gel Nystatin (Mycostatin) Candidiasis of skin and mucous membranes To affected areas, after cleansing, 2–3 times daily until healing is complete Oxiconazole (Oxistat) Tinea infections To affected areas, once or twice daily for 2–4 wk Sulconazole (Exelderm) Tinea infections To affected areas, once or twice daily Terbinafine (Lamisil) Tinea infections To affected areas, twice daily for 1–4 wk Antiviral Agents Acyclovir (Zovirax) Herpes genitalis To lesions, q3h six times daily for 7 d Herpes labialis in immunosuppressed clients Penciclovir (Denavir) Herpes labialis To lesions, q2h while awake for 4 d Drugs at a Glance: Topical Corticosteroids Generic/Trade Names Dosage Forms Potency Alclometasone (Aclovate) Cream, ointment Low Amcinonide (Cyclocort) Cream, lotion, ointment High Augmented betamethasone Cream, gel, lotion, ointment Ointment very high; cream high dipropionate (Diprolene) Betamethasone dipropionate Aerosol, cream, lotion, ointment Cream and ointment high; lotion medium (Alphatrex, others) Betamethasone valerate Cream, foam, lotion, ointment Ointment high; cream medium (Valisone, others) Clobetasol (Temovate) Cream, gel, ointment, scalp application Very high Clocortolone (Cloderm) Cream Medium Desonide (Tridesilon) Cream, lotion, ointment Low Desoximetasone (Topicort) Cream, gel, ointment Medium Dexamethasone (Decaderm, Aerosol, cream Low Decadron) Diflorasone (Florone, Maxiflor) Cream, ointment Ointment, very high; cream, high Fluocinolone (Synalar, others) Cream, oil, ointment, shampoo, solution High Fluocinonide (Lidex) Cream, gel, ointment, solution High Flurandrenolide (Cordran) Cream, lotion, ointment, tape Medium Fluticasone (Cutivate) Cream, ointment Medium Halcinonide (Halog) Cream, ointment, solution High Halobetasol (Ultravate) Cream, ointment Very high Hydrocortisone (Cortril, Cream, lotion, ointment, solution, spray, Medium or low Hydrocortone, others) roll-on stick Mometasone (Elocon) Cream, lotion, ointment Medium Triamcinolone acetonide Aerosol, cream, lotion, ointment 0. Also available in combination with hydrocortisone and other substances Colloidal oatmeal (Aveeno) Antipruritic Pruritus Topically as a bath solution (1 cup in bathtub of water) Dextranomer (Debrisan) Absorbs exudates from wound Cleansing of ulcers (eg, venous Apply to a clean, moist wound sur- surfaces stasis, decubitus) and wounds face q12h initially, then less (eg, burn, surgical, traumatic) often as exudate decreases Fluorouracil (Efudex) Antineoplastic Actinic keratoses Topically to skin lesions twice daily Superficial basal cell carcinomas for 2–6 wk Masoprocol (Actinex) Inhibits proliferation of keratin- Actinic keratoses Topically to skin lesions morning containing cells and evening for 28 d Salicylic acid Keratolytic, antifungal Removal of warts, corns, calluses Topically to lesions Superficial fungal infections Seborrheic dermatitis Acne Psoriasis Selenium sulfide (Selsun) Antifungal, antidandruff Dandruff Topically to scalp as shampoo once Tinea versicolor or twice weekly 956 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS effects and increased blood flow to the area. Many commonly used drugs may mation and pain may result from inhibition of arachadonic acid cause skin lesions, including antibiotics (eg, peni- metabolism and formation of inflammatory prostaglandins. Commercial products are available for topical use, but • Irritants or allergens may cause contact dermatitis. When used for this For example, dermatitis involving the hands may be purpose, a clear, thin, gel-like liquid can be squeezed directly caused by soaps, detergents, or various other cleans- from a plant leaf onto the burned or injured area several times ing agents. Topical use has not been associated with se- from allergic reactions to clothing. Oats contain gluten, which forms a sticky mass that drainage, and whether the lesion appears infected or con- holds moisture in the skin when it is mixed with a liquid and tains necrotic material. For topical use, oats are contained in described as petechiae (pinpoint hemorrhages) or ecchy- bath products, cleansing bars, and lotions (eg, Aveeno prod- moses (bruises). Burn wounds are usually described in ucts) that can be used once or twice daily. They should not be terms of depth (partial or full thickness of skin) and per- used near the eyes or on inflamed skin. Venous stasis, pressure, and other cutaneous ulcers are usually described in terms of diame- ter and depth. Nursing Process • When assessing the skin, consider the age of the client. School-aged children have a relatively high inci- indicate current or potential dermatologic disorders. Older adults are more likely to • When a skin rash is present, interview the client and in- have dry skin, actinic keratoses (premalignant lesions that spect the area to determine the following: occur on sun-exposed skin), and skin neoplasms. Basal cell carcinoma is the described as specifically as possible so changes can be most common type of skin cancer. Terms commonly used in dermatology in- as a pale nodule, most often on the head and neck. Squa- clude macule (flat spot), papule (raised spot), nodule mous cell carcinomas may appear as ulcerated areas. These (small, solid swelling), vesicle (blister), pustule (pus- lesions may occur anywhere on the body but are more com- containing lesion), petechia (flat, round, purplish-red mon on sun-exposed parts, such as the face and hands. Ma- spot the size of a pinpoint, caused by intradermal or sub- lignant melanoma is the most serious skin cancer. Lesions also involves melanocytes, the pigment-producing cells of the may be described as weeping, dry and scaly, or crusty. Malignant melanoma may occur in pigmented nevi • Location or distribution. In nevi, malignant clusively or primarily on certain parts of the body (eg, melanoma may be manifested by enlargement and ulcera- face, extremities, trunk), and distribution may indicate tion. Pruritus occurs with most any area, malignant melanoma is most likely to be located dermatologic conditions. Fever, malaise, and other on the back in white people and in toe webs and soles of the symptoms may occur as well. Appropriate questions include • Color changes and skin rashes are more difficult to detect • When and where did the skin rash appear?

Massaging the injec- tion site accelerates drug absorption and thus relief of symptoms purchase 200mg provigil with mastercard sleep aid generic. For inhalation cheap 200 mg provigil fast delivery insomnia korean version, be sure to use the correct drug concentration, Inhalation medications are often administered by clients them- and use the nebulizing device properly. The nurse may need to demonstrate and super- vise self-administration initially. Do not give epinephrine and isoproterenol at the same time Both of these drugs are potent cardiac stimulants, and the com- or within 4 hours of each other. However, they have synergistic bronchodilating effects, and doses can be alter- nated and given safely if the drugs are given no more closely together than 4 hours. For IV injection of epinephrine, dilute 1 ml of 1 1000 so- Dilution increases safety of administration. A solution that is brown lution with 10 mL of sodium chloride injection, or use a com- or contains a precipitate should not be used. For IV infusion of isoproterenol and phenylephrine: (1) Administer in an intensive care unit when possible. Frequent recording of blood pressure and pulse and continuous electrocardiographic monitoring are needed. Do not add the drug until and the amount of IV solution to which it is added. Flow rate usually requires frequent adjustment according to blood pressure measurements. An infusion device helps to regulate drug administration, so wide fluctuations in blood pressure are avoided. Only one bottle contains an adrenergic drug, and it can be regu- lated or discontinued without disruption of the primary IV line. When giving adrenergic drugs as eye drops or nose drops, Contaminated droppers can be a source of bacterial infection. When the drug is used as a bronchodilator, observe for ab- Indicates prevention or relief of bronchospasm. Acute broncho- sence or reduction of wheezing, less labored breathing, and spasm is usually relieved within 5 minutes by injected or inhaled decreased rate of respirations. When epinephrine is given in anaphylactic shock, ob- Epinephrine injection usually relieves laryngeal edema and bron- serve for decreased tissue edema and improved breathing chospasm within 5 minutes and lasts for approximately 20 minutes. When isoproterenol or phenylephrine is given in hypo- These are indicators of improved circulation. When a drug is given nasally for decongestant effects, observe The drugs act as vasoconstrictors to reduce engorgement of nasal for decreased nasal congestion and ability to breathe through mucosa. When given as eye drops for vasoconstrictor effects, ob- serve for decreased redness. Observe for adverse effects Adverse effects depend to some extent on the reason for use. For example, cardiovascular effects are considered adverse reactions when the drugs are given for bronchodilation. Adverse effects occur with usual therapeutic doses and are more likely to occur with higher doses. Cardiovascular effects—cardiac dysrhythmias, hypertension Tachycardia and hypertension are common; if severe or pro- longed, myocardial ischemia or heart failure may occur. Prema- ture ventricular contractions and other serious dysrhythmias may occur. Propranolol (Inderal) or another beta blocker may be given to decrease heart rate and hypertension resulting from overdosage of adrenergic drugs. Excessive central nervous system (CNS) stimulation— These effects are more likely to occur with ephedrine or high doses nervousness, anxiety, tremor, insomnia of other adrenergic drugs. Sometimes, a sedative-type drug is given concomitantly to offset these effects.

Perhaps most convincing is the growing number of studies that show low- carbohydrate diets are the most efficient and most satisfying way to lose weight and keep it off buy provigil 200 mg with amex insomnia video. In other words purchase provigil 100mg on-line insomnia from anxiety, all the food you put in your mouth will be as fresh as possible, and as low in fat as possible, and it will contain as little processing as possible. PROTEIN MAKES A COMEBACK Countless clinical trials by the most accredited researchers and universities in the country have concluded that, lo and behold, low carb is the real deal. THE ULTIMATE BODY NUTRITION PLAN 113 TLFeBOOK Though most had sought to discredit the low carb phenomenon, all have since realized that restricting carbohydrate intake is no mere fad diet, but rather is a true scientific advancement for the new millennium. At the time, scientists blamed the high amounts of saturated fats in the American diet for our bulging waistlines and skyrocketing rates of heart dis- ease. A plethora of low-fat and nonfat products soon hit the supermarket shelves, from nonfat cookies to baked potato chips. Americans caught on quickly to the new trend and cut back on meat, switched from whole milk to skim, and gave up their chocolate chip cookies for reduced fat cookies. As more and more people turned to pasta, rice, bagels, and nonfat snacks, more and more people got fat. She came in one day and proudly announced that she had eaten really well the night before: just one box of nonfat crackers, a one-pound contain- er of nonfat cottage cheese, and a box of reduced-fat cookies. In her mind, she had eaten really well because she had consumed almost no grams of fat. This is just one classic example of how Americans were really duped in the 1980s and the 1990s into believing that fat was the only culprit making us fat. Although some people certainly were able to lose weight during these low-fat years, the vast majority of Americans porked out. Perplexed, scien- tists went back to the drawing board, trying to figure out where things went wrong. After many years of research, scientists have made some interesting discoveries. They reasoned that sim- ply switching from high-fat foods to high-carbohydrate foods would auto- matically lower the overall caloric intake, thus resulting in weight loss. First, thanks to the addition of sugar and high fructose corn syrup, many low-fat, high-carbohydrate foods are not lower in calories than their high-fat 114 THE ULTIMATE NEW YORK BODY PLAN TLFeBOOK counterparts. For instance, to make low-fat cookies taste good, manufactur- ers added more sugar in place of the fat. From a calorie standpoint, low-fat cookies are just as bad for your waistline as high-fat cookies. Second, most people eat a larger portion size of low-fat foods than they do of high-fat foods, possibly under the false belief that low fat equals low calorie. If you were scooping some low-fat ice cream into a bowl, would you scoop out the same amount as you would high-fat ice cream? High-carb, low-fat foods are not as satisfying as their original counterparts. In the end, many people consume more calories on a low-fat diet than when on a high fat diet. NOT ALL FATS ARE BAD Not only was cutting fat out of the diet not the answer, but it was shortsighted. There are many different types of fat, rang- ing from the artery-clogging saturated fats found in fatty cuts of meat and whole milk to the processed trans fats found in commercially baked goods and margarine (which, by the way, may be worse for your health than but- ter)—and often in movie popcorn—to the heart-friendly unsaturated fats found in certain vegetables, nuts, flaxseed, and fish. When researchers compared diets rich in maize (corn) oil, beef tallow, and fish oil, they found that rats who ate the diet rich in fish oil gained less weight than rats on the beef or corn oil diet. Other studies show that replacing saturated and trans fats with unsaturated fats results in weight loss, even when total caloric intake is held constant. Eating unsaturated fats instead of saturated or trans fats lowers your unhealthy LDL cholesterol and lowers levels of triglycerides (a nasty type of blood fat). For many years, scientists told us that to lose weight, you had to eat fewer calories than you burned. Some of the calories you eat are more likely to lead to weight gain than others.