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Level B reflects the microsystem where care is delivered by small provider teams purchase bactroban 5 gm line skin care collagen. Level C is the organiza- tional level—the macrosystem or aggregation of the microsystems and sup- porting functions cheap bactroban 5 gm on-line acne 7 days past ovulation. Level D is the external environment where payment mechanisms order 5gm bactroban visa acne 6 days after ovulation, policy, and regulatory factors reside. The environment affects how organ- izations operate, which affects the microsystems housed in organizations, which in turn affect the patient. A Focus on the Patient All healthcare organizations exist to serve their patients; so does the work of healthcare professionals. Technically, medicine has never in its history had more potential to help than it does today. The number of efficacious therapies and life-prolonging pharmaceutical regimens has exploded. Providers are overburdened and uninspired by a system that asks too much and makes their work more dif- ficult. The IOM proposes that at the cen- ter of efforts to improve and restructure healthcare there ought to be a laserlike focus on the patient. Patient-centered care is the proper future of medicine, and the current focus on quality and safety is a step on the path to excellence. These emotions include the following: • Frustration and despair, much of which is exhibited by patients who experience healthcare services firsthand or family members who observe the care of their loved ones; • Anxiety over the ever-increasing costs and complexities of care; • Tension between their need for care and the difficulty and incon- venience in obtaining care; and • Alienation from a care system that seems to have little time for understanding, much less meeting, their needs. To illustrate these issues, we will explore the insights and experi- ences of one patient. We will examine in depth the experience of this patient who has lived with chronic back pain for almost 50 years and use this case study to understand both the inadequacies of the current delivery system and the potential for improvement. This one case study1 is representative of the frustrations and challenges of the patients we are trying to serve and reflective of the opportunities that await us to radically improve the health- care system. An important message is that changes are being made, patient care is getting better, and the health of communities is beginning to demonstrate marked improvement. Let us take this opportunity to high- light examples of improvement projects in various settings to provide insight into the progress. Improvement Project: Improving ICU Care One improvement project success story takes place in the intensive care unit (ICU) at Dominican Hospital in Santa Cruz County, California. Ventilator Bundling and Glucose Control After attending a conference in critical care, Dominican staff began focus- ing on a number of issues in the ICU. Ventilator bundling refers to a group of five procedures that, taken together, have been shown to improve outcomes for ventilator patients. The team tested ideas using Plan-Do-Study-Act (PDSA) cycles, run- ning small tests of change, and then widening implementation of those that worked. To ensure that nurses checked the head of the bed elevation, for example, Camille Clark, R. Now when we [perform rounds] in the ICU we always check to see that the head of the bed is right. The form, now in use 100 percent of the time for ICU patients, went through more than 20 PDSA cycles and 25 different versions before it was final. It is now standard protocol, and from the data we have so far it has been extremely successful. We attribute our very low rate of ventila- tor-associated pneumonia to changes like the ventilator bundle and glu- cose control. Equally important is lis- tening to the frontline staff who must implement the new procedures. We have vigorous dialogues with both nurses and physicians when we try things. People know they have the ability to make changes at the work level and show the trends associated with them. He demonstrates his commitment to quality by join- ing clinical staff on rounds in the ICU on a frequent, yet purposefully irreg- ular, basis. Bringing in expertise from the outside has strengthened our approach and our commitment. The project in this section provides evi- dence of the power of complete redesign of healthcare by addressing multiple parts of the healthcare system and using the six IOM dimensions of qual- ity as a measuring stick. CareSouth, which serves 20,000 South Carolina patients in six loca- tions, is a heavy hitter when it comes to improvement work, determined to make significant improvements in office practice in all six categories of aim identified by IOM, plus an additional category of equal importance to the organization. As one of the first participants in the Health Disparities Collaborative, run jointly by IHI and the federal Bureau of Primary Health Care, which provides significant funding for CareSouth and other similar clinics throughout the nation, CareSouth focused on improving access to quality care for patients with diabetes, asthma, and depression. The results inspired Lewis to lead her organiza- tion into further improvement efforts. But I learned that every percentage drop in HbA1c represents a 13 percent drop in mortality, and that got my attention. And I would go to group visits where patients with diabetes were practically in tears with gratitude about how much our new approach to care was help- ing them. The knowledge is there—we know how to make people healthy and how to make care acces- sible. Staff chose to add one more category, vitality, a measure of staff morale. Effectiveness Goal: Asthma patients will have an average of 10 or more symptom-free days out of 14. Action: the experience that CareSouth staff had already gained in chronic care management through the Health Disparities Collaborative gave them the tools they needed to improve effectiveness of care. Wagner, a general internist/epidemiologist, is the director of Improving Chronic Illness Care and of the Seattle-based MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative of Puget Sound. Patient Safety Goal: 100 percent of all medication lists will be updated at every visit (see Figure 1. Action: Patients have a hard time remembering what medications they are taking, especially when they take several, says Lewis. Patients told us that it would help if they had something to bring them in. So we had very nice cloth med- ication bags made for everyone on three meds or more. They have our logo on them, and a reminder to bring their medications to each visit. Patient Centeredness Goal: 80 percent of self-management goals set by patients will be met (see Figure 1. Action: One of the biggest challenges the healthcare system faces is to help patients meet their own goals, says Lewis.

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Vaccinations designed to en- tal tissue buy generic bactroban skin care and pregnancy, peripheral nerve cheap 5 gm bactroban mastercard acne breakouts, and Schwann cell hance autoreactive lymphocyte responses after grafts buy bactroban 5 gm on-line acne routine, but tend not to extend beyond these CNS trauma may cause greater injury in pa- stimuli into distal white matter. Olfactory en- tients who are genetically predisposed to au- sheathing cells have led to greater growth into toimmune diseases. Inosine enabled uninjured axons to sprout collaterals into normal white matter. MOLECULES FOR ATTRACTION Other axons, especially serotonergic and nora- AND REPULSION drenergic fibers, have traversed longer dis- tances after injury. Around a SCI contusion and cavity, axons re- tract less than 1 cm and then may sprout. Bres- nahan and colleagues found corticospinal tract LIMIT GLIAL SCAR sprouting between 3 weeks and 3 months af- Immediately after a spinal cord contusion, pe- ter a moderate SCI in rodents. Thus, a modest percentage of injured activated inflammatory cells infiltrate an in- axons may regenerate into the trabecular tis- creasingly necrotic cavity. Neutrophils, mi- sue that thinly bridges the cavity, as well as into croglia, and proinflammatory chemokines and residual gray and white matter around the cyst cytokines initiate macrophage phagocytosis. Within a week, T-lymphocytes and circulating Antibodies to specific myelin-associated in- monocytes enter the region of injury. Neurotrophin-3, but not and bystander damage inflicted by natural and BDNF injected into the lesioned rat spinal autoimmune inflammatory responses. Drugs cord increased the regenerative sprouting of that block cytokines have not had clinical effi- the transected corticospinal tract; neutralizing cacy. Focal irradiation within several days of a the myelin-associated neurite growth in- contusion may quench the influx of inflamma- hibitory proteins resulted in regeneration of up tory cells. Under the in- growth of axons from the transplant into the fluence of anti-Nogo antibodies, axons have host. Although the regenerated tracts seem to enhance aspects Different neuronal populations vary in the ease of locomotor gains in the dorsal hemisection with which they have been induced to regen- model,246–248 which is the location of the cor- erate. The goal is to get critical supraspinal and ticospinal tracts in rats, stepping depends propriospinal axons to sprout and reach targets largely upon residual reticulospinal and in the gray matter of the cord. Mul- monaminergic and serotonergic axons seem tiple inhibitors of axonal outgrowth are being most able to traverse around a cavity or hemi- identified on the surface of oligodendrocytes section of the spinal cord. A vaccine against months after a transplant of OECs into a rat extracts of myelin, for example, appeared to model of spinal cord transection, regenerated block MAG, Nogo, and other less well-defined corticospinal, raphespinal, and coerulospinal inhibitors of the growth cone in mice. Potential means to increase cAMP, Olfactory ensheathing cells may produce block Rho, and neutralize semaphorins were substances that degrade proteoglycans and described earlier for animal models. Also, in dorsal root ganglia regenerates central sen- OECs secrete at least a few varieties of adhe- sory axons. Of interest, Myelin-associated inhibitors may be no corticospinal axons after exposure to OECs in more harmful than proteoglycans such as chon- the rat model used by Ramon-Cueto regener- droitin sulfate and keratan sulfate and tenascin, ated on the surface of the cord through the pia which suffuse scar tissue. Perilesional infusion mater, suggesting that meningeal fibroblasts of chondroitinase may degrade proteoglycans may also play a role. Further experiments with and make the milieu more conducive to re- these cells will determine the reproducibility generation of axons. Other clever interventions, including gene Proteoglycans, for example, formed at the gray therapies, have enticed axonal regeneration. White matter tracts have approximately 85% of their fibers to white matter bridging and transected con- crossing in the medulla, but approximately trol animals did not improve behaviorally in 10%–15% do not cross and descend in either their hindlimb stepping as much as those with the ipilateral lateral or ventral column of the the more sophisticated bridges. The axons from any of these residual corticospinal tracts and other tracts were said paths may reinnervate motor pools in the cord to grow through the grafted channels and ap- that have been deafferented, leading to better peared to extend into the favorable environ- motor control. These experiments need may lead to greater synaptic sprouting of a pre- to be reproduced in nonhuman primates. In served ventral or lateral corticospinal tract addition to neurotrophins, peripheral nerve after a lesion damages the other lateral corti- grafts laced with an immunophilin may en- cospinal tract. Spared axons a permissive bridge that draws in ascending generate new processes around the lesion, not and descending axons from the host (see dis- through it. However, regenerating axons may not injured cord segment by application of a direct leave the implant, because the embryonic tis- current electric field. Electrical field growth cone guid- ance may exert its effects through calcium 254a ENGINEERED BRIDGES fluxes and cAMP. Synthetic channels and biopolymers may also fill a cavity and allow axonal growth. Solid fe- BRIDGES tal spinal cord tissue was seeded into semiper- the scar and cavity created by a SCI may have meable mini-guidance channels up to 3 mm to be bridged by cells or other materials, so that long. Cultured Schwann cells, pe- ditional interventions may enhance such re- ripheral nerve implants, OECs, and embryonic generation. For example, carbon filaments spinal cord transplants are among the sub- helped direct axon growth across a spinal con- stances that may permit central axon regener- tusion when combined with fetal grafts. Bridges in Polymers seeded with Schwann cells, everyday life are passive structures, meant to OECs,147 or neural stem cells259a add to the get a person across a barrier and on the road effects of biologic signals for regeneration. For regeneration, axons and cells must Collagen gels and porous, 3-dimensional hy- go past the bridge to find their targets. Per- drogels that are biocompatible may integrate missive substrates255 must lace the lanes at the with the host and can be biodegradable. Such end of the bridge, as well as along the road gels, which are still a work in progress, offer ahead if regenerating axons are going to grow considerable flexibility for repair strate- past the nurturing haven of the bridge. With micron-sized pores, the produce effort, Cheng and colleagues smoothly bridges may encourage directional regenera- Biologic Adaptations and Neural Repair 123 tion, receive nutrients from the host and graft, tained axons. The animals that received BDNF and allow diffusion of embedded neu- or NT-3 neurotrophins filled the site with the rotrophins and other molecules. Indeed, the largest number of axons, myelin proteins, and biocompatible microenvironment may be de- new oligodendrocytes. The two neurotrophins, signed to incorporate neurons, glia, and blood then, induced significant proliferation and mi- vessels and release molecules on demand over gration of host oligodendrocytes or their pre- time. Thus, growth cones coaxed into the poly- cursors and myelinated ingrowing axons over mer graft may also be coaxed out of it so they lengths of 1. Surgeons may tained cholinergic, serotonergic, and other phe- implant, in the near future, smart biopolymers notypes. In another model, oligodendrocytes with feedback sensors or an architecture that derived from embryonic stem cells were able releases embedded substances and cell types to myelinate mutant mice spinal cords that on demand. A more sophisticated polymer as- lacked myelin and myelinate the dorsal columns sembly could contain simple neural networks of rats after chemical demyelination. For example, Grafts of cultured Schwann cells have also a biohybrid microprobe was described that may successfully aided axonal regeneration and re- stimulate encapsulated neurons implanted into myelination, and improved the conduction of the spinal cord. Up to 3% of the cells taken Demyelination with intact axons has been ob- from excised temporal lobe tissue during sur- served in pathological specimens in animal gery for epilepsy have, in tissue culture, dif- models264 and in humans265 after compressive ferentiated into oligodendrocytes and type II SCI, along with regions of remyelination. For example, regulate the expression of ion channels on ax- neurospheres were induced from stem cells of ons and partially myelinated fibers by injecting the subventricular zone of human brain tissue growth factors. The cells dif- impulse conduction by blocking potassium ferentiated into neuronal and oligodendro- channels with drugs such as 4-aminopyri- cyte/Schwann cell precursors. The re- the normal spinal cord may have ongoing en- myelinated axons recovered normal conduc- dogenous proliferation and migration of oligo- tion velocities. Remyelination associ- ated with the regeneration of oligodendrocyte precursors also appears to have a signaling Other Transplantation Strategies mechanism in man that could be switched on.


It is a prescription drug used for bowel Drugs at a Glance: Laxatives and Cathartics purchase 5gm bactroban fast delivery acne 25. Polyethylene glycol solution (MiraLax) is an oral laxative Bulk-Forming Laxatives that may be used to treat occasional constipation best order for bactroban skin care yang bagus untuk jerawat. It is a prescription drug and should not be Bulk-forming laxatives (eg buy genuine bactroban online skin care 2 in 1, polycarbophil, psyllium seed) taken longer than 2 weeks. The added bulk or size of the fecal mass stimulates peri- stalsis and defecation. The substances also may act by pulling Stimulant Cathartics water into the intestinal lumen. Bulk-forming laxatives are the most physiologic laxatives because their effect is similar the stimulant cathartics are the strongest and most abused lax- to that of increased intake of dietary fiber. These drugs act by irritating the GI mucosa and within 12 to 24 hours, but may take as long as 2 to 3 days to pulling water into the bowel lumen. These drugs should not be used frequently or longer than 1 week be- cause they may produce serum electrolyte and acid–base im- Surfactant Laxatives (Stool Softeners) balances (eg, hypocalcemia, hypokalemia, metabolic acidosis or alkalosis). Surfactant laxatives (eg, docusate calcium, potassium, or Oral stimulant cathartics include bisacodyl, cascara sagrada, sodium) decrease the surface tension of the fecal mass to castor oil, and senna products. As a result, a single bedtime dose tergent to facilitate admixing of fat and water in the stool. These agents pository products include bisacodyl, which produces effects have little if any laxative effect. They usually act within ritant, stimulant effects, glycerin exerts hyperosmotic effects 1 to 3 days and should be taken daily. Saline Laxatives Lubricant Laxative Saline laxatives (eg, magnesium citrate, milk of magnesia) are not well absorbed from the intestine. Consequently, they Mineral oil is the only lubricant laxative used clinically. It lu- increase osmotic pressure in the intestinal lumen and cause bricates the fecal mass and slows colonic absorption of water water to be retained. Distention of the bowel leads to in- from the fecal mass, but the exact mechanism of action is un- creased peristalsis and decreased intestinal transit time for the known. These laxatives may cause several adverse effects and is not recommended are used when rapid bowel evacuation is needed. Mineral oil enemas are sometimes used to magnesium preparations, effects occur within 0. Saline laxatives are generally useful and safe for short- term treatment of constipation, cleansing the bowel prior to Miscellaneous Laxatives endoscopic examinations, and treating fecal impaction. How- ever, they are not safe for frequent or prolonged usage or for Lactulose is a disaccharide that is not absorbed from the GI certain patients because they may produce fluid and elec- tract. It exerts laxative effects by pulling water into the in- trolyte imbalances. It is used to treat constipation and hepatic function are at risk of developing hypermagnesemia with encephalopathy. The latter condition usually results from alco- magnesium-containing laxatives because some of the mag- holic liver disease in which ammonia accumulates and causes nesium is absorbed systemically. Ammonia is produced by metabolism of dietary CHAPTER 61 LAXATIVES AND CATHARTICS 885 Drugs at a Glance: Laxatives and Cathartics Routes and Dosage Ranges Generic/Trade Name Adults Children Bulk-forming Laxatives Methylcellulose (Citrucel) PO 1 heaping tbsp 1–3 times daily with water PO 1 level tbsp 1–3 times daily with water (4 oz) (8 oz or more) Polycarbophil (FiberCon, PO 1 g 4 times daily or PRN with 8 oz of fluid; 6–12 y: PO 500 mg 1–3 times daily or PRN; Mitrolan) maximum dose, 6 g/24 h maximum dose, 3 g/24 h 2–6 y: PO 500 mg 1 or 2 times daily or PRN; maximum dose, 1. Lactulose decreases production Indications for Use of ammonia in the intestine. The goal of treatment is usually to maintain two to three soft stools daily; effects usually occur Despite widespread abuse of laxatives and cathartics, there within 24 to 48 hours. The drug should be used cautiously be- are several rational indications for use: cause it may produce electrolyte imbalances and dehydration. To relieve constipation in pregnant women, elderly Sorbitol is a monosaccharide that pulls water into the in- clients whose abdominal and perineal muscles have testinal lumen and has laxative effects. It is often given with become weak and atrophied, children with megacolon, sodium polystyrene sulfonate (Kayexalate), a potassium- and clients receiving drugs that decrease intestinal removing resin used to treat hyperkalemia, to prevent consti- motility (eg, opioid analgesics, drugs with anticholin- pation and aid expulsion of the potassium–resin complex. To prevent straining at stool in clients with coronary Laxative Abuse artery disease (eg, postmyocardial infarction), hyper- tension, cerebrovascular disease, and hemorrhoids and Laxatives and cathartics are widely available on a nonpre- other rectal conditions scription basis and are among the most frequently abused 3. One reason for overuse is the common misconception diagnostic procedures (eg, colonoscopy, barium enema) that a daily bowel movement is necessary for health and well- 4. To accelerate elimination of potentially toxic substances being, even with little intake of food or fluids. This notion from the GI tract (eg, orally ingested drugs or toxic may lead to a vicious cycle of events in which a person fails compounds) to have a bowel movement, takes a strong laxative, again fails 5. To prevent absorption of intestinal ammonia in clients to have a bowel movement, and takes another laxative before with hepatic encephalopathy the fecal column has had time to become reestablished (2 to 6. To obtain a stool specimen for parasitologic examination 3 days with normal food intake). To accelerate excretion of parasites after anthelmintic dependence and abuse is established. To reduce serum cholesterol levels (psyllium products) most often by people with eating disorders and those who must meet strict weight requirements (eg, some athletes). Contraindications to Use This is a very dangerous practice because it may lead to life- threatening fluid and electrolyte imbalances. Laxatives and cathartics should not be used in the presence of undiagnosed abdominal pain. The danger is that the drugs may cause an inflamed organ (eg, the appendix) to rupture Nursing Notes: Apply Your Knowledge and spill GI contents into the abdominal cavity with subse- You are a home health nurse visiting Gina Simboli, a 36-year-old How Can You Avoid This Medication Error? Her disease has progressed to a point where she is taking large amounts of narcotics to control the pain and You are a consulting nurse working on the Health Telephone Infor- she spends most of the day in a recliner chair. A 72-year-old caller complains of severe constipation, reveals complaints of feeling full and bloated. Simboli has been incontinent of small amounts of liquid so much I can hardly stand it. What will you recommend to pro- magnesia, which he can buy at his pharmacy. CHAPTER 61 LAXATIVES AND CATHARTICS 887 quent peritonitis, a life-threatening condition. Oral drugs • Noncompliance with recommendations for nondrug mea- also are contraindicated with intestinal obstruction and fecal sures to prevent or treat constipation impaction. These have long been used the client will: and are safe and effective when used as directed. When used for this purpose, and prevent constipation a gel-like liquid can be squeezed directly from a plant leaf • Regain normal patterns of bowel elimination onto the burned area. Oral aloe is sometimes used as a laxa- • Avoid excessive losses of fluids and electrolytes from tive. However, it is not recommended for this use because it laxative use is a strong stimulant laxative. With oral ingestion, aloe can • Be protected from excessive fluid loss, hypotension, and cause severe cramping and other potentially serious adverse other adverse drug effects, when possible effects including hypokalemia and cardiac dysrhythmias.

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