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Although the alignment of the cervical spine purchase atrovent 20 mcg mastercard symptoms hypoglycemia, creased since the reconstructed or preserved laminae still the relative position of the facets to the vertebral body 20mcg atrovent with visa medications joint pain, have a protective function to diminish blood pooling and and the distance from the cord to the dura–nerve root soft tissue swelling after surgery. We have experienced junction were all analyzed, no factor was proven to be a this complication in only 0. Foraminotomy or facetectomy has not been proven to Fracture of a hinge or loss of spinal canal enlargement be a preventive measure. However, controlled opening of due to insufficient fixation of the lifted lamina is reported the lamina can prevent this problem – although a defini- to cause nerve root or spinal cord palsy when a lamina mi- tive method for control of opening has not been found. Computerized tomography Postoperatively, patients with laminoplasty complain (CT) is useful for delineating the pathology in this case, of various axial symptoms such as nuchal pain and stiff- and total or partial removal of the lifted lamina is neces- ness of the neck and shoulder muscles. The prognosis is usually good if salvage is carried ally appeared on the hinge side in our en-bloc lamino- out promptly. After Nerve root palsy due to thermal damage or mechanical spinous process splitting laminoplasty, a few of the patients injury to the nerve root is known to develop occasionally complained of neck and/or shoulder pain. The symptoms following posterior decompression, and a different type of were usually distributed on both sides. The causes of these nerve root palsy is reported to occur after laminoplasty symptoms are not clear. The initial symptom is severe pain in the the facet joints caused by surgical intervention may be the shoulder and upper arm, which is followed by paresis or cause. The symptoms resolved by about 1 year after sur- paralysis of the deltoid and biceps brachii muscles. However, axial symptoms are the is a motor-dominant type of nerve root paralysis. The for- chief complaint in some patients, and their cause should mer symptom is the more frequent form of this complica- also be clarified. It occurs on the 1st, 2nd, or 3rd postoperative day, of the neck and shoulder is recommended for treatment. The fifth cervical nerve Nonsteroidal anti-inflammatory agents and muscle-relax- root is most frequently involved, followed by the sixth ant drugs have little effect. The eighth nerve root is rarely have started to assess the usefulness of various postopera- affected. Out of 239 laminoplasty patients in our series, tive muscle exercises and neck motion programs to pre- 12 patients developed fifth or sixth nerve root palsy, 3 pa- vent these complaints as well as to maintain or create a tients had seventh nerve root involvement, and 1 patient cervical lordosis after laminoplasty, but none of these pro- had an eighth root complication. Tsuzuki N, Zhogshi L, Abe R, Aiki K losis with moderate to severe myelopa- Wada E, Yonenobu K (1996) Expan- (1993) Paralysis of the arm after poste- thy. Spine 2:151–162 sive laminoplasty for cervical radicu- rior decompression of the cervical spi- 2. Cloward RB (1958) The anterior ap- lomyelopathy due to soft disc hernia. Anatomical investigation proach for removal of ruptured cervical A comparative study between lamino- of the mechanism of paralysis. Iwasaki M, Kawaguchi Y, Kimura T, (1993) Paralysis of the arm after poste- hand characterized by muscle wasting. Yonenobu K (2002) Long-term results rior decompression of the cervical spi- A different type of myelopathy hand in of expansive laminoplasty for ossifica- nal cord. Eur Spine J 2:197–202 Spine 13:785–791 ment of the cervical spine: more than 29. J Neurosurg (Spine) suoka T, Miyamoto S, Yonenobu K cervical spine surgery. In: Shark HH, 96:180–189 (2001) Subtotal corpectomy versus et al (eds) The cervical spine, 2nd edn. Kawai S, Sunago K, Doi K, Saika m, laminoplasty for multilevel cervical Lippincott, Philadelphia, pp 831–837 Taguchi T (1988) Cervical lamino- spondylotic myelopathy: a long-term 5. Spine 13:1245– 26:1443–1447 ing ceramic laminas for cervical mye- 50 30. Matsuzaki H, Hoshino M, Kiuchi T, problem of clinical instability in the 6. Herkowitz HN (1988) A comparison Toriyama S (1989) Dome-like expan- human spine.

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Metabolism of drugs metabolized by conjugative reactions (eg cheap atrovent 20mcg line medications given for migraines, acetaminophen purchase atrovent 20mcg without prescription treatment non hodgkins lymphoma, diazepam, morphine, steroids) does not change significantly with aging). Decreased blood flow to the kidneys, decreased • Impaired drug excretion, prolonged half-life, and increased risks of toxicity number of functioning nephrons, decreased • Age-related alterations in renal function are consistent and well described. When glomerular filtration rate, and decreased tubular renal blood flow is decreased, less drug is delivered to the kidney for elimination. Also available are drug containers with This conservative, safe approach is sometimes called doses prepared and clearly labeled as to the day start low, go slow. Use nondrug measures to decrease the need for drugs system, the client can tell at a glance whether a and to increase their effectiveness or decrease their dose has been taken. When a client acquires new symptoms or becomes less avoiding caffeine-containing beverages and excessive capable of functioning in usual activities of daily liv- napping) is much safer than taking sedative-hypnotic ing, consider the possibility of adverse drug effects. They may then be ignored or treated by pre- use measures to help them take drugs safely and scribing a new drug, when stopping or reducing the effectively. If vision is impaired, label drug containers with large lettering for easier readability. For example, avoid childproof containers for an older Many clients have or are at risk for impaired renal function. Several devices may be used to schedule drug doses or heart failure may have renal insufficiency on first contact, and decrease risks of omitting or repeating doses. In clients with nor- 64 SECTION 1 INTRODUCTION TO DRUG THERAPY mal renal function, renal failure may develop from depletion not be used as the sole indicator of renal function unless of intravascular fluid volume, shock due to sepsis or blood the client is a young, relatively healthy, well-nourished loss, seriously impaired cardiovascular function, major surgery, person with a sudden acute illness. Acute renal failure inine clearance are more accurate for clients with stable (ARF) may occur in any illness in which renal blood flow or renal function (ie, stable serum creatinine) and average function is impaired. Chronic renal failure (CRF) usually re- muscle mass (for their age, weight, and height). If a fluctuating serum creatinine is treated effectively, and medication dosages are adjusted ac- used to calculate the GFR, an erroneous value will be ob- cording to the extent of renal impairment. If a client is oliguric (<400 mL urine/24 hours), tive treatment can help to conserve functioning nephrons and for example, the creatinine clearance should be esti- delay progression to end-stage renal disease (ESRD). If ESRD mated to be less than 10 mL/minute, regardless of the develops, dialysis or transplantation is required. In relation to drug therapy, the major concern with renal im- Serum creatinine is also a relatively unreliable in- pairment is the high risk of drug accumulation and adverse ef- dicator of renal function in elderly or malnourished fects because the kidneys are unable to excrete drugs and drug clients. Guidelines have been established for the use of muscle mass, they may have a normal serum level of many drugs; health care providers need to know and use these creatinine even if their renal function and GFR are recommendations to maximize the safety and effectiveness of markedly reduced. Some general guidelines are listed here; specific Some medications can increase serum creatinine lev- guidelines for particular drug groups are included in appropri- els and create a false impression of renal failure. Drug therapy must be especially cautious in clients with terfere with secretion of creatinine into kidney tubules. Drug selection should be guided by baseline renal func- all health care providers need to be knowledgeable tion and the known effects of drugs on renal function, about risk factors for development of renal impairment, when possible. Many commonly used drugs may ad- illnesses and their physiologic changes (eg, hemo- versely affect renal function, including nonsteroidal dynamic, renal, hepatic, and metabolic alterations) that anti-inflammatory drugs such as prescription or OTC affect renal function, and the effects of various drugs on ibuprofen (Motrin, Advil). Renal status should be monitored in any client with most are excreted primarily or to some extent by the kid- renal insufficiency or risk factors for development of neys. Signs and symptoms of ARF in- ment (eg, tetracyclines except doxycycline); others can clude decreased urine output (<600 mL/24 hours), in- be used if safety guidelines are followed (eg, reducing creased blood urea nitrogen or increased serum creatinine dosage, monitoring serum drug levels and renal function (>2 mg/dL or an increase of ≥0. In addition, an adequate fluid in- toxic should be avoided when possible. Any stances, however, there are no effective substitutes and factors that deplete extracellular fluid volume (eg, in- nephrotoxic drugs must be given. Some commonly used adequate fluid intake; diuretic drugs; loss of body fluids nephrotoxic drugs include aminoglycoside antibiotics, with blood loss, vomiting, or diarrhea) increase the risk amphotericin B, and cisplatin. Dosage of many drugs needs to be decreased in renal have impairment or of causing impairment in those who failure, including aminoglycoside antibiotics, most previously had normal function. Clients with renal impairment may respond to a drug For some drugs, a smaller dose or a longer interval be- dose or serum concentration differently than clients with tween doses is recommended for clients with moderate normal renal function because of the physiologic and (creatinine clearance 10 to 50 mL/minute) or severe renal biochemical changes. Thus, drug therapy must be indi- insufficiency (creatinine clearance < 10 mL/minute). Be- For clients receiving renal replacement therapy cause serum creatinine is determined by muscle mass as (eg, hemodialysis or some type of filtration), the well as the GFR, the serum creatinine measurement can- treatment removes variable amounts of drugs that are CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 65 usually excreted through the kidneys. The consequence drugs, such as many antimicrobials, a supplemental may be toxicity from the inhibited drugs if the dose is dose may be needed to maintain therapeutic blood not decreased.

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People with diabetes who develop hypoglycemia may have Caution is needed in the treatment of hypoglycemia purchase atrovent 20mcg free shipping medicine that makes you throw up. Although impaired secretion of these hormones buy 20 mcg atrovent mastercard nioxin scalp treatment, especially those with type the main goal of treatment is to relieve hypoglycemia and restore the 1 diabetes. The client having a hypoglycemic re- cretion of epinephrine also occurs in people who have been action should not use it as an excuse to eat high-caloric foods or treated with insulin for several years. Health care personnel caring for the client creases tachycardia, a common sign of hypoglycemia, and may should avoid giving excessive amounts of glucose. Posthypoglycemia Care The Conscious Client Once hypoglycemia is relieved, the person should have a snack or Treatment of hypoglycemic reactions consists of immediate ad- a meal. Slowly absorbed carbohydrate and protein foods, such as ministration of a rapidly absorbed carbohydrate. For the conscious milk, cheese, and bread, are needed to replace glycogen stores in client who is able to swallow, the carbohydrate is given orally. In addition, the episode needs to include: be evaluated for precipitating factors so that these can be mini- • Two sugar cubes or 1 to 2 teaspoons of sugar, syrup, honey, mized to prevent future episodes. Repeated episodes mean that the or jelly therapeutic regimen and client compliance must be re-evaluated • Two or three small pieces of candy or eight Lifesaver candies and adjusted if indicated. Glitazones tion increases or restores the effectiveness of circulating insulin and results in increased uptake of glucose by pe- • These drugs, pioglitazone and rosiglitazone, are also ripheral tissues and decreased production of glucose by called thiazolidinediones or TZDs and insulin sensitizers. The drugs stimulate exercise or in combination with insulin, metformin, or receptors on muscle, fat, and liver cells. The drugs lower blood sugar by decreasing absorption or production of glucose, by increasing secretion of insulin, or by increasing the effectiveness of available insulin (decreasing insulin resistance). They are also con- should be skipped; if a meal is added, a drug dose traindicated in clients who are hypersensitive to them. Glitazones increase plasma volume and may cause HERBAL AND DIETARY fluid retention and heart failure. In people who did not With most herbs and dietary supplements, even the commonly take a glitazone, 2. Thus, anyone with diabetes who Meglitinides wishes to take an herbal or dietary supplement should consult • Nateglinide and repaglinide are nonsulfonylureas that a health care provider, read product labels carefully, seek the lower blood sugar by stimulating pancreatic secretion of most authoritative information available, and monitor blood insulin. Described • They can be used as monotherapy with diet and exercise below are some products that reportedly affect blood sugar and or in combination with metformin. They are metabolized in the liver; Blood Glucose Levels metabolites are excreted in urine and feces. After a dose of 2 mg is reached, increase dose in increments of 2 mg or less at 1- to 2-week inter- vals, based on blood glucose levels. In combination with insulin, PO 8 mg once daily with the first main meal. Alpha-Glucosidase Inhibitors Acarbose (Precose) Delays digestion of carbohydrate foods PO, initially 25 mg, three times daily with first bite when acarbose and food are present of main meals; increase at 4- to 8-week intervals in gastrointestinal (GI) tract at the to a maximum dose of 50 mg three times daily same time (for patients weighing under 60 kg) if necessary, depending on 1-h postprandial blood glucose lev- els and tolerance. Clients weighing more than 60 kg may need doses up to 100 mg three times daily (the maximum dose). Miglitol (Glyset) Delays digestion of carbohydrates in the PO, initially 25 mg three times daily with the first GI tract bite of each main meal, gradually increased if necessary. Maximum dose, 100 mg three times daily Biguanide Metformin (Glucophage) Older adults are at higher risk for devel- PO, initially 500 mg twice daily, with morning and opment of lactic acidosis, a rare but evening meals; increase dose in increments of potentially fatal reaction. Thus, smaller 500 mg/d every 2–3 weeks if necessary, up to a doses and monitoring of renal function maximum of 3000 mg daily, based on patient are recommended. Glitazones Pioglitazone (Actos) Increases effects of insulin; may be used PO 15–30 mg once daily alone or with insulin, metformin, or a sulfonylurea Rosiglitazone (Avandia) Increases effects of insulin; may be used PO 4–8 mg once daily , in one dose or two divided alone or with metformin doses Meglitinides Nateglinide (Starlix) Onset of action, within 20 min; peak, 1 PO 120 mg three times daily, 1–30 min before h; duration, 3–4h meals. Repaglinide (Prandin) Onset of action, within 30 min; peak, PO 1–2 mg 15–30 min. Combination Drug* Glyburide/metformin (Glucovance) Available in preparations with 1. Patients previously treated with glyburide or mg glyburide and 500 mg metformin; other sulfonylurea plus metformin: Initially, PO 2. States, may play a role in the development of diabetes Jean Watson, a 52-year-old type 2 diabetic, has been managed for and atherosclerosis. If so, beneficial effects of a supple- the last 3 years on 500 mg of metformin (Glucophage) bid.

Finding the real causative or triggering factors for any symptom takes collabo- ration between the physician and the patient atrovent 20mcg on line symptoms for pneumonia. For patients who fall into Groups I cheap atrovent 20mcg otc conventional medicine, II, or even III, the collaborative effort to trace causa- tion will likely be productive. For patients with the characteristics of Group IV, the effort will be largely futile. Maybe future studies and research of this group of patients will lead to more productive approaches than I was able to find. Although I did not test the idea systematically, I found this method for grouping by awareness and connectedness to life events also useful for patients with a defined medical disease. Even though I did not subject the excluded seventy-two patients to detailed analysis, it was my experience that patients who fell into Groups I, II, or III were more amenable to examining their daily lives, even when there was a medical disease present. Tey were amenable to changing habits, making adjustments in their lives, and taking medications that the disease process required for maximum im- provement. For patients with the characteristics of Group IV, disease is a way of life whether it is objectively demonstrable or not. I believe, but cannot prove, that patients with the characteristics of Group IV will do more poorly with medical diseases than those in Groups I, II, or III. Some patients in Group IV use their diseases to manipu- late their families and friends. Tere were 165 previous surgi- Symptoms Without Disease 91 cal operations among the seventy-eight patients, an average of 2. One of the most telling aspects of this study is the number and nature of the false diagnoses carried by these patients. Table 11-2 lists the forty-two diagnoses that were not substantiated by fur- ther study. Aside from diverting the attention of patients from the real source of their problems, some of these labels are serious and harmful enough to be worthy of comment. Another patient was told the lipoma on her forearm was potentially malignant. Two patients were taking propylthiouracil for unsubstantiated hyperthyroidism. Sweet Ting was taking insulin for her misdiag- nosed diabetes and having frequent hypoglycemic episodes. One patient was referred for cobalt therapy to the pituitary gland for a false diagnosis of acromegaly. Te diagnosis was based on borderline physical findings of a large face, jaw, and hands, and a growth-hormone level at the upper limits of normal that allegedly was not suppressed with glucose administration. When I ques- tioned the patient, she said she had not received any glucose on the day of the serial measurements. An infusion of glucose produced complete suppression of her growth-hormone levels. One patient had had serial teeth extractions until all the teeth had been removed from the entire left side of her mouth. Tere were two patients on glucocorticoids for false diagnoses of thyroid- itis. One patient was on chronic coumadin therapy for phlebitis, which turned out to be self-produced bruises along the course of the veins in her legs. Most of the false diagnoses in the patients I saw concerned en- docrine diseases, because this was my specialty practice. Clearly, the false diagnoses had the potential to pro- duce serious and harmful consequences, both psychologically and physically. Prevalence of False Diagnoses: An Unanswered Question One of the questions I posed in the introduction to this book was, How common is the error of assigning a false diagnosis to a pa- tient? I have found only one study that defined the extent of false diagnoses of a disease in a popula- tion, and that tracked the number of false diagnoses of heart disease in 20,000 school children in Seattle. Bergman and Stamm (1967) found 110 children with a diagnosis of heart disease who were then subjected to detailed cardiac evaluation. Only 18 percent actually had heart disease; 72 percent had no heart disease. If false diagno- ses of other chronic diseases are even close to this magnitude, there is obviously a serious problem in the health-care system.

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