Professor of Medicine, Department of Medicine, University of Utah
Staff Physician, Department of Medical Service,
Veterans Affairs Salt Lake City Healthcare System,
Salt Lake City, UT
Hemodialysis Adequacy
More limited coverage is provided on the opioid antagonist naltrexone zinc antimicrobial properties purchase on line ceftin, which ChapterOChapter is not used widely for opioid addiction treatment in the United States which antibiotics for sinus infection uk ceftin 250mg mastercard. Methadone maintenance treatment has veniam quis W ithdrawal the longest successful track record in patients addicted to opioids for Dolore eu more than a year and has been shown to control withdrawal symptoms antimicrobial herbs and phytochemicals buy cheapest ceftin, fugiat nullaTake-Home stabilize physiologic processes antibiotic resistance not finishing prescription cheap 500 mg ceftin with amex, and improve functionality antimicrobial hand soap buy ceftin mastercard. If a never life threatening bacteria scientific name buy generic ceftin canada, but it can produce dis clear history of opioid abuse or addiction comfort severe enough to warrant urgent inter exists but a person currently is not addicted infection blood purchase ceftin with visa, vention bacteria ua rare purchase ceftin us. Detoxification might be abuse, and detoxification alone may yield only attempted with applicants who have a shorter short-term benefits. Therefore, i Applicants who cannot attend treatment when detoxification from short-acting opioids is sessions regularly, especially for medication provided, the consensus panel recommends dosing (unless a clinical exception can be linkage to ongoing psychosocial treatment, with obtained [see chapter 7]); this requirement is or without additional maintenance therapy less of a hindrance for patients receiving with an opioid antagonist such as naltrexone. Access and easy transfer to this care should remain available as part of any In addition, people who are opioid addicted detoxification program. Inclusion rather than ing such as daily BreathalyzerJ tests, ongoing exclusion should be the guiding principle. The stages of Observed dosing is the only way to ensure that naltrexone pharmacotherapy may differ. Regardless of the medication sometimes by requir used, safety is key during the induction stage. Administration of the first dose ounces of liquid in which an appropriate dose also should await a physical assessment to rule of medication is dissolved. For buprenorphine, out any acute, life-threatening condition that a sublingual tablet should be observed to have opioids might mask or worsen (see chapter 4 dissolved completely under the tongue. If same-day and from long-acting opioids, such as dosing adjustments must be made, patients methadone, for at least 10 days before begin should wait 2 to 4 more hours after the addi ning the medication to prevent potentially tional dosing, for further evaluation when peak severe withdrawal symptoms (OiConnor and effects are achieved. This observation is particu such as benzodiazepines or alcohol should be larly important for patients at higher risk of ruled out before induction to minimize the overdose, including those naive to methadone, likelihood of oversedation with the first dose. Naltrexone of medication accumulate in body tissues (see typically is prescribed without observed dosing, below), the effects begin to last longer. Initial dosing should be followed to look at using family members to ensure that by dosage increases over subsequent days until patients take their medication (Fals-Stewart withdrawal symptoms are suppressed at the and OiFarrell 2003). The first dose of any opioid tissues, including the liver, from which their treatment medication should be lower if a slow release keeps blood levels of medication patientis opioid tolerance is believed to be low, steady between doses. It is important for physi the history of opioid use is uncertain, or no cians, staff members, and patients to under signs of opioid withdrawal are evident. Some stand that doses of medication are eliminated former patients who have been released from more quickly from the bloodstream and medi incarceration or are pregnant and are being cation effects wear off sooner than might be readmitted because they have a history of expected until sufficient levels are attained in addiction might have lost their tolerance. During induction, even without dosage of tolerance should be considered for any increases, each successive dose adds to what is patient who has abstained from opioids for present already in tissues until steady state is more than 5 days. The blood remains fairly steady because that drugis amount of opioid abuse estimated by patients rate of intake equals the rate of its breakdown usually gives only a rough idea of their toler and excretion. Approximately four to five patient estimates of dollars spent per day on half-life times are needed to establish a steady opioids. For example, because transferred from methadone has a half-life of 24 to 36 hours, its other treatment pro steady stateothe time at which a relatively grams should start constant blood level should remain present in with medication the bodyois achieved in 5 to 7. However, dosages identical to those prescribed at individuals may differ significantly in how long principle istart it takes to achieve steady state. Dosage adjustments Patients should stay on a given dosage for a low and go slowi in the first week of reasonable period before deciding how it will treatment should be ihold. Patients who effects of a medica wake up sick during the first few days of opioid tion last. In contrast, patients who wake up sick for pharmacotherapy because of concerns after the first week of treatmentowhen tissue about its cardiovascular effects. Outpatient programs are its extended duration of action can result in limited in this approach because patients can toxic blood levels leading to fatal overdose. W hereas 60 mg of Sunjic 2000), it is important to adjust methadone per day may be adequate for some methadone dosage carefully until stabilization patients, it has been reported that some and tolerance are established. Looking for clinical signs and listening drawal symptoms persist after 2 to 4 hours, the to patient-reported symptoms related to daily initial dose can be supplemented with another 5 doses or changes in dosage can lead to adjust to 10 mg (Joseph et al. The total first ments and more favorable outcomes (Leavitt et day dose of methadone allowed by Federal reg al. Exhibit 5-1 illustrates the use of signs ulations is 40 mg unless a program physician and symptoms to determine optimal methadone documents in the patient record that 40 mg was dosages. Clinical Pharm acotherapy 67 Exhibit 5-1 Using Signs and Sym ptom s To Determ ine Optim al M ethadone Levels Adapted from Leavitt et al. It is important to understand No stated requirement exists for observed dos that steady state is achieved after a dosage ing with buprenorphine, although guidelines change. Awaiting signs of withdrawal tablets without naloxone (sometimes called before administering the first dose is especially monotherapy tablets) are recommended during important for buprenorphine induction the first 2 days of induction for patients because, as explained in chapter 3, buprenor attempting to transfer from a longer acting phine can precipitate withdrawal in some cir opioid such as sustained-release morphine or cumstances (Johnson and Strain 1999). If levels of a full agonist are a factor and the withdrawal symptoms persist after 2 to 4 hours, buprenorphine-naloxone tablet is adminis the initial dose can be supplemented with up to tered, it may be difficult to determine whether 4 mg for a maximum dose of 8 mg of buprenor precipitated withdrawal is caused by the par phine on the first day (Johnson et al. Three national evaluations of the buprenorphine-naloxone combination tablet For most patients who are appropriate found that direct induction with buprenor candidates for induction with the combination phine alone was effective for most people who tablet, the initial target dose after induction were opioid addicted. However, buprenorphine should be 12 to 16 mg of buprenorphine in Clinical Pharm acotherapy 69 a 4-to-1 ratio to naloxone. The stabilization stage of opioid pharma to this target dosage may be achieved over the cotherapy focuses on finding the right dosage first 3 days of treatment by doubling the dose for each patient. There is no single recommended dosage or even a fixed range of dosages for all Induction w ith naltrexone patients. For many patients, the therapeutic the standard procedure for induction to nal dosage range of methadone may be in the trexone therapy is first to make certain that neighborhood of 80 to 120 mg per day (Joseph there is an absence of physiological dependence et al. Then the the desired responses to medication that patient is given 25 mg of naltrexone initially, usually reflect optimal dosage include (Joseph followed by 50 mg the next day if no withdrawal et al. The first dose usually is smaller to abstinence minimize naltrexoneis side effects, such as nau i Elimination of drug hunger or craving sea and vomiting, and to ensure that patients have been abstinent from opioids for the i Blockade of euphoric effects of self requisite time (Stine et al. In contrast, a patient is stabi it increasingly difficult to achieve complete lized when he or she no longer exhibits drug blockade in patients through cross-tolerance; seeking behavior or craving. The correct consequently, some patients require dosages (steady-state) medication dosage contributes to considerably greater than 120 mg per day to a patientis stabilization, but it is only one of achieve this effect. For perception or physical or emotional response example, if the goal is to suppress opioid with i Tolerance for most analgesic effects produced drawal symptoms, then dose increases can be by treatment medication (see iPain less frequent. Even when a medication higher has been dosage is controlled for body weight (Leavitt et shown to prolong the Dosage require al. In addition, be dosed every other day, which is an methadone, the extent of other drug use and alcohol con sumption should be considered when determin option with buprenor ing dosage adequacy. A patient can does not increase buprenorphine experience opioid craving or withdrawal but buprenorphineis manage to abstain from illicit opioids. Strong evidence supports the use because of its partial mined on an indi of daily methadone doses in the range of 80 mg agonist properties or more for most patients (Strain et al. Some do well on dosages below 80 to buprenorphine is a 120 mg per day, and others require significant partial agonist, ly higher dosages (Joseph et al. As reviewed by Johnson patientsi ability to refrain from opioid abuse and colleagues (2003b), if patients continue to (Bickel et al. Cross-tolerance should be monitored closely during the first occurs when medication diminishes or prevents 2 weeks of treatment and adjustments in dosage the euphoric effects of heroin or other short made accordingly. Although some treatment retention high priorities and justify patients take the same dose on Monday, additional studies on the safety and efficacy of W ednesday, and Friday, most benefit from an methadone doses exceeding 120 mg. For the latter, the usual Another study (Maxwell and Shinderman 2002) practice is to give 100 mg on Monday and monitored 144 patients who were not doing well W ednesday and 150 mg on Friday (Stine et al. Patients receiving 72 Chapter 5 Exhibit 5-3 Heroin Use in Preceding 30 Days (407 M ethadone-M aintained Patients by Current M ethadone Dose) Adapted from Ball and Ross, the Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome, Appendix B, p. More would be expected to affect treatment negative research is needed to understand better the ly (Leavitt et al. Given these and similar relationship between methadone blood levels data, it is incorrect to conclude that a particu and cessation of opioid abuse. When split dosing is used, patients receive two or three doses per the consensus panel recommends that a main day to achieve the targeted peak-to-trough tenance dosage of methadone not be predeter ratio in blood level measurements and to avoid mined or limited by policy if that policy does withdrawal symptoms for 24 hours (Payte et al. Data were dose are well known, but patient changes derived by averaging a series by Inturrisi and associated with overmedicating and undermedi Verebely (1972) and another one by Kreek cating are less dramatic and often more (1973). Patients also might report feeling high dosage requirements to change, including (but or iloadedi and ask for a reduced dosage. Patients who report that they opioid craving, withdrawal symptoms, medica have vomited their medication pose special tion side effects, or intoxication always should problems. Mildly to moderately over handled by reassuring patients that the full medicated patients might show inoddingi dose has been absorbed. Emesis at 15 to 30 and closing of the eyes or might fall asleep at minutes after dosing can be handled by replac inappropriate times. These patients might ing half the dose, and the whole dose should be scratch their faces continuously, especially their replaced if emesis occurs within 15 minutes of noses. If vomiting persists, it is important to be unapparent, and some overmedicated remember that only a portion of the gut is patients might feel mildly stimulated. Nausea emptied with forceful emesis; therefore, the also can occur, particularly in newer patients. Causes of emesiso is suspected, and their dosage should be including pregnancyoshould be explored. An increase in medication as can the occasional use of antiemetic dosage should not be a reward for positive medicines. Environmental cues, extensive work has demonstrated the effective including people, places, things, and feelings ness of using increased dosage (as well as extra associated with drug taking, can be associated take-home doses) as an incentive to decrease strongly with opioid craving and withdrawal. Although the consensus ing and relapse long after opioid use has panel acknowledges important behavioral stopped and physical dependence has been con aspects of addiction and the value of contingen trolled (Self and Nestler 1998). Environmental cy management as an aid to behavioral change, changes and other stressors can cause patients using medication dosage as a reward or punish to perceive that a dose on which they were sta ment is considered inappropriate. Events that increase the availability of substances of abuse, such as M aintenance another person who uses drugs moving into a Pharm acotherapy patientis home or new sources of illicit drugs, the maintenance stage of opioid pharma can intensify craving. When their discomfort cotherapy begins when a patient is responding resumes after a period of abstinence, patients optimally to medication treatment and routine might feel that they are weak willed. In opioids and other substances and have resumed animal models, withdrawal symptoms have productive lifestyles away from the people, been conditioned to appear with environmental places, and things associated with their addic cues after months of abstinence from opioids tions. Patients who believes that increased medication dosages are continue to abuse substances, do not seek appropriate in such cases, although efforts also employment, or remain connected to their drug should focus on resolving the troublesome situ using social networks have not reached this ations such as developing ways to avoid people, stage. Along with continued observed medication places, and things that trigger opioid craving or treatment, these latter patients are candidates relapse. Conversely, diminished triggers and for intensified counseling and other services to reduced drug availability can diminish drug help them reach the maintenance stage. During the maintenance stage, many patients remain on the same dosage of treatment medi Contingent use of dosage. The consensus panel cation for many months, whereas others believes that any manipulation of dosage as require frequent or occasional adjustments. Take-home medication is controlled by emotional crises may require long-term or Federal regulations, and access is based on sev temporary dosage adjustments. In such cases, providers When stable patients in the maintenance stage should refer patients to other programs that ask for dosage reductions, it is important to are more reasonable and practical in terms of explore their reasons. Patients often perceive that those on lower In a review of research on withdrawal from dosages are ibetter patients. They the dosage necessary to achieve stability concluded, therefore, that planned withdrawal (Leavitt et al. Voluntary Tapering and Relapse prevention techniques should be incorporated into counseling and other support Dosage Reduction services both before and during dosage reduc For various reasons, some patients attempt tion. Such structured techniques can be useful reduction or cessation of maintenance medica safeguards in preventing and preparing for tion. Use of mutual-help techniques (see often 80 percent or more, for this group, chapter 8) is recommended highly, especially including patients judged to be rehabilitated during dosage reduction. However, the likelihood of successful Although most data about outcomes after dose tapering also depends on individual fac tapering from opioid medication come from tors such as motivation and family support. Patients who choose tapering should be monitored closely and taught relapse preven M ethadone dosage reduction tion strategies. They and their families should the techniques and rates of graded methadone be aware of risk factors for relapse during and reduction vary widely among patients. The rate of withdrawal can be protracted course, increased or decreased based on individual although symptoms patient response. A slow withdrawal gives might be less intense patients and staff time to stop the tapering or than with other opi resume maintenance if tapering is not working oids. Special should be moni steady-state occupancy of opiate receptors is no counseling might be longer complete and discomfort, often with needed to address drug hunger and craving, emerges. Some patients appear medication free, to have specific thresholds at which further dosage can be dosage reductions become difficult. Patients who prefer less alert to the possibility of patients attempting protracted withdrawal can be converted to and dose tapering by substituting other psychoac then tapered from methadone. Blind dosage reduction is appropri M edically Supervised ate only if requested by a patient. It should be W ithdraw al After discussed and agreed on before it is implement ed. It is inappropriate, clinically and ethically, Detoxification to withdraw a patient from maintenance medi For patients who neither qualify for nor desire cation without his or her knowledge and con opioid maintenance treatment, methadone or sent. Regulations specify two kinds of detoxification with methadone: short-term W ithdraw al and term ination treatment of less than 30 days and long-term treatment of 30 to 180 days. Clinical Pharm acotherapy 79 Dosing decisions in medically supervised daily dosing requirements have failed, mainte withdrawal are related to the intended nance pharmacotherapy no longer may be steepness of tapering. Treatment decisions should be made short-term withdrawal may never achieve in the patientis best interest. If patient progress steady state, and tapering from methadone is unsatisfactory at a particular level of care, may be too steep if it begins at a dose greater the physician should explore the possibility of than about 40 mg. In long-term withdrawal, increasing that patientis care while maintaining stabilization of dosage at a therapeutic range him or her on methadone. Involuntary taper is followed by more gradual reduction (see ing and discontinuation of maintenance medi Exhibit 5-7). Dosage Reduction If a patient is intoxicated repeatedly with alco When patients violate program rules or no hol or sedative drugs, the addition of an opioid longer meet treatment criteria, involuntary medication is unsafe, and any dose should be tapering might be indicated although it should withheld, reduced, or tapered. For violent behavior or threats to staff and other example, if many days of dosing are missed and patients might be reasons for dismissal without repeated attempts to help a patient comply with Exhibit 5-7 Types of Detoxification From Illicit Opioids 80 Chapter 5 tapering or for immediate transfer to another decisions on dispensing take-home medication facility where a patient may be treated under are determined by the medical director in safer conditions. Absence of recent drug and alcohol abuse addiction treatment, a patientis sudden lack of 2. Acceptable length of time in comprehensive methadone before withdrawal because clinical maintenance treatment experience with methadone withdrawal is more extensive. At this writing, few correc Once these clinical criteria are met, maximum tional institutions offer methadone mainte take-home doses must be further restricted nance to nonpregnant inmates (National Drug based on length of time in treatment as follows: Court Institute 2002). Regardless of take-home doses per week which opioid medication is used, maintenance or medically supervised withdrawal is prefer i Fourth 90 days (months 10 through 12): 6 able to sudden discontinuation of the medica daysi supply of take-home doses per week tion. No take-home doses are permitted for M edications patients in short-term detoxification or interim Take-home medication refers to unsupervised maintenance treatment. Beyond this, Clinical Pharm acotherapy 81 Specific Clinical Considerations concurrent disease, to avoid methadone-related complications of a concurrent medical disor in Take-Hom e Status der, and to ensure that the pharmacological benefits of administering methadone are main Dem ands of a concurrent tained during the course and treatment of the m edical disorder concurrent disease. The existence and severity of a concurrent medical disorder (see chapter 10) are additional Enhancement of rehabilitative considerations in determining whether take potential home medication is appropriate. Under the disinhibiting effects avoided until a of other substances, patients might be unable patient is stable on to safeguard or adequately store their take these new medica home doses. They should be encouraged to tions and the risks of an undesirable outcome keep their medication in a locked cabinet away have diminished. In these instances, more from food or other medicines and out of the frequent observations are important to monitor reach of children. Staff members who accept these considered carefully because most such con bottles should inspect them to ensure that tainers are large and visible, which might serve they are coming from the indicated patient more to advertise that a patient is carrying during the appropriate period. Staff should when methadone diskettes are reconstituted or consider discontinuing take-home medication liquid methadone oral concentrate is used and for these patients. Although methadone has a significant street value, a National Institutes of Health consensus Behavior, social stability, and statement refers to it as ia medication that is not often diverted to individuals for recreation take-hom e m edications al or casual use but rather to individuals with Patients appearing intoxicated; demonstrating opiate dependence who lack access to aggressive, seriously impaired, or disordered [methadone maintenance treatment] pro behavior; or engaging in ongoing criminal gramsi (National Institutes of Health 1997b, p. Their home environments also are to methadone have increased significantly in keys to the safety and storage of medication. According to data from the Drug W here social relationships are unstable, a Abuse W arning Network, more than 10,000 significant risk exists that methadone take emergency room visits related to methadone home doses will be secured inadequately from were reported in 2001 compared with more diversion or accidental use. This increase If patients with take-home privileges develop has occurred in the context of overall increases altered mental competency, such as in demen in abuse of prescription opioids, in particular tia, frequent loss of consciousness, or delusional hydrocodone and oxycodone. Local reports states, then take-home privileges should be indicate that most diverted methadone comes reevaluated. Although the slow M onitoring Patients W ho onset of methadone makes it less attractive Receive Take-Hom e than prescription opioids to potential abusers, M edications it also makes methadone more dangerous because respiratory depression can become Monitoring should ensure that patients with significant hours after ingestion. To guard take-home medication privileges are free of against the possibility of methadone-related illicit drug use and consume their medication as respiratory depression, the consensus panel directed. This goal can be met through random recommends the following diversion control drug testing and periodic interdisciplinary policies for take-home medication: assessment of continuing eligibility. It usually is helpful to provide Issues for review psychiatric consultation to medical or surgical the rationale for providing take-home staff members, especially for patients with co medication should be reviewed regularly occurring disorders. W ritten patient consent is and documented to determine whether initial necessary for this kind of program-to-hospital justifications continue to apply. Reviewing the original rationale for take-home Hospitalization, particularly of unconscious medication is a necessary but insufficient patients, raises the issue of using identification condition for increased patient monitoring. Smart cards con taining a complete medical history are already Disability or illness. Various forms of this treatment have been stud Concerns should include whether a patient has ied in the United States and found to be safe been using illicit drugs or taking other medica and efficacious (King et al. Patient selection for this treatment option should focus on a history of negative drug tests, One dose missed.
Syndromes
Chest CT scan
Diabetes
How to handle sick days
Restlessness
Have you had any past urinary problems?
MRI of the head
Eye care products
Size of the AVM
Shivering
Pain in the upper belly (from ulcers)
Demonstrate the seven methods for preventing hip prosthesis dislocation that a nurse would teach a patient antibiotic resistance future buy cheap ceftin 500 mg on line. Outline in detail the patient education guidelines for home care after hip replacement bacteria have cell walls generic 250mg ceftin free shipping. On the basis of her knowledge of running traction antibiotics nausea generic 500mg ceftin otc, the nurse knows to expect that: a antibiotic of choice for uti cheap ceftin 250mg otc. The nurse knows that countertraction must be considered whenever traction is applied bacteria on hands order ceftin with amex. To prevent pressure ulcers and nerve damage antimicrobial fogger generic ceftin 500 mg mastercard, excessive pressure is avoided over the and virus with rash order ceftin. Sports activities antimicrobial quiz cheap 250 mg ceftin overnight delivery, especially baseball, have been the focus of his energies since he was in high school and college. Because of prior hip joint injuries and degenerative joint disease, he is scheduled for a total hip replacement. Preoperatively, the nurse assesses the status of the cardiovascular system based on the knowledge that mortality for patients over 60 years is directly related to the complications of: and. As part of preoperative teaching, the nurse makes the patient aware of five major potential complications of hip replacement:, and. On the basis of knowledge that limited hip flexion decreases hip prosthesis dislocation, the nurse knows to: a. The nurse teaches Tom how to minimize hip extension during transfers and while sitting. A dislocated prosthesis is evidenced by any of the following six indicators:, and. The nurse advises the patient that an acute infection may occur within how many months of surgery with delayed infections occurring up to how many months The intervertebral disks that are subject to the greatest mechanical stress and greatest degenerative changes are: a. Back pain is classified as chronic when the pain lasts without improvement for longer than: a. When lifting objects, patients with low back pain should be encouraged to maximize the use of the following muscles: a. The nurse should encourage a patient with low back pain to do all of the following except: a. The average 75-year-old woman with osteoporosis has lost how much of her cortical bone The estimated intake of calcium to prevent bone loss for a postmenopausal woman is mg/day. Appropriate nursing actions when caring for a patient with a primary malignant bone tumor would include all of the following except: a. List four nursing diagnoses for a patient undergoing foot surgery:, and. Three significant characteristics of osteoporosis are:, and. Primary osteoporosis in women usually begins between the ages of:. Explain the effects of the following on the development of age-related osteoporosis: a. Describe impingement syndrome and the measures necessary to promote shoulder healing. Discuss the etiology and medical treatment for the nine common foot problems listed in the chapter; for example, plantar fascitis, corn, and hammer toe. Describe the risk factors (modifiable and nonmodifiable) that are associated with osteoporosis. Describe the clinical manifestations and medical and nursing interventions for septic arthritis. What two reasons could the nurse use to explain why women develop osteoporosis more frequently than men: and. The nurse advises Emily that about of Caucasian women older than 50 years of age have some degree of osteoporosis. The nurse advises Emily that the development of osteoporosis is significantly dependent on: a. The nurse knows that Emily has probably already exhibited demineralization. After arthroscopic surgery for a rotator cuff tear, a patient can usually resume full activity in: a. A patient who has a meniscectomy by arthroscopic surgery needs to know that normal athletic activities can usually be resumed after: a. An open fracture with extensive soft tissue damage is classified as a what grade fracture The femur fracture that commonly leads to avascular necrosis or nonunion because of an abundant supply of blood vessels in the area is a fracture of the: a. Patients who experience a fracture of the humeral neck are advised that healing will take an average of weeks, with restricted vigorous activity for an additional weeks. An immediate nursing concern for a patient who has suffered a femoral shaft fracture is assessment for: a. The longest immobilization time necessary for fracture union occurs with a fracture of the: a. A nurse can foster a positive self-image in a patient who has had an amputation by all of the following except: a. Crepitus, a grating sensation felt when the hands are placed over an extremity, is caused by:. Patients with open fractures risk three major complications:, and. List three early and delayed complications of fractures: Early:, and. Treatment of early shock in fractures consists of five activities:, and. List three early and serious complications associated with bed rest and reduced skeletal muscle contractions for a patient with an open fracture:, and. The most common fracture of the distal radius is:. The most common complication of hip fractures in the elderly is:. Common pulmonary complications, after hip fracture, for the elderly include: and. Three range-of-motion activities are avoided for a patient with a lower extremity amputation:, and. The residual limb should never be placed on a pillow to avoid:. A dislocation: lack of contact between the articular surfaces of bones:: : partial dislocation of associated joint structures. Closed reduction: the alignment of bone fragments into opposition:: open reduction:. Delayed union: delayed healing due to infection or poor nutrition:: nonunion:. Intracapsular fracture: neck of the femur:: extracapsular fracture:. Compare the nursing assessment and medical management for first-, second-, and third-degree strains and sprains. Distinguish between open and closed reduction as a management technique for fractures. Explain the clinical manifestations and underlying pathophysiology of fat embolism. Explain the etiology, clinical manifestations, and medical management for compartment syndrome. Distinguish between the clinical manifestations and medical and nursing management of intracapsular and extracapsular fractures. The foot is firmly planted and the knee is struck laterally, as in basketball or soccer. The patient will immediately experience, and the inability to walk without assistance. Patients who report that their knees give way or lock after twisting or repetitive squatting are most likely experiencing a. Normal activities can be resumed in (weeks/months). He is scheduled to have an above-the-knee amputation of his left leg because of peripheral vascular disease. Preoperatively, the nurse knows that the circulatory status of the affected limb should be evaluated by assessing for: a. Preoperatively, the nurse needs to assist William in exercising the muscles needed for crutch walking. Preprosthetic nursing care should attempt to avoid any problem that can delay prosthetic fitting, such as: a. A gram-positive organism that is less virulent than a gram-negative organism is: a. Chickenpox and Herpes Zoster (also known as Shingles) are both caused by the same viral agent: a. A gram-negative bacillus, linked to contaminated eggs or chicken, that causes diarrhea is: a. A common bacterial cause of diarrhea that has been linked to the ingestion of undercooked beef is: a. A chancre initially appears 2 to 3 weeks after inoculation with the spirochete, Treponema pallidum, in the sexually transmitted disease known as: a. Latent syphilitic lesions may still be treated with penicillin G benzathine for up to: a. Gonorrhea is a sexually transmitted infection that involves the mucosal surface of the: a. List the three components of a microbiology report, the primary source of information about most bacterial infection:, and. The two primary agencies involved in setting guidelines about infection prevention are: the and the. Two bacteria that are part of normal skin flora are: and, whereas and, considered transient flora, have increased pathogenic potential. Immunosuppressed adults should be vaccinated for: and. List at least six infectious diseases that have been controlled by successful vaccine programs:, and. The two types of antiviral therapy available to treat a pandemic are: and. Identify 5 of 10 conditions classified as sexually transmitted diseases:, and. The most common infectious diseases in the United States are:, infecting approximately million Americans annually. They are:, and. The most common complication of infection is, which is usually treated with one of three antibiotics:, and. The most well-known viral hemorrhagic fever viruses are: and. For each of the six links in the infection cycle, describe specific nursing interventions that can be used to break transmission. Distinguish between the activities associated with four types of infection precautions: standard, airborne, droplet, and contact. Discuss general ways a nurse can help the community respond to an influenza pandemic. Describe local responses put into place in your community in response to the swine flu pandemic in 2009. Discuss eight potential complications that a nurse needs to be aware of when treating and educating a patient with a sexually transmitted disease. In the United States, the elderly, who are major consumers of emergency health care, account for about how many million visits to the emergency department annually John, a 16-year-old boy, is brought to the emergency department after a vehicular accident. A triage nurse in the emergency department determines that a patient with dyspnea and dehydration is not in a life-threatening situation. A nurse at the scene of an industrial explosion uses field triage to categorize victims for treatment. The initial nursing measure for the control of hemorrhage caused by trauma is to: a. Indicators of hypovolemic shock associated with internal bleeding include all of the following except: a. The leading cause of death in children and adults younger than 44 years of age is: a. Nursing measures for a penetrating abdominal injury (gunshot and stab wound) would include: a. The nurse assesses the patient with the knowledge that the most frequently injured solid abdominal organ is the: a. Identify the sequence of medical or nursing management for a patient who experiences multiple injuries. Establish an airway, control hemorrhage, establish an airway, prevent hypovolemic prevent hypovolemic shock, assess for head shock injuries b. Prevent hypovolemic shock, assess for shock, establish an airway, assess for head head injuries, establish an airway, control injuries hemorrhage 16. Progressive deterioration of body systems occurs when hypothermia lowers the body temperature to: a. When assisting with the physical examination, the nurse should do all of the following except: a. Emergency department visits have increased by % since 1995, with injuries accounting for % of visits. For those over age 65, % of emergency department visits account for hospital admissions. Emergency department personnel are at increased risk for exposure to communicable disease through blood or body fluids because of the number of people infected with, and. A patient with a foreign body airway obstruction typically demonstrates the inability to:, or. With complete obstruction, permanent brain injury will occur in minutes. List six clinical signs/symptoms of probable internal hemorrhage:, and. Heat stroke is a medical emergency evidenced by symptoms such as:, and. The second most common cause of unintentional death in children younger than 14 years of age is:. The most common victims of snakebites are those between the ages of: and years of age. Antivenin to treat snakebites must be administered within a time frame of: to hours. An easy and immediate treatment for an ingested poison that is not caustic is, which immediately induces vomiting. Using three examples provided by your classmates, describe some activities an emergency department nurse would employ to provide patient and family-focused holistic care. Describe the criteria distinguishing the five levels of a comprehensive triage system: resuscitation, emergent, urgent, nonurgent, and minor. Demonstrate the nursing management role in establishing an airway using the abdominal thrust, the head-tilt-chin-lift maneuver, the jaw-thrust maneuver, and oropharyngeal airway insertion. Describe the immediate nursing intervention for a patient hemorrhaging externally from an extremity injury. Describe the nursing assessment and management for a patient experiencing a crush injury.
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However antibiotics for uti female purchase ceftin in united states online, several families with congenital eryth the outlook for autoimmune hemolytic anemia in child rocytosis have been described bacteria 3d models order cheap ceftin. The designation M is given to several abnormal hemoglobins Studies in a number of families have revealed (1) abnormal associated with methemoglobinemia bacteria que se come la piel generic ceftin 250 mg amex. Affected individuals hemoglobin with altered oxygen affinity infection heart buy ceftin 500mg otc, (2) reduced red cell are heterozygous for the gene antibiotics for uti in horses purchase ceftin 500 mg on-line, which is transmitted as an diphosphoglycerate antibiotic 500 mg ceftin amex, (3) autonomous increase in erythropoie autosomal dominant disorder how long on antibiotics for sinus infection to feel better buy ceftin 500 mg mastercard. The different types of hemo tin production treatment for viral uti ceftin 250mg lowest price, or (4) hypersensitivity of erythroid precursors globin M result from different amino acid substitutions in to erythropoietin. Hemoglobin electrophoresis at the usual Treatment is not indicated unless symptoms are marked. Secondary polycythemia occurs in response to hypox this type of methemoglobinemia does not respond to any emia. Persons living at extremely high altitudes, as well as Due to Enzyme Deficiencies some with methemoglobinemia, develop polycythemia. It Congenital methemoglobinemia is caused most frequently has on rare occasions been described without hypoxemia by congenital deficiency of the reducing enzyme diaphorase in association with renal tumors, brain tumors, Cushing I (coenzyme factor I). Affected patients may have as much as 40% Polycythemia may occur in the neonatal period; it is methemoglobin but usually have no symptoms, although a particularly exaggerated in infants who are preterm or small mild compensatory polycythemia may be present. In these infants, polycythemia is some with methemoglobinemia associated with a deficiency of times associated with other symptoms. It may occur in diaphorase I respond readily to treatment with ascorbic acid infants of diabetic mothers, in Down syndrome, and as a and methylene blue (see next section), but treatment is not complication of congenital adrenal hyperplasia. Iron deficiency may complicate polycythemia and aggravate the associated hyperviscosity. Coagulation and bleeding abnormalities, Several compounds activate the oxidation of hemoglobin including thrombocytopenia, mild consumption coagulop from the ferrous to the ferric state, forming methemoglobin. When this cannot be done, chemical containing one of these substances should be sus phlebotomy may be necessary to control symptoms. Iron pected in any infant or child who presents with sudden sufficiency should be maintained. Methemoglobin levels in such cases may be patient and phlebotomy with plasma replacement may be extremely high and can produce anoxia, dyspnea, uncon indicated prior to major surgical procedures. Young infants and sures prevent the complications of thrombosis and hemor newborns are more susceptible to acquired methemoglobin rhage. Isovolumetric exchange transfusion is the treatment emia because their red cells have difficulty reducing hemo of choice in severe cases. Methemoglobin is continuously formed at a slow rate by Patients with the acquired form of methemoglobinemia the oxidation of heme iron to the ferric state. Cya tered orally or intravenously also reduces methemoglobin, nosis is produced with methemoglobin levels of approxi but the response is slower. Severe congenital neutropenia (Kostmann syndrome) Chronic idiopathic neutropenia of childhood Ulceration of oral mucosa and gingivitis. Chediak-Higashi syndrome Shwachman syndrome Cartilage-hair hypoplasia Dyskeratosis congenita General Considerations Fanconi anemia Neutropenia is an absolute neutrophil (granulocyte) count Organic acidemias (eg, propionic, methylmalonic) of less than 1500/ L in childhood, or below 1000/ L be Glycogenosis Ib Osteopetrosis tween ages 1 week and 2 years. During the first few days of Acquired neutropenias affecting stem cells life, an absolute neutrophil count of less than 3500 cells/ L Malignancies (leukemia, lymphoma) and preleukemic disorders may be considered neutropenia. Hypersplenism the most severe types of congenital neutropenia include reticular dysgenesis (congenital aleukocytosis), Kostmann syndrome (severe neutropenia with maturation defect in the increased when the absolute neutrophil count is less than 500/ marrow progenitor cells), Shwachman syndrome (neutrope L, the actual susceptibility is variable and depends on the nia with pancreatic insufficiency), neutropenia with immune cause of neutropenia, marrow reserves, and other factors. The deficiency states, cyclic neutropenia, and myelokathexis or most common types of infection include septicemia, cellulitis, dysgranulopoiesis. Genetic mutations for Chediak-Higashi skin abscesses, pneumonia, and perirectal abscesses. Sinusitis, syndrome, Kostmann and Shwachman syndromes, and aphthous ulcers, gingivitis, and periodontal disease also cause cyclic neutropenia have been identified. In addition to local signs and symptoms, also be associated with storage and metabolic diseases and patients may have chills, fever, and malaise. Staphylococcus aureus and tropenia are viral infection or drugs resulting in decreased gram-negative bacteria are the most common pathogens. Although rare, neonatal alloimmune neu tropenia can be severe and associated with risk for infection. Neutrophils are absent or markedly reduced in the periph Autoimmune neutropenia in the mother can result in pas eral blood smear. In most forms of neutropenia or agranulo sive transfer of antibody to the fetus and neutropenia in the cytosis, the monocytes and lymphocytes are normal and the neonate. Malignancies, osteopetrosis, marrow failure syn red cells and platelets are not affected. The bone marrow dromes, and hypersplenism usually are not associated with usually shows a normal erythroid series, with adequate isolated neutropenia. Symptoms and Signs tent, cyclic), attention should be paid to the duration and Acute severe bacterial or fungal infection is the most signifi pattern of neutropenia, the types of infections and their cant complication of neutropenia. A careful family history and blood counts from the Dror Y: Update on childhood neutropenia: Molecular and clinical parents are useful. Bone marrow aspiration and biopsy are most severe congenital neutropenia induce the unfolded protein important to characterize the morphologic features of response and cellular apoptosis. Some neutropenia Neutrophilia is an increase in the absolute neutrophil count disorders have abnormal neutrophil function. Increased apop philia occurs acutely in association with bacterial or viral tosis in marrow precursors or circulating neutrophils has infections, inflammatory diseases (eg, juvenile rheumatoid been described in several congenital disorders. Prophylactic antimicrobial lithium, and epinephrine increase the blood neutrophil therapy is not indicated for afebrile, asymptomatic patients. Depending on the counts, the dose may stress such as from electric shock, trauma, burns, surgery, be adjusted. Tumors involving the bone marrow, dose should be regulated to keep the absolute neutrophil such as lymphomas, neuroblastomas, and rhabdomyosar count below 10,000/ L. At times this process may affect other cell lines the prognosis varies greatly with the cause and severity of and mimic myeloproliferative disorders or acute leukemia. In severe cases with persistent agranulocy the neutrophilias must be distinguished from myelopro tosis, the prognosis is poor in spite of antibiotic therapy; in liferative disorders such as chronic myelogenous leukemia and mild or cyclic forms of neutropenia, symptoms may be juvenile chronic myelogenous leukemia. In general, abnor minimal and the prognosis for normal life expectancy excel malities involving other cell lines, the appearance of immature lent. Up to 50% of patients with Shwachman syndrome may cells on the blood smear, and the presence of hepatospleno develop aplastic anemia, myelodysplasia, or leukemia during megaly are important differentiating characteristics. Contact with a microbe that is properly infections, such as osteomyelitis, liver abscesses, sepsis, men opsonized with complement or antibodies triggers inges ingitis, and necrotic or gangrenous soft-tissue lesions, occur tion, a process in which cytoplasmic streaming results in the in specific syndromes (eg, leukocyte adherence deficiency or formation of pseudopods that fuse around the invader, chronic granulomatous disease). During the ingestion phase, the trophil dysfunction may die in childhood from severe infec oxidase enzyme system assembles and is activated, taking tions or associated complications. Concurrently, granules from the two main classes Treatment (azurophil and specific) fuse and release their contents into the mainstays of management of these disorders are antici the phagolysosome. The concentration of toxic oxygen pation of infections and aggressive attempts to identify the metabolites (eg, hydrogen peroxide, hypochlorous acid, foci and the causative agents. Surgical procedures to achieve hydroxyl radical) and other compounds (eg, proteases, these goals may be both diagnostic and therapeutic. Broad cationic proteins, cathepsins, defensins) increases dramati spectrum antibiotics covering the range of possible organ cally, resulting in the death and dissolution of the microbe. When infections are unresponsive or they recur, cesses may lead to inadequate cell function and an increased granulocyte transfusions may be helpful. Recently described is a syndrome of severe neutro Chediak-Higashi syndrome improve clinically when given phil dysfunction and severe infections associated with a ascorbic acid. New ber and severity of infections in patients with chronic granu syndromes of innate immune dysfunction include defects lomatous disease. Demonstration of this activity with one in interferon and interleukin-12 receptor and signaling patient group raises the possibility that cytokines, growth pathways, leading to monocyte and macrophage dysfunc factors, and other biologic response modifiers may be helpful tion and toll-like receptor signaling pathways (interleukin in other conditions in preventing recurrent infections. Other congenital or acquired congenital neutrophil dysfunction syndromes, and reconsti causes of mild to moderate neutrophil dysfunction include tution with normal cells and cell function has been docu metabolic defects (eg, glycogen storage disease, diabetes mented. Combining genetic engineering with autologous mellitus, renal disease, and hypophosphatemia), viral bone marrow transplantation may provide a future strategy infections, and certain drugs. Cells from patients with thermal injury, Prognosis trauma, and overwhelming infection have defects in cell For mild to moderate defects, anticipation and conservative motility and bactericidal activity similar to those seen in medical management ensure a reasonable outlook. In some diseases, the development of noninfectious Clinical Findings complications, such as the lymphoproliferative phase of Recurrent bacterial or fungal infections are the hallmark of Chediak-Higashi syndrome or inflammatory syndromes in neutrophil dysfunction. Although many patients will have chronic granulomatous disease, may influence prognosis. Inheritance Disorder Clinical Manifestations Functional Defect Biochemical Defect (Chromosome; Gene) Chediak-Higashi Oculocutaneous albinism, pho Neutropenia. Many patients die during lym Also milder defects in phoproliferative phase with microbicidal activity and hepatomegaly, fever. Deficient Deficient fucosyl transferase Autosomal recessive adherence retardation, craniofacial abnor rolling interactions with results in deficient sialyl (11p11. Neutrophils Several molecular defects in matous with catalase-positive bacteria demonstrate deficient bac oxidase components. May involve skin, tericidal activity but normal cytochrome b558 with mucous membranes. Fungal infec Diminished capacity to Diminished or absent myelo Autosomal recessive dase defi tions when deficiency associated enhance hydrogen perox peroxidase; post-translational (17q22-23) ciency with systemic diseases (eg, dia ide-mediated microbicidal defect in processing protein. Specific granule Recurrent skin and deep tissue Decreased chemotaxis and Failure to produce specific Autosomal recessive deficiency infections. From the first week up to the fifth year of life, lymphocytes are the most numerous leukocytes in human blood. The ratio then reverses gradually to reach the adult pattern of neutrophil predominance. The presence of enlarged the most critical aspect in evaluating the bleeding patient liver, spleen, or lymph nodes is crucial to the differential is obtaining detailed personal and family bleeding histories, diagnosis, which includes acute leukemia and lymphoma. Excessive mucosal bleeding is suggestive of a platelet and thrombocytopenia helps to differentiate these disor disorder, von Willebrand disease, dysfibrinogenemia, or vas ders. Bleeding into muscles and joints may be associated peripheral blood smear is crucial. In either ularly infectious mononucleosis, are associated with atypi scenario, the abnormality may be congenital or acquired. A cal features in the lymphocytes such as basophilic cyto thorough physical examination should be performed with plasm, vacuoles, finer and less-dense chromatin, and an indented nucleus. These features are distinct from the characteristic morphology associated with lymphoblastic leukemia. Lymphocytosis in childhood is most commonly Vascular injury Endothelial associated with infections and resolves with recovery from cell the primary disease. Increased eosinophil counts are a prominent feature of many invasive parasitic infections. The procoagulant system and formation damage (hepatosplenomegaly, cardiomyopathy, pulmonary of a fibrin clot. Vascular injury initiates the coagulation fibrosis, and central nervous system injury). Eosino indicate thrombin actions in addition to clotting of fibrin philic leukemia has been described, but its existence as a ogen. The finely dotted lines indicate the feedback activa distinct entity is controversial. Solid arrows indi mias, rare disorders such as Wiskott-Aldrich syndrome and cate activation; dotted line arrows indicate inhibition. The spleen plays a predominant the following laboratory tests may also be useful: role in the disease by forming the platelet cross-reactive anti bodies and sequestering the antibody-bound platelets. Thrombin time to measure the generation of fibrin from fibrinogen following conversion of prothrombin to throm bin, as well as the antithrombin effects of fibrin-split Clinical Findings products and heparin. Laboratory Findings ranted, as congenital deficiency in these fibrinolytic inhibitors may cause hyperfibrinolysis. Increased Turnover Decreased Production Antibody-Mediated Coagulopathy Other Congenital Acquired Idiopathic thrombocyto Disseminated intravascu Hemolytic-uremic syndrome Fanconi anemia Aplastic anemia penic purpura lar coagulopathy Infection Sepsis Thrombotic thrombocytopenic Wiskott-Aldrich syndrome Leukemia and other purpura malignancies Immunologic diseases Necrotizing enterocolitis Hypersplenism Thrombocytopenia with Vitamin B12 and folate Thrombosis Respiratory distress syndrome absent radii deficiencies Cavernous hemangioma Wiskott-Aldrich syndrome Metabolic disorders Osteopetrosis erated production of new platelets. Platelet transfusion should be avoided differential are normal, and the hemoglobin concentration is except in circumstances of life-threatening bleeding, in which preserved unless hemorrhage has been significant. Family history or the finding of predom regardless of the platelet count unless significant bleeding inantly giant platelets on the peripheral blood smear is helpful recurs, at which time prednisone is administered in the in determining whether thrombocytopenia is hereditary. Bone smallest dose that achieves resolution of bleeding episodes marrow examination should be performed if the history is (usually 2. Follow-up continues until the atypical (ie, the child is not otherwise healthy, or if there is a steroid can again be discontinued, spontaneous remission family history of bleeding), if abnormalities other than purpura occurs, or other therapeutic measures are instituted. The most important risk during life-threatening hemorrhage but are rapidly destroyed. These symptoms may mimic those of intracranial hemorrhage and necessitate radio Treatment logic evaluation of the brain. Aspirin and other medications that compromise platelet function should be avoided. Bleeding precautions (eg, this polyclonal immunoglobulin binds to the D antigen restriction from physical contact activities, use of helmets, etc) on red blood cells. This idiopathic thrombocytopenic purpura and hemophilia with approach is effective only in Rh(+) patients with a func inhibitors. The risk of with Platelet Alloantibodies (Neonatal overwhelming infection (predominantly with encapsulated Alloimmune Thrombocytopenia) organisms) is increased after splenectomy, particularly in the young child. Therefore, the procedure should be postponed, Platelet alloimmunization occurs in 1 in approximately 350 if possible, until age 5 years. Meningococcal vaccine, gressive over the course of gestation and worse with each although controversial, may be considered. Petechiae or at presentation, insidious onset of bruising, and the presence other bleeding manifestations are usually present shortly of other autoantibodies. Appropriate screening by history and labora If alloimmunization is associated with clinically signifi tory studies (eg, antinuclear antibody) is warranted. If and 75% of neonates with bacterial sepsis are thrombocyto thrombocytopenia is not severe and bleeding is absent, penic. Intrauterine infections such as rubella, syphilis, toxo observation alone is often appropriate. In alloimmune thrombocytopenia is the strongest risk factor addition to specific treatment for the underlying disease, for severe fetal thrombocytopenia and hemorrhage in a platelet transfusions may be indicated in severe cases. If alloimmunization has occurred with a previous preg (Kasabach-Merritt Syndrome) nancy, irrespective of history of intracranial hemorrhage, screening cranial ultrasound for hemorrhage should begin at A rare but important cause of thrombocytopenia in the 20 weeksgestation and be repeated regularly. In addition, newborn is kaposiform hemangioendotheliomas, a benign cordocentesis should be performed at approximately 20 neoplasm with histopathology distinct from that of classic weeksgestation, with prophylactic transfusion of irradiated, infantile hemangiomas. Intense platelet sequestration in the leukoreduced, maternal platelet concentrates. The bone marrow typically shows megakaryocytic section is recommended if the fetal platelet count is less than hyperplasia in response to the thrombocytopenia. Cortico 50,000/ L, to minimize the risk of intracranial hemorrhage steroids, interferon, and vincristine are all useful for associated with birth trauma. Thrombocytopenia Associated with Idiopathic ture, or the lesion is cosmetically unacceptable. If consump Thrombocytopenic Purpura in the Mother tive coagulopathy is present, heparin or aminocaproic acid (Neonatal Autoimmune Thrombocytopenia) may be useful. Disorders of Platelet Function Most neonates with neonatal autoimmune thrombocy Individuals with platelet function defects typically develop topenia do not develop clinically significant bleeding, and skin and mucosal bleeding similar to that occurring in thus treatment for thrombocytopenia is not often required.
