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Although morphine and codeine are contraindicated in drugs are related to aspirin and nonsteroidal anti- chronic diarrhea buy generic levlen on-line birth control pills examples, they may occasionally be used in the inflammatory drugs (see Chap purchase generic levlen online birth control for 13 year old. Dosages required CHAPTER 62 ANTIDIARRHEALS 899 for antidiarrheal effects are smaller than those required sures to decrease GI irritants levlen 0.15mg birth control pills list, and drug therapy apply as for for analgesia. Most antidiarrheal drugs may be given to approximately equivalent in antidiarrheal effectiveness: older adults, but cautious use is indicated to avoid inducing 4 mg morphine, 30 mg codeine, 10 mL paregoric, 5 mg constipation. Use in Renal Impairment Use in Children Difenoxin and diphenoxylate should be used with extreme Antidiarrheal drugs, including antibiotics, are often used in caution in clients with severe hepatorenal disease because he- children to prevent excessive losses of fluids and electrolytes. In small children, fluid volume deficit may rapidly develop with diarrhea. Drug therapy should be accompanied by appro- priate fluid replacement and efforts to decrease further stimuli. Use in Hepatic Impairment Oral rehydration solutions (eg, Pedialyte solution and freezer pops) are commercially available in ready-to-use formulations Difenoxin and diphenoxylate should be used with extreme in the United States. Packets of powder (containing glucose, caution in clients with abnormal liver function test results or sodium, potassium, chloride, and citrate), to be mixed with severe hepatorenal disease because hepatic coma may be pre- 1 liter of boiled or treated water, are available in developing cipitated. With loperamide, monitor clients with hepatic im- countries, usually provided by the World Health Organization. Loperamide normally Difenoxin and diphenoxylate contain atropine, and signs undergoes extensive first-pass metabolism, which may be of atropine overdose may occur with usual doses. As a result, a larger portion of a and diphenoxylate are contraindicated in children younger dose reaches the systemic circulation and may cause adverse than 2 years of age; loperamide should not be used in chil- effects. Use in Immunocompromised Patients Use in Older Adults Diarrhea often occurs in immunocompromised patients (eg, those with AIDS, organ transplant, or anticancer chemo- Diarrhea is less common than constipation in older adults, but therapy) and may be difficult to treat with the usual anti- it may occur from laxative abuse and bowel cleansing proce- diarrheal drugs. Octreotide may be effective, but it should be dures before GI surgery or diagnostic tests. Fluid volume used only after other medications have failed because it is deficits may rapidly develop in older adults with diarrhea. General principles of fluid and electrolyte replacement, mea- Home Care Nursing Notes: Apply Your Knowledge Prescription and over-the-counter antidiarrheal aids are often taken in the home setting. The role of the home care nurse may include advising clients and caregivers about appropri- Mrs. Greta Riley, a 72-year-old resident of the retirement center ate use of the drugs, trying to identify the cause and severity where you work as the nurse, comes in to see you. She states, of the diarrhea (ie, risk of fluid and electrolyte deficit), and My bowels have been in an uproar for over 3 weeks. First I had teaching strategies to manage the current episode and pre- terrible constipation and had to use all sorts of laxatives to get vent future episodes. With liquid diphenoxylate, use only the calibrated dropper For accurate measurement furnished by the manufacturer for measuring dosage. The To add sufficient volume for the drug to reach the stomach mixture appears milky. Do not exceed maximal daily doses of diphenoxylate, lo- To decrease risks of adverse reactions, including drug dependence peramide, difenoxin, and paregoric. Give cholestyramine and colestipol with at least 120 mL of the drugs may cause obstruction of the gastrointestinal (GI) tract water. Also, do not give within approximately 4 h of other if swallowed in a dry state. Decreased number, frequency, and fluidity of stools Therapeutic effects are usually evident within 24 to 48 h. Signs of normal fluid and electrolyte balance (adequate hydration, urine output, and skin turgor) d. It can be pre- vented by using antidiarrheal drugs only as prescribed and stop- ping the drugs when diarrhea is controlled. Drug dependence Dependence is unlikely with recommended doses but may occur with long-term use of large doses of paregoric, diphenoxylate, and difenoxin. With diphenoxylate, anorexia, nausea, vomiting, dizziness, Although numerous adverse reactions have been reported, their abdominal discomfort, paralytic ileus, toxic megacolon, hyper- incidence and severity are low when diphenoxylate is used sensitivity (pruritus, urticaria, angioneurotic edema), headache, appropriately. Overdose can be prevented by using the result from diphenoxylate or difenoxin content and anticholin- drug in recommended doses and only when required. Overdose ergic effects (eg, dry mouth, blurred vision, urinary retention) can be treated with naloxone (Narcan) and supportive therapy. With loperamide, abdominal cramps, dry mouth, dizziness, Abdominal cramps are the most common adverse effect. No serious nausea, and vomiting adverse effects have been reported with recommended doses of lo- peramide. Overdose may be treated with naloxone, gastric lavage, and administration of activated charcoal. With cholestyramine and colestipol, constipation, nausea, Adverse effects are usually minor and transient because these and abdominal distention drugs are not absorbed from the GI tract. With octreotide, diarrhea, headache, cardiac dysrhythmias, These are commonly reported adverse effects. Observe for drug interactions Few clinically significant drug interactions have been reported with commonly used antidiarrheal agents. Drugs that increase effects of antidiarrheal agents: (1) Central nervous system (CNS) depressants (alcohol, Additive CNS depression with opiate and related antidiarrheals. Which types of diarrhea do not require antidiarrheal drug How Can You Avoid This Medication Error? How do antidiarrheal drugs decrease frequency or fluidity had a total of 15 mg, which is still under the 24-hour limit of of stools? What are adverse effects of commonly used antidiarrheal (after every bowel movement). 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. Louis: Facts and is very important to have a bowel movement every day; thus, Comparisons. 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.

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With in- than 2 months of age (except for treatment of congenital dwelling catheters buy levlen 0.15 mg fast delivery birth control wiki, bacteria colonize the bladder and toxoplasmosis) buy 0.15 mg levlen amex birth control gain weight, and people who have had hypersensitivity produce infection within 2 to 3 weeks buy 0.15 mg levlen free shipping birth control 40s, even with metic- reactions to them or to chemically related drugs (eg, thi- ulous care. Sulfasalazine • When indwelling catheters must be used, measures to (Azulfidine) is contraindicated in people who are allergic decrease UTI include using a closed drainage system; to salicylates and people with intestinal or urinary tract keeping the perineal area clean; forcing fluids, if not con- obstruction. CHAPTER 36 TETRACYCLINES, SULFONAMIDES, AND URINARY AGENTS 543 levels (12 to 15 mg/100 mL) more rapidly. The amount traindicated, to maintain a dilute urine; and removing the is usually twice the maintenance dose. Urine pH is important in drug therapy with sulfonamides and irrigate the catheter unless obstruction is suspected. With sulfonamide therapy, alkaline urine increases • Force fluids in anyone with a UTI unless contraindicated. In ad- also increases the rate of sulfonamide excretion and dition, emptying the bladder frequently allows it to refill the concentration of sulfonamide in the urine. This decreases the bacterial popu- urine can be alkalinized by giving sodium bicarbon- lation of the bladder. Alkalinization is not needed with sulfisoxazole • Teach women to cleanse themselves from the urethral area (because the drug is highly soluble) or sulfonamides toward the rectum after voiding or defecating to avoid used to treat intestinal infections or burn wounds contamination of the urethral area with bacteria from the (because there is little systemic absorption). With mandelamine therapy, urine pH must be acidic helps cleanse the lower urethra and prevent UTI. At a higher pH, Evaluation mandelamine does not hydrolyze to formaldehyde, the antibacterial component. Urine can be acidified • Observe for improvement in signs of the infection for by concomitant administration of ascorbic acid. Urine cultures and sensitivity tests are indicated in sus- • Interview and observe for adverse drug effects. The best results are obtained with drug therapy indi- cated by the microorganisms isolated from each client. Culture and susceptibility studies are needed before Tetracyclines should not be used in children younger than tetracycline therapy is started because many strains of 8 years of age because of their effects on teeth and bones. In organisms are either resistant or vary greatly in drug sus- teeth, the drugs interfere with enamel development and may ceptibility. Cross-sensitivity and cross-resistance are cause a permanent yellow, gray, or brown discoloration. The oral route of administration is usually effective and tissue and may interfere with bone growth. Intravenous (IV) therapy is used when oral Systemic sulfonamides are contraindicated during late administration is contraindicated or for initial treat- pregnancy, lactation, and in children younger than 2 months. Tetracyclines decompose with age, exposure to light, tal transfer, in breast milk, or by direct administration, the and extreme heat and humidity. Because the break- drug displaces bilirubin from binding sites on albumin. As a down products may be toxic, it is important to store result, bilirubin may accumulate in the bloodstream (hyper- bilirubinemia) and central nervous system (kernicterus) and these drugs correctly. Few data are available regarding the effects of long-term or recurrent use of sulfamethoxazole in chil- Sulfonamides and Urinary Antiseptics dren younger than 6 years of age with chronic renal disease. With systemically absorbed sulfonamides, an initial prim (Bactrim, Septra), although trimethoprim has not been loading dose may be given to produce therapeutic blood established as safe and effective in children younger than 12 years of age. Some clinicians recommend that asymptomatic bacteriuria be treated in children younger than 5 years of age to decrease How Can You Avoid This Medication Error? Trimethoprim-sulfamethoxazole (Bactrim) DS bid is ordered for a client after urologic surgery. He takes no medications and reports an allergy to eggs, nuts, sulfa, and morphine. The unit dose provided Use in Older Adults from the pharmacy is a tablet containing 160 mg of trimethoprim and 800 mg of sulfamethoxazole. A major concern with the use of tetracyclines and sulfon- amides in older adults is renal impairment, which commonly 544 SECTION 6 DRUGS USED TO TREAT INFECTIONS CLIENT TEACHING GUIDELINES Oral Tetracyclines General Considerations Self-Administration ✔ Because tetracyclines inhibit rather than kill bacteria, ✔ Take most tetracyclines on an empty stomach, at least they must be taken correctly to achieve desired effects. Doxycycline and ✔ These drugs increase sensitivity to sunlight and risks minocycline may be taken with food (except dairy prod- of sunburn. These symptoms may indicate a need for changing or stopping the tetracycline. Except for doxycycline and minocy- antianabolic effect increases tissue breakdown (catabolism) cline, tetracyclines are contraindicated in clients with renal and the amount of waste products to be excreted by the kid- impairment. As with younger adults, a fluid intake of 2 L daily functioning kidneys, but waste products are retained when is needed to reduce formation of crystals and stones in the renal function is impaired. Severe skin reactions and bone mar- microbial drugs, doxycycline or minocycline may be given. Folic acid deficiency Systemic sulfonamides should probably be avoided in may also occur because both of the drugs interfere with folic clients with renal impairment, if other effective drugs are acid metabolism. Acute renal failure (ARF) has occurred when the drugs or their metabolites precipitated in renal tubules and caused obstruction. ARF is rarely associated with newer Use in Renal Impairment sulfonamides, which are more soluble than older ones, but has increased with the use of sulfadiazine to treat toxoplas- As discussed previously, most tetracyclines are contraindi- mosis in clients with acquired immunodeficiency syndrome cated in clients with renal impairment. Preventive measures include a fluid intake of 2 to tetracyclines inhibit protein synthesis in human cells. CLIENT TEACHING GUIDELINES Oral Sulfonamides General Considerations Self-Administration ✔ Sulfonamides inhibit rather than kill bacteria. Thus, it is ✔ Take oral sulfonamides on an empty stomach with at especially important to take them as prescribed, for the least 8 oz of water. Avoid sunlamps, tanning beds, and intense or ✔ Drink 2 to 3 quarts of fluid daily, if able. A good fluid in- prolonged exposure to sunlight; if unable to avoid expo- take helps the drugs to be more effective, especially in sure, wear protective clothing and a sunblock preparation. These symptoms may indicate adverse drug effects and the need to change or stop the drug. CHAPTER 36 TETRACYCLINES, SULFONAMIDES, AND URINARY AGENTS 545 levels should not exceed 15 mcg/mL, and other hepatotoxic Nursing Notes: Apply Your Knowledge drugs should be avoided. Sulfonamides cause cholestatic jaundice in a small per- centage of clients and should be used with caution in clients You are working in a nursing home, caring for an elderly, with hepatic impairment. You notice her urine is cloudy with lots of sediment and it has a strong, foul odor. Analyze these data and discuss how you will Use in Critical Illness proceed. Tetracyclines may be used to treat sepsis caused by rick- ettsial, chlamydial, or mycoplasma infection and pulmonary infection caused by Mycoplasma pneumoniae or Legionella Use in Hepatic Impairment pneumophila. When necessary, doxycycline is the drug of choice be- Tetracyclines are contraindicated in pregnant women be- cause it can be given to clients with renal impairment, a com- cause they may cause fatal hepatic necrosis in the mother.

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This was done one time per day levlen 0.15 mg amex can xanax affect birth control pills, and six days equaled one course of treatment purchase 0.15mg levlen visa birth control exam. Study outcomes: Thirty-five cases were cured trusted 0.15mg levlen birth control 24, 21 cases markedly improved, four cases improved, and two cases did not improve. According to the book, Bai Zheng Fu (Ode on the Hundreds of Symptoms), [For] tiredness to speak and liking to lie down, Tong Li and Da Zhong brightens [these]. The author uses this concept to treat enuresis because children with enuresis are often heavy sleepers and diffi- cult to wake up. The treatment of the kidney and heart channels with the points above promotes the interaction between the heart and the kidney and restrains the bladder. Moxibustion on Guan Yuan makes the kidneys exuberant and boosts the kidney qi, securing and containing the lower origin. From the Treatment of 38 Cases of Enuresis with Acupuncture & Moxibustion on the Point Hui Yin (CV 1) by Xu Yi-jing et al. Treatment method: the patient lied down on his or her back with both knees flexed. After disinfecting the point Hui Yin (CV 1), it was needled perpen- dicularly to a depth of 1-1. Then moxibustion was applied for five minutes until the patient felt heat coursing upward to the face and head. Then the needle was inserted at a 15˚ angle under the skin forward, after which it was moxaed for another five min- utes. Now the patient was supposed to feel a warm sensation in their lower abdomen. Finally, the needle was inserted at a 15˚ angle under the skin backward, and again the point was moxaed for five minutes. At this time, the patient was supposed to feel warmth in their lumbar region. One treatment lasted approximate- ly 20 minutes, and this treatment was given once per day for three times. Study outcomes: All 38 cases in this study were cured in 1-2 courses of treatment. Discussion: Hui Yin is the meeting place of the conception vessel, the sea of yin, the governing vessel, the sea of yang, and chong mai, the sea of blood. Therefore, acupuncture and moxibustion on this point can regulate yin and yang and harmonize qi and blood as well as having an effect on the cerebral cortex. From A Comparison Study of Acupuncture & Massage and Chinese Medicinals in the Treatment of Occult Spina Bifida Enuresis by Xue Hong & Hu Jun-xia, Liao Ning Zhong Yi Za Zhi (Liaoning Journal of Chinese Medicine), 2001, #8, p. These patients were randomly divided into two equal groups—an acupuncture massage treatment group and a Chinese medicine comparison group. Treatment method: All members of the treatment group received acupuncture based on the principles of supplementing the kidneys, securing and con- taining. The main acupoints used in this study consisted of: Guan Yuan (CV 4) Shen Shu (Bl 23) Pang Guang Shu (Bl 28) Qi Jie Gu (Seven Joints & Bones, a pediatric tuina point located on the posterior midline from Ming Men, GV 4, to the tip of the coccyx) the area where the spina bifida was located Supplementation method was used on Guan Yuan, Shen Shu, and Pang Guang Shu and the needles were retained for 15 minutes. After acupuncture, the lesser thenar eminence was used to rub Qi Jie Gu until the area was warm. This last method was meant to quicken the blood and dispel stasis, relax and disinhibit the local area. After this, the area of the occult spina bifida was pressed and stretched. This treatment was given every other day, and 10 treatments equaled one course of therapy. It was also suggested that all other treatments for this disorder be discontinued during the treatment period. All members of the comparison group received Gong Ti Wan (Dyke-Strengthening Pills) based on the same treatment principles as above. These pills consisted of: Shu Di (cooked Radix Rehmanniae) Tu Si Zi (Semen Cuscutae) Bai Zhu (Rhizoma Atractylodis Macrocephaleae) Wu Wei Zi (Fructus Schisandrae) 142 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine Fu Ling (Poria) Yi Zhi Ren (Fructus Alpiniae Oxyphyllae) Bu Gu Zhi (Fructus Psoraleae) Fu Zi (Radix Lateralis Praeparatus Aconiti Carmichaeli) Jiu Cai Zi (Semen Alli Tuberosi) If there was a bright white facial complexion, fatigued spirit, and lack of strength, Huang Qi (Radix Astragali) and Tai Zi Shen (Radix Pseudostellariae) were added. For poor appetite, Chen Pi (Pericarpium Citri Reticulatae) and Gu Ya (Fructus Germinatus Oryzae) were added. If there was long, clear urination, chilled limbs, and aversion to cold, Jin Ying Zi (Fructus Rosae Laevigatae) and Gui Zhi (Ramulus Cinnamomi) were added. One packet of these medicinals were decocted in water and administered per day, and one month of this treatment equaled one course of therapy. Study outcomes: In the treatment group, 16 cases were cured, 12 cases improved, and two cases had no improvement. In the comparison group, five cases were cured, 17 cases improved, and eight cases had no improvement. From A Clinical Study & Comparison on the Use of Varied Forms of Acupuncture & Massage for the Treatment of Occult Spina Bifida Enuresis by Hu Jun-xia et al. These patients were randomly divided into two equal groups—an acupuncture and massage treatment group and a Chinese medicine comparison group. Treatment method: the main acupoints for all members of the treatment group in Chinese Research on the Treatment of Pediatric Enuresis 143 order to supplement the kidneys, secure and contain were: Guan Yuan (CV 4) Shen Shu (Bl 23) Pang Guang Shu (Bl 28) Qi Jie Gu (Seven Joints & Bones) the area where the spina bifida was located Supplementation method was used on Guan Yuan, Shen Shu, and Pang Guang Shu, and the needles were retained for 15 minutes. After acupuncture, the lesser thenar eminence was used to rub Qi Jie Gu until it was red. After this, the area of the occult spina bifida was pressed and stretched. For members of the comparison group, the main points were: Shen Shu (Bl 23) Qi Jie Gu (Seven Joints & Bones) the area where the spina bifida was located Supplementation method was used at Shen Shu, and the nee- dles were retained for 15 minutes. However, the needles were stimulated only one time throughout the treatment. After acupuncture, Qi Jie Gu was rubbed with the lesser thenar emi- nence until red, and the area of the spina bifida was pressed and stretched. In both groups, treatment was given every other day, and 10 days equaled one course of treatment. It was also suggested that all other treatments for this disorder be discontinued during the treatment period. Study outcomes: In the treatment group, 16 cases were cured, 10 cases improved, and four cases had no improvement. In the comparison group, 15 cases were cured, 12 cases improved, and three cases had no improvement. From the Treatment of 36 Cases of Enuresis [By Comparing Acupuncture] to the Combination of Acupuncture and Zhi Yi San (Stop Loss [of Urine] Powder) by Yu Qing-zhi & Yu Yang, Zhong Yi Wai Zhi Za Zhi (The Chinese Medicine Journal of External Treatments), 2002, #6, p. The Chinese medicine group consisted of 18 cases all between the ages of 3-15 years old. Treatment method: All patients in both groups took the Chinese medicinals, but the first group also received acupuncture in addition to the herbs.