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For severe symptoms or a needed to ensure a daily intake of 1000 to 1500 mg buy cheap imitrex 25mg on line muscle relaxant drug class, serum calcium level above 12 mg/dL purchase imitrex 25 mg with mastercard spasms from colonoscopy, the priority is re- especially in adolescent girls, frail elderly, and those hydration. After rehydration, furosemide Vigorous, weight-bearing exercise helps to promote may be given IV to increase renal excretion of calcium and maintain strong bone; inactivity promotes bone and prevent fluid overload. Alendronate (Fosamax) and risedronate (Actonel) are in combination with estrogen and calcium and vitamin approved by the Food and Drug Administration (FDA) D supplements. Treatment of men is similar to that of women except ommended dosage is smaller for prevention than for that testosterone replacement may be needed. Raloxifene (Evista) is approved for prevention of post- treatment measures may be needed, including increased menopausal osteoporosis in women who are unable or dietary and supplemental calcium and possibly vitamin unwilling to take ERT. An adequate intake of vitamin D helps to prevent os- steroid dosage reduction, exercise, and a bisphospho- teoporosis, but supplementation is probably not indi- nate or calcitonin to slow skeletal bone loss. Serum calcitriol can be measured in clients at risk for vitamin D deficiency, including elderly adults and those on Use in Children chronic corticosteroid therapy. Preventive measures are needed for clients on chronic Hypocalcemia is uncommon in children. If hypocalcemia or dietary calcium de- most of the preceding guidelines apply (eg, calcium ficiency develops, principles of using calcium or vitamin D supplements, regular exercise, a bisphosphonate drug). Children should In addition, low doses and nonsystemic routes help be monitored closely for signs and symptoms of adverse ef- prevent osteoporosis and other adverse effects. Hypercalcemia is probably men, corticosteroids decrease testosterone levels by most likely to occur in children with a malignant tumor. Guide- approximately one half, and replacement therapy may lines for treating hypercalcemia in children are essentially the be needed. Safety, effectiveness, and dosages of etidronate, pamidronate, and zoledronate have not been established. Management of Osteoporosis Once bone loss is evident (from diagnostic tests of bone Use in Older Adults density or occurrence of fractures), several interventions may help slow further skeletal bone loss or prevent frac- Hypocalcemia is uncommon because calcium moves from tures. Most drugs used to treat osteoporosis decrease the bone to blood to maintain normal serum levels. However, rate of bone breakdown and thus slow the rate of bone loss; calcium deficiency commonly occurs because of long-term di- a newer drug, teriparatide (Forteo), actually increases bone etary deficiencies of calcium and vitamin D, impaired absorp- formation. As with prevention, those diagnosed with osteoporosis and impaired liver or kidney metabolism of vitamin D to its ac- need adequate calcium and vitamin D (at least the rec- tive form. These and other factors lead to demineralization and ommended dietary allowance), whether obtained from weakening of bone (osteoporosis) and an increased risk of frac- the diet or from supplements. Postmenopausal women are at high risk for development vitamin D are sometimes used to treat clients with se- of osteoporosis. If such doses are used, caution men, it occurs less often, at a later age, and to a lesser extent should be exercised because excessive amounts of vita- min D can cause hypercalcemia and hypercalciuria. Numerous studies indicate that regular physical activity helps to reduce bone loss How Can You Avoid This Medication Error? Women who smoke should be encouraged to stop be- taking alendronate (Fosamax), 10 mg ac breakfast for her severe cause smoking has effects similar to those of menopause osteoporosis. Wenzel before breakfast to ad- (estrogen deficiency and accelerated bone loss). Alendronate (Fosamax), 10 mg daily or 70 mg weekly, ing, I think I will just skip breakfast and sleep a little longer this and risedronate (Actonel), 5 mg daily, are Food and morning. She does so with a sip of water Drug Administration (FDA) approved for treatment of and sends you on your way. The drugs can 378 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM than in older women. Both men and women who take corti- Pamidronate and zoledronate are nephrotoxic and renal func- costeroids are at risk of developing osteoporosis. In general, apparently does not require dosage adjustment in renal all older adults need to continue their dietary intake of dairy impairment.

If the client is unable cheap imitrex 25 mg without a prescription muscle relaxant new zealand, who will be the pri- mail may be a convenient and efficient method of mary caregiver for medication administration and ob- communication generic imitrex 50mg visa spasms pelvic floor. If giving medications to a group of patients, start preparing about 30 minutes before the scheduled administration time when possi- ble, to avoid rushing and increasing the risk of errors. Medications and supplies are usually kept on a medication cart in a hospital or long-term care facility. Except for very simple calculations, use pencil and paper to de- crease the risk of errors. If unsure about the results, ask a colleague or a pharmacist to do the calculation. Check blood pressure (recent recordings) before giving anti- hypertensive drugs. Commonly needed reports include serum potassium levels before giving diuretics; prothrombin time or international normalized ratio (INR) before giving Coumadin; culture and susceptibility re- ports before giving an antibiotic. This is often needed to look up new or unfamiliar drugs; other uses include assessing a drug in relation to a particular client (eg, Is it contraindicated? Can a tablet be crushed or a cap- sule opened without decreasing therapeutic effects or increasing adverse effects? Practice the five rights of drug administration (right drug, These rights are ensured if the techniques described in Chapter 3 right client, right dose, right route, and right time). For example, a drug ordered for 9 AM can be usually given between 8:30 AM and 9:30 AM. For example, sterile equipment and techniques are required for injection of any drug. Follow label instructions regarding mixing or other aspects Some drugs require specific techniques of preparation and ad- of giving specific drugs. Look for improvement in signs and symptoms, laboratory In general, the nurse should know the expected effects and when or other diagnostic test reports, or ability to function. Ask questions to determine whether the client is feeling Specific observations depend on the specific drug or drugs being better. Look for signs and symptoms of new problems or worsening severity of adverse reactions vary among drugs and clients. Check laboratory (eg, complete blood count [CBC], elec- drugs being given. Ask questions to determine how the client is feeling and whether he or she is having difficulties that may be associated with drug therapy. Consider a possible interaction when a client does not more drugs concurrently and the number of possible interactions experience expected therapeutic effects or develops adverse is very large. Look for signs and symptoms of new problems or wors- drugs (eg, warfarin, sedatives, cardiovascular drugs). Anticipate the questions a client might ask about a drug How Can You Avoid This Medication Error? With children, what are some potential difficulties with cillin, rather than 100 mg, which should be administered every 8 hours. Carefully reread the order and recalculate the dosage drug administration, and how can they be prevented or ordered. With older adults, what are some potential difficulties with drug administration, and how can they be prevented or minimized? For older adults, explain what is meant by start low, go slow and why it is a good approach to drug therapy. Why is client teaching about drug therapy needed, and what information should usually be included? Describe at least three important nursing considerations the danger of potential drug toxicity is high. This is especially for clients who have renal or hepatic impairment or crit- true for a drug like digoxin that has a narrow therapeutic range. Decreased protein binding may result in higher blood levels of digoxin, causing toxicity.

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All aspects of pediatric drug therapy must be guided to treat severe hypertension or serious infections cheap imitrex 50mg overnight delivery spasms during mri. Choice of drug is often restricted because many drugs binations are increasingly available and commonly used effective 50 mg imitrex spasms definition, commonly used in adult drug therapy have not been suf- mainly because clients are more likely to take them. The least amount of the least potent drug that yields ther- children than for adults. Some drugs are not recom- apeutic benefit should be given to decrease adverse re- mended for use in children, and therefore dosages have actions. For many drugs, doses for chil- opioid analgesic are both ordered, give the non-opioid dren are extrapolated from those established for adults. In drug literature, recommended dosages are listed in ture, these should be used. Often, however, they are ex- amounts likely to be effective for most people. For example, clients with and the amount needed for a specific dose must be cal- serious illnesses may require larger doses of some drugs culated as a fraction of the adult dose. The following than clients with milder illnesses; clients with severe methods are used for these calculations: kidney disease often need much smaller doses of renally a. Calculating dosage based on body surface area is lowed by a regular schedule of smaller (maintenance) considered a more accurate method than those based doses. When drug actions are not urgent, therapy may be on other characteristics. In general, different salts of the same drug rarely differ pharmacologically. Pharmacists and chemists choose Nursing Notes: Apply Your Knowledge salts on the basis of cost, convenience, solubility, and stability. For example, solubility is especially important with parenteral drugs; taste is a factor with oral drugs. You are assigned to care for a low-birth-weight infant, who has Dermatologic drugs are often formulated in different been started on digoxin to treat congenital heart problems until salts and dosage forms, however, according to their in- corrective surgery can be performed. What factors might you consider before ques- tended uses (eg, application to intact skin or the mucous tioning the physician regarding the dosage that was ordered? CHAPTER 4 NURSING PROCESS IN DRUG THERAPY 61 Neonates, Infants, and Children: Physiologic Characteristics and TABLE 4–2 Pharmacokinetic Consequences Physiologic Characteristics Pharmacokinetic Consequences Increased thinness and permeability of skin in Increased absorption of topical drugs (eg, corticosteroids may be absorbed sufficiently to neonates and infants suppress adrenocortical function) Immature blood–brain barrier in neonates Increased distribution of drugs into the central nervous system because myelinization and infants (which creates the blood–brain barrier to the passage of drugs) is not mature until approximately 2 years of age Increased percentage of body water (70% Usually increased volume of distribution in infants and young children, compared with to 80% in neonates and infants, compared with adults. However, prolonged drug 50% to 60% in children older than 2 years of half-life and decreased rate of drug clearance may offset. Altered protein binding until approximately 1 year The amount and binding capacity of plasma proteins may be reduced. This may result in of age, when it reaches adult levels a greater proportion of unbound or pharmacologically active drug and greater risks of adverse drug effects. Drugs with decreased protein binding in neonates, compared with older children and adults, include ampicillin (Omnipen, others), diazepam (Valium), digoxin (Lanoxin), Iidocaine (Xylocaine), nafcillin (Unipen), phenobarbital, phenytoin (Dilantin), salicylates (eg, aspirin), and theophylline (Theolair). Decreased glomerular filtration rate in neonates In neonates and infants, slowed excretion of drugs eliminated by the kidneys. Decreased activity of liver drug-metabolizing Decreased capacity for biotransformation of drugs. This results in slowed metabolism and enzyme systems in neonates and infants elimination, with increased risks of drug accumulation and adverse effects. Increased activity of liver drug-metabolizing Increased capacity for biotransformation of some drugs. This results in a rapid rate of enzyme systems in children metabolism and elimination. For example, theophylline is cleared about 30% faster in a 7-year-old child than in an adult and approximately four times faster than in a neonate. In addition, adverse effects are likely because of physiologic changes associated with aging (Table 4–3), patho- Body surface area (in square meters) logic changes due to disease processes, multiple drug therapy 1. If intramuscular injections are required in infants, use person over time.

The spectrum of neurophysiological assessment consists Bladder and bowel function (3 points) depend on both of electromyography (EMG) purchase 50mg imitrex free shipping muscle relaxant 2mg, electroneurography (ENG) purchase 25mg imitrex mastercard spasms left upper abdomen, motor and sensory integrity. While somatosensory evoked po- ever, bladder or bowel dysfunction is caused primarily by tentials (SEPs) and motor evoked potentials (MEPs) are a bilateral upper motor neuron lesion. Cervical myelopa- most helpful in the investigation of the central nervous sys- thy is generally due to degenerative changes of the middle tem pathways, electromyography, conventional neurogra- and lower cervical spine. Therefore, impairment of hand phy and F-wave studies are more useful for evaluation of function can be attributed mainly to lower motor neuron the peripheral segments of the sensory and motor path- function (4 points), although similar disturbances of preci- ways. Proprioception and coordination depend on posterior column function (3 points). Posterior Somatosensory evoked potentials column function was included in the European Myelopa- thy Score instead of the JOA subscores for sensory function For spinal cord evaluation, SEPs are relevant. These are – a disturbance which is very difficult to classify into cat- potentials recorded from the lumbar and cervical spine as egories. Pain is not a major symptom in cervical myelopa- well as the first components of scalp recordings. Nevertheless, unpleasant sensations such as paresthe- SEPs are generally recorded after electrical stimulation sia or dysesthesia are often reported, and are mostly caused of peripheral nerves or skin. The nerves used are: the pos- by a mechanical irritation of the afferent posterior cervical terior tibial, sural, or common peroneal nerves of the roots (3 points). The maximum number of points a normal lower limbs, and the median radial and the ulnar nerve for subject can reach is 18. In radicular and spinal disease, several Borrowing from the Glasgow Coma Scale, the worst nerves, supplied by different segments, must be stimulated result is rated with 1 point for each subscore. Depending on the sum reached in the mended for the diagnosis of cervical myelopathy. Subjects with 17 or 18 points are consid- Motor evoked potentials ered free of signs of cervical myelopathy. The functional character of the criteria used in the Eu- Somatosensory evoked potentials are delayed in cervical ropean Myelopathy Score allows a critical evaluation of spondylosis and the latency of N11 is significantly delayed cervical myelopathy from different centers and different statistically. The European Myelopathy Score helps to judge previously in electrical cortical stimulation studies [1, 12]. It also allows a more objective control of stimulation of the cerebral cortex was introduced in 1985 postoperative outcome. They applied short magnetic pulses, is a valuable tool for the evaluation of all conditions involv- designed to stimulate peripheral nerves, to the scalp, and 102 recorded muscle action potentials from upper and lower However, as the excitability of the spinal motor neuron limb muscles. In spite of ulate the motor cortex, the cervical nerve roots, and the these limitations, F-waves have a diagnostic value for an- lumbar nerve roots. When F-waves are recorded in a chronic following muscles: abductor pollicis, adductor minimi, neuropathic process, axonal reflexes must be differenti- quadriceps, tibialis anterior, gastrocnemius, extensor hal- ated [18, 33]. The segmental innerva- tion of these muscles is used for a level diagnosis in anal- ogy to the segmental distribution of the afferent nerves Electromyography (EMG) stimulated for SEPs. Needle electromyography examines segmentally affected For motor root stimulation over the cervical and lum- muscles, chosen based upon the clinical investigation. Increased inser- With this, the onset latency is not critically dependent on tional activity, spontaneous activity (involuntary) such as the positioning of the coil or the stimulation strength. In patients diagnosed as In normal muscles, motor unit action potentials having a lateral compression of the nerve root, the periph- (MUAPs) are elicited only in response to neural discharges. These signs of denervation in EMG can be spotted at the earliest about 8 days after the nerve lesion, and are termed acute signs of M-wave and F-wave evaluation denervation. In order to judge the MEP waveform it is also necessary to obtain an M-wave recording by means of conventional neurography. The M-wave is the response to a supramax- Diagnostic reliability imal stimulus of the peripheral nerve, and therefore an electric measure of muscle size. It is used as a ref- EMG is important in the differential diagnosis of cervical erence signal with which post transcranial stimulation spondylosis. It shows degrees of denervation and the num- MEP amplitude and duration are compared, i. The increased CML can be found in not only degenerative but also inflammatory dis- eases of the central nervous system, such as multiple scle- F-wave rosis.

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