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Would your recommendation differ if the proposed recip- Nursing Notes: Apply Your Knowledge ient were a child? Riley about her normal bowel pattern SELECTED REFERENCES and her usual management strategies elimite 30 gm discount acne under microscope. Louis: Facts and is very important to have a bowel movement every day; thus buy generic elimite 30gm acne active, Comparisons discount elimite amex skin care unlimited. Diarrhea in adults: When is inter- importance of exercise and ﬁber in the diet. Porth Unless the diarrhea is severe, causing signiﬁcant ﬂuid loss and (Ed. Approach to the patient with diar- Review and Application Exercises rhea. Discuss guidelines for preventing, minimizing, process implications of selected antiemetic or treating nausea and vomiting. Critical Thinking Scenario Kelly Morgan, a 44-year-old woman, is having elective abdominal surgery. Her physician orders lorazepam (Ativan), prochlorperazine (Compazine), and metoclopramide (Reglan) on a PRN basis to treat postoperative nausea and vomiting. Reﬂect on: Factors that contribute to nausea and vomiting for the postoperative client. How you will make decisions regarding which antiemetic medications to give Ms. OVERVIEW symptoms may occur with most drugs, they are espe- cially associated with alcohol, aspirin, digoxin, anti- Antiemetic drugs are used to prevent or treat nausea and cancer drugs, antimicrobials, estrogen preparations, and vomiting. Pain and other noxious stimuli, such as unpleasant sights the expulsion of stomach contents through the mouth. Nau- and odors sea may occur without vomiting, and vomiting may occur 5. Emotional disturbances, physical or mental stress without prior nausea, but the two symptoms often occur 6. Postoperative status, which may include pain, impaired by virtually everyone. These symptoms may accompany GI motility, and receiving various medications almost any illness or stress situation. Causes of nausea and Vomiting occurs when the vomiting center (a nucleus of vomiting include the following: cells in the medulla oblongata) is stimulated. Gastrointestinal (GI) disorders, including infection or layed to the vomiting center from peripheral (eg, gastric mu- inﬂammation in the GI tract, liver, gallbladder, or pan- cosa, peritoneum, intestines, joints) and central (eg, cerebral creas; impaired GI motility and muscle tone (eg, gastro- cortex, vestibular apparatus of the ear, and neurons in the paresis); and overeating or ingestion of foods or ﬂuids fourth ventricle, called the chemoreceptor trigger zone [CTZ]) that irritate the GI mucosa sites. Cardiovascular, infectious, neurologic, or metabolic diazepine, cholinergic, dopamine, histamine, opiate, and sero- disorders tonin receptors, which are stimulated by emetogenic drugs 3. Nausea and vomiting are the most com- and toxins circulating in blood and cerebrospinal ﬂuid. Although the example, in cancer chemotherapy, emetogenic drugs stimu- 902 CHAPTER 63 ANTIEMETICS 903 late the CTZ, which then transmits signals to the vomiting tive in preventing and treating motion sickness. In motion sickness, rapid changes in body motion histamines are effective as antiemetic agents. When stimulated, the vomiting center initiates efferent Although corticosteroids are used mainly as antiallergic, impulses that cause closure of the glottis, contraction of ab- anti-inﬂammatory, and antistress agents (see Chap. The mechanism by which the esophageal sphincter, and reverse peristalsis, which moves drugs exert antiemetic effects is unknown; they may block stomach contents toward the mouth for ejection. Dexamethasone and methylprednisolone are commonly used in the manage- ment of chemotherapy-induced emesis, usually in combina- ANTIEMETIC DRUGS tion with one or more other antiemetic agents. Regimens vary from a single dose before chemotherapy to doses every Drugs used to prevent or treat nausea and vomiting belong 4 to 6 hours for 24 to 48 hours. With this short-term use, to several different therapeutic classifications, and most adverse effects are mild (eg, euphoria, insomnia, mild fluid have anticholinergic, antidopaminergic, antihistaminic, or retention).
This can happen where the management (no treatment) purchase elimite 30 gm without a prescription skin care jakarta barat, insemination alone buy 30 gm elimite visa skin care wholesale, intervention is an information package for the clomiphene alone or clomiphene and insemina- management of menorrhagia in primary care9 tion treatment as shown in Figure 21 buy elimite us acne when pregnant. In been expected to manage both study (information this case, the effect of IUI alone can be assessed leaﬂet, clinical guidelines) and control patients. Cluster C and D with A and B, while the effect of randomisation should only be carried out when clomiphene can be evaluated by comparing B and there is a strong justiﬁcation for doing so. The primary implication of cluster randomised trials is that the measurements on individuals CLUSTER RANDOMISED TRIALS IN are not statistically independent of one another; GYNAECOLOGY AND INFERTILITY that is measurements from individuals within the A potential problem that can occur with ran- same cluster will be correlated to one another. Cluster randomised trials should ence in implantation rates was likely to be wider adjust for this clustering when determining the than that reported due to failure to adjust for number of patients required. The sample size the clustering of embryos/oocytes transferred to that would be required if patients were to be each woman. Studies where oocytes have been randomised must be inﬂated by a factor which randomised have no clustering implications since takes into account the extent of the clustering oocytes retrieved from the same women are ran- and the size of the cluster. When there is implicit clustering that fail to adequately inﬂate the sample size will in the data, the statistical analysis should account for this using the methods described above. Similarly, the correlated responses obtained from each cluster have an implication for the QUASI-RANDOMISED TRIALS statistical analysis, since standard statistical tests These are controlled experimental studies where. There are a number of patient unit numbers or days of the week when approaches to analysing cluster randomised tri- 13 the patients are recruited. Failure to treatment allocation affords an element of chance, account for the correlated responses in the anal- it cannot be considered to be genuine randomi- yses will result in an increased type I error. This type of design may still appeal to Clustering of outcomes can also occur in infer- those involved in laboratory trials involving incu- tility trials where alternative treatments are being bation or cryopreservation of human embryos. For example, in randomised controlled In these cases, it may be easier and cheaper to trials comparing IVF with ICSI the unit of allo- 14 15 use a certain protocol for all embryos on alter- cation varies between patients, oocytes and 16 nate days or alternate weeks rather than change cycles. Often, outcomes such as implantation the protocol or a freezer setting for each embryo rate and fertilisation rate are considered. The consequent loss of allo- are both expressed as percentages out of the total cation concealment will lead to serious inclu- number of oocytes retrieved. Hence, in trials that sion bias as some patients may be deliberately randomise patients (couples) or cycles and report excluded. This, is turn, can exaggerate treatment implantation or fertilisation rates, there will be effects. In trials that randomise by patients and be randomised on grounds of strong treatment report fertilisation of implantation rates, some preferences. However, for outcomes affect the generalisability of the results as par- such as live birth rate or pregnancy rate no ticipants may not be representative. Yet recruit- adjustment is required since the percentages are ment of these patients may introduce substantial expressed out of the total number of patients ran- bias especially when it is impossible to blind domised. In addition, compliance and satisfaction and reported implantation rates per transferred may be higher with the preferred intervention. Dissatisfaction number of patients into either the randomised or with the allocation may lead to differential com- the preference arms is also a problem, as the trial pliance and follow-up resulting in groups which will not be completed unless the appropriate num- cannot then be assumed to be similar. The out- ber have been recruited into the two components of come measures could also be affected by how the trial. The situation may be further complicated satisﬁed patients are with their allocated treat- by patients favouring one treatment over another, ment. The effect of patient preference on outcome making comparison of the two groups in the pref- would depend to a great extent on the speciﬁc erence arm more difﬁcult. If the principal out- A further problem with this approach lies in come is death or live birth, then the effect of the analysis. Any comparison using the non- patient preferences is likely to be small. If the randomised groups is unreliable because of principal outcome is satisfaction with care, then unknown and uncontrolled confounders. Patients with strong preferences are allowed their EQUIVALENT TRIALS desired treatment. For example in a trial Often in reproductive health care the aim is to of medical and surgical termination of pregnancy show that one treatment is as effective (equiv- we end up with four groups–randomised to alence), or no less effective (non-inferior), as medical, randomised to surgical, prefer medical another. The size of a total PRPP lence trials, attention must be given to deﬁning cohort will need to be much larger than for a con- an equivalence margin. In addi- riority trials, larger sample sizes are needed tion, the number of patients in the non-randomised to demonstrate equivalence.
Just as importantly buy elimite with a mastercard acne paper, these exercises will help you maintain your body makeover and translate the positive effects and bene- fits well beyond the two-week period and into your everyday life generic 30 gm elimite with amex acne essential oil recipe. The mental order generic elimite on line skin care 10 year old, physical, and spiritual all work in concert to bring about real, meaningful, and lasting changes. Without a solid approach to carry you beyond the ﬁrst two weeks, how can anyone expect you to maintain your inspirational results? ULTIMATE MOTIVATION 25 TLFeBOOK STEP 1 FIND YOUR TRUE SOURCE OF MOTIVATION Incentive, inspiration, drive, enthusiasm, impetus, stimulus, spur, impulse, and driving force are just some of the synonyms I found when I looked up the word motivation in the dictionary. One of the prerequisites to successfully completing any challenge is motivation. Without it, any challenge, including this one, will ultimately become too daunting to see to completion. We all need to ﬁnd that special something that takes us beyond the ordinary. The trick is to ﬁnd and identify a challenge—something that evokes pas- sion and meaning in your life. It is important to identify whether you are moti- vated for a cause, such as getting ready for a high school reunion or your wedding, or whether you are self-motivated and interested mostly in self- betterment. I caution you, however, against setting your sights on a particu- lar number on the scale. Each pound of muscle you build burns an additional 35 to 50 calories a day just to maintain itself. So even if your weight remains stable on the scale, exchanging a few pounds of fat for a few pounds of muscle will result in a slimmer, ﬁrmer, sexier body! Over the course of the two weeks, you will be transforming your body into a more efﬁcient fat-burning machine. Of course, you may initially have decided to tackle the two-week Ultimate Body Plan because you wanted to look great in a swimsuit or stun your high 26 THE ULTIMATE NEW YORK BODY PLAN TLFeBOOK school buddies at your next reunion. To uncover the true source of your moti- vation, however, look a little deeper. The pride found from looking great in a swimsuit pales in comparison to the pride and conﬁdence gained from suc- cessfully completing the program without cheating or backsliding. Then, just imagine how conﬁdent and successful you can become when you maintain your results. To ﬁnd the true source of your motivation, contemplate the following questions: 1 Why am I taking this makeover challenge? Those last two questions may seem out of left ﬁeld to you at this point. I found myself get- ting caught up in a New York moment—not very pretty—when a homeless person stopped me and asked me if I had any spare change. In that split sec- ond I realized that this was all happening for a reason. I reached into my wal- let, and the smallest dollar denomination I had was $20. I ULTIMATE MOTIVATION 27 TLFeBOOK gladly gave him the $20 and told him to ﬁnd someplace to get warm. That small act of charity allowed me to reconnect with my soul and, in the process, release unwanted toxic energy and replace it with positive energy, which I could feel pulsing through my body. My mother discovered her soul light and inspiration to exercise recently when she was admitted to a hospital for surgery. As she was being adminis- tered the intravenous drip, the nurse told her to breathe deeply and think of something calming. For my mom, that meant thinking of my aunt (her youngest sister), who had been her best friend and who had passed away 13 years earlier. With that pleasant thought, Mom drifted off peacefully and awakened from the surgery feeling a little groggy but full of positive energy. If at 67 years of age she could ﬁnd the strength, courage, and fortitude to rise above a little adversity (and pain), then it was time to rethink and reprioritize the things that were most important to her. We spent the day looking at pic- tures and reminiscing about old times and people who had touched us over the years. Rather than taking on a sad tone, the experience was positive and uplift- ing.
Physiologic menopause results from Tami Smithford generic 30 gm elimite free shipping skin care brand owned by procter and gamble, a 19-year-old college student purchase elimite australia acne 2000, comes into the col- the gradual cessation of ovarian function and the resultant lege health clinic to renew her prescription for oral contraceptives quality 30gm elimite acne prevention. Surgical menopause results When she is there, she complains of a sore throat and having a fever for the last 2 days. A culture for streptococcus is performed, from excision of both ovaries and the sudden loss of ovar- she is placed on ampicillin, and her oral contraceptives are re- ian estrogen. The nurse provides the following patient teaching: Take and other sites are still produced, the amount is insufficient ampicillin 500 mg (1 capsule) 4 times a day for 10 days. ERT prevents vasomotor instability (hot ﬂashes) and Drink lots of ﬂuids and get plenty of rest. A commonly prescribed regimen CHAPTER 28 ESTROGENS, PROGESTINS, AND HORMONAL CONTRACEPTIVES 421 is a conjugated estrogen (eg, Premarin) 0. The main function of the progestin is to progestins in postmenopausal women may be indicated for decrease the risk of endometrial cancer; thus, women who have management of menopausal symptoms. Another regimen uses estra- estrogen/progestin combination is no longer recommended for diol as a transdermal patch (Estraderm), which releases the drug most women, because of potentially serious adverse effects. A newer synthetic conjugated es- trogen (Cenestin) is also approved for short-term treatment of hot ﬂashes and sweating; it is not approved for long-term use in Use in Hepatic Impairment preventing osteoporosis in postmenopausal women. Estrogens are contraindicated in impaired liver function, liver Prevention and Treatment of Osteoporosis disease, or liver cancer. Impaired liver function may lead to impaired estrogen metabolism, with resultant accumulation Estrogen or estrogen/progestin therapy is effective and has and adverse effects. In addition, women who have had jaun- been widely used to prevent or treat osteoporosis and pre- dice during pregnancy have an increased risk of recurrence if vent fractures in postmenopausal women (see Chap. Any client in Estrogenic effects in preventing bone loss include de- whom jaundice develops when taking estrogen should stop creased bone resorption (breakdown), increased intestinal the drug. Because jaundice may indicate liver damage, the absorption of calcium, and increased calcitriol concentra- cause should be investigated. Calcitriol is the active form of vitamin D, which is re- Progestins are contraindicated in clients with impaired quired for absorption of calcium. These hormones may be used less often for osteoporosis in future for two main reasons. First, recent evidence (see Box 28–2) indicates that the risks of estrogen/progestin hor- monal therapy outweigh the beneﬁts. Second, there are other effective measures for prevention and treatment of osteoporosis, in- Estrogens, progestins, and hormonal contraceptives are usu- cluding calcium and vitamin D supplements, bisphosphonate ally self-administered at home. The home care nurse may drugs (eg, alendronate and risedronate), and weight-bearing encounter clients or family members taking one of the drugs exercise. Teaching or as- sisting clients to take the drugs as prescribed may be needed. In addition, clients may need encouragement to Use in Children keep appointments for follow-up supervision and blood pressure monitoring. When visiting families that include There is little information about the effects of estrogens in chil- adolescent girls or young women, the nurse may need to dren, and the drugs are not indicated for use. Because the drugs teach about birth control or preventing osteoporosis by im- cause epiphyseal closure, they should be used with caution be- proving diet and exercise patterns. With families that in- fore completion of bone growth and attainment of adult height. NURSING Estrogens, Progestins, and Hormonal Contraceptives ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Give oral estrogens, progestins, and contraceptive prepara- To decrease nausea, a common adverse reaction tions after meals or at bedtime. With aqueous suspensions to be given intramuscularly, roll To be sure that drug particles are evenly distributed through the the vial between the hands several times. Give oil preparations deeply into a large muscle mass, preferably gluteal muscles. With estradiol skin patches, apply to clean dry skin of the To facilitate effective absorption and adherence to the skin and abdomen, buttocks, upper inner thigh, or upper arm. Avoid avoid skin irritation breasts, waistline areas, and areas exposed to sunlight. Observe for therapeutic effects Therapeutic effects vary, depending on the reason for use.
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