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Commonly used ingredients include chlorpheniramine scribes pseudoephedrine (Sudafed) to relieve nasal congestion buy accutane 40mg low price acne soap. Discuss the error and gestant) buy accutane 30 mg amex skin care brands, acetaminophen (analgesic and antipyretic) order accutane without prescription acne jaw line, dextro- the impact it will have on Mr. Although antihistamines are popular OTC drugs because they dry nasal secretions, they are not recommended because they Antitussives can also dry lower respiratory secretions and worsen secre- tion retention and cough. Antitussive agents suppress cough by depressing the cough Many products come in several formulations, with differ- center in the medulla oblongata or the cough receptors in the ent ingredients, and are advertised for different purposes throat, trachea, or lungs. Centrally acting antitussives include (eg, allergy, sinus disorders, multisymptom cold and flu reme- narcotics (eg, codeine, hydrocodone) and non-narcotics dies). For example, allergy remedies contain an antihistamine; (eg, dextromethorphan). Locally acting agents (eg, throat nondrowsy or daytime formulas contain a nasal decon- lozenges, cough drops) may suppress cough by increasing the gestant, but do not contain an antihistamine; PM or night flow of saliva and by containing demulcents or local anes- formulas contain a sedating antihistamine to promote sleep; thetics to decrease irritation of pharyngeal mucosa. Flavored pain, fever, and multisymptom formulas usually contain acet- syrups are often used as vehicles for other drugs. It is not desirable to suppress a productive cough because products list ingredients by generic name, without identifying the secretions need to be removed. As a result of these bewildering products, tinue to be used and some people report beneficial effects, consumers, including nurses and other health care providers, some research studies indicate that cough medicines are no may not know what medications they are taking or whether more effective than placebos in children or adults. INDIVIDUAL DRUGS Expectorants Individual decongestants, antitussives, expectorants, and mu- Expectorants are agents given orally to liquefy respiratory se- colytics are listed in Drugs at a Glance: Nasal Decongestants, cretions and allow for their easier removal. Guaifenesin is the Antitussives, and Expectorants; selected combination prod- most commonly used expectorant. Several supplements are commonly used to prevent or treat Mucolytics symptoms of the common cold. Mucolytics are administered by inhalation to liquefy mucus in Echinacea preparations differ in chemical composition the respiratory tract. Solutions of mucolytic drugs may be neb- depending on which of the nine species or parts of the plant ulized into a face mask or mouthpiece or instilled directly into (eg, leaves, roots, whole plants) are used, as well as the sea- the respiratory tract through a tracheostomy. Sodium chloride solution and acetylcysteine (Mucomyst) are the only agents recommended for use as mucolytics. Acetylcysteine is effec- tive within 1 minute after inhalation, and maximal effects Nursing Notes: Apply Your Knowledge occur within 5 to 10 minutes. Oral acetylcysteine is widely used in the treatment of acetaminophen overdosage (see Chap. Joan, a college student, comes to the health clinic with cold symptoms (productive cough, low-grade fever, continuous nasal Cold Remedies discharge, and general malaise and discomfort). She states she went to the drugstore to buy some cold medicine, but there were so many different preparations that she was confused. Discuss Many combination products are available for treating symp- your recommendations for Joan, with their underlying rationale. Many of the products contain an CHAPTER 49 NASAL DECONGESTANTS, ANTITUSSIVES, AND COLD REMEDIES 731 Drugs at a Glance: Nasal Decongestants, Antitussives, and Expectorants Routes and Dosage Ranges Generic/Trade Name Adults Children Nasal Decongestants Ephedrine sulfate 0. Maximum, 6 doses/24 h 6–11 y: 2–3 sprays in each nostril no more often than q4h. Maximum 120 mg/24 h 12 y and older: Same as adults Topically, 2–3 sprays or drops of 0. Maximum 60 mg/24 h or 1% solution in each nostril no more often Topically, 2–3 sprays of 0. Pseudoephedrine (Sudafed, Dimetapp) Regular tablets, PO 60 mg q4–6 h 12 y and older: Same as adults for regular and Extended-release tablets, PO 120 mg q12h or extended release tablets 240 mg q24h. Maximum, 60 mg/24 h <2 y: Consult pediatrician Tetrahydrozoline (Tyzine) 0. Nonnarcotic Antitussive Dextromethorphan (Benylin DM, others) Liquid, lozenges, and syrup, 10–30 mg q4–8h. Sustained action liquid, 6–12 y: 30 mg q12h 2–5 y: 15 mg q12h Expectorant Guaifenesin (glyceryl guaiacolate) PO 100–400 mg q4h. Mucolytic Acetylcysteine (Mucomyst) Nebulization, 1–10 mL of a 20% solution or Acetaminophen overdosage, see literature 2–20 mL of a 10% solution q2–6h Instillation, 1–2 mL of a 10% or 20% solution q1–4h Acetaminophen overdosage, PO 140 mg/kg initially, then 70 mg/kg q4h for 17 doses; dilute a 10% or 20% solution to a 5% solution with cola, fruit juice, or water 732 SECTION 8 DRUGS AFFECTING THE RESPIRATORY SYSTEM TABLE 49–1 Representative Multi-Ingredient Nonprescription Cold, Cough, and Sinus Remedies Ingredients Trade Name Antihistamine Nasal Decongestant Analgesic Antitussive Expectorant Actifed Cold & Allergy Triprolidine Pseudoephedrine 2. Also, which constituents of the plants are cause adverse effects and about 90% of large doses is ex- pharmacologically active is unclear. Very little is absorbed and blood levels of Some studies indicating effectiveness of echinacea in vitamin C are raised only slightly. Most of the studies suggesting benefit are consid- controlled study showed no benefit of using echinacea for ered flawed in methodology. For example, although some preventing the common cold or respiratory infection. Thus, there is no convincing evidence that echi- Nursing Process nacea is effective. Moreover, the purity and potency of echinacea products are unknown or variable among prod- Assessment ucts. Vitamin C, usually in large doses of more than 1000 mg • With nasal congestion, observe for decreased ability to daily, is used to reduce the incidence and severity of colds breathe through the nose. However, such usage is not recommended or the amount, color, and thickness. In general, high doses of vitamin C the duration and extent of nasal congestion and factors that demonstrate little or no benefit in shortening the duration of precipitate or relieve the symptom. In addition, they may CHAPTER 49 NASAL DECONGESTANTS, ANTITUSSIVES, AND COLD REMEDIES 733 PRINCIPLES OF THERAPY • With coughing, a major assessment factor is whether the cough is productive of sputum or dry and hacking. If the Drug Selection and Administration cough is productive, note the color, odor, viscosity, and amount of sputum. Single-drug formulations allow flexibility and individ- ualization of dosage, whereas combination products Nursing Diagnoses may contain unneeded ingredients and are more expen- • Risk for Injury related to cardiac dysrhythmias, hyper- sive. However, many people find combination products tension, and other adverse effects of nasal decongestants more convenient to use. With nasal decongestants, topical preparations (ie, nasal • Deficient Knowledge: Appropriate use of single- and solutions or sprays) are often preferred for short-term multi-ingredient drug formulations use. They are rapidly effective because they come into direct contact with nasal mucosa. If used longer than Planning/Goals 7 consecutive days or in excessive amounts, however, the client will: these products may produce rebound nasal congestion. Oral agents are • Avoid overuse of decongestants usually contraindicated because of cardiovascular • Avoid preventable adverse drug effects effects (eg, increased force of myocardial contraction, • Act to avoid recurrence of symptoms increased heart rate, increased blood pressure). Antihistamines are clearly useful in allergic condi- Interventions tions (eg, allergic rhinitis; see Chap. First gen- the incidence and severity of symptoms: eration antihistamines (eg, chlorpheniramine, diphen- • Avoid smoking cigarettes or breathing secondhand smoke, hydramine) have anticholinergic effects that may when possible. Cigarette smoke irritates respiratory tract reduce sneezing, rhinorrhea, and cough. Also, their mucosa, and this irritation causes cough, increased secre- sedative effects may aid sleep.

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It is ✔ Notify your physician if you become pregnant or intend to helpful to write the date opened and the expiration date become pregnant during therapy purchase accutane 10mg without a prescription acne 2007. The sprinkle capsule may be opened and the contents sprinkled on soft food for administration 5mg accutane with mastercard acne around nose. The Self-administration syrup formulation may be diluted in water or milk but ✔ Take most antiseizure medications with food or a full glass should not be mixed in carbonated beverages order accutane 5mg with visa acne care. This will prevent or decrease nausea, vomiting, ✔ Swallow tablets or capsules of valproic acid (Depakene and gastric distress, which are adverse reactions to most or Depakote) whole; chewing or crushing may cause irri- of these drugs. Do not switch from a generic to Dilantin, or vice versa, ✔ If taking lamotrigine, notify the physician immediately if a without discussing with the prescribing physician. CHAPTER 11 ANTISEIZURE DRUGS 193 comply with the prescribed regimen and attain seizure How Can You Avoid This Medication Error? The nurse holds all medica- drug (monotherapy) is recommended when possible. If tions, including her antiseizure medication, which is usually taken effective in controlling seizures, monotherapy has the ad- at midnight and 6 AM. If the first drug, in adequate dosage, fails to control seizures or causes unacceptable ad- verse effects, then another agent should be tried as PRINCIPLES OF THERAPY monotherapy. Most practitioners recommend sequen- tial trials of two to three agents as monotherapy before Therapeutic Goal considering combination therapy. When substituting one AED for another, the second Drug therapy is the main treatment of epilepsy for clients of all drug should be added and allowed to reach therapeutic ages. The goal is to control seizure activity with minimal ad- blood levels before the first drug is gradually decreased verse drug effects. In most clients, treatment with a single AED is substituting oxcarbazepine for carbamazepine or vice sufficient to meet this goal. In 20% to 30% of clients, however, versa, because the drugs are similar. In general, combination ther- When monotherapy is ineffective, a second, and some- apy is associated with more severe adverse effects, interactions times a third, drug may be added. Dosage forms may increase seizure control, client con- diagnosis is essential before drug therapy is started. For example, extended re- general, AEDs with activity against both partial-onset lease or long-acting dosage forms can maintain more and generalized seizures include lamotrigine, leve- consistent serum drug levels and decrease frequency of tiracetam, topiramate, valproic acid, and zonisamide. Most of the AEDs are available in oral Drugs considered most useful for partial seizures include tablets or capsules; a few are available as oral liquids carbamazepine, gabapentin, oxcarbazepine, phenobarbi- or injectable solutions. Cost should be considered because this may be a major ethosuximide is the drug of choice; clonazepam and factor in client compliance. For mixed seizures, a com- are generally effective and better tolerated than older bination of drugs is usually necessary. Most of these agents are approved for com- other factors, may vary among pharmacies and change bination therapy with other AEDs in clients whose over time. However, the following list of costs per seizures are not adequately controlled with a single month allow comparisons among AEDs and may be drug. Oxcarbazepine is approved for monotherapy of useful in clinical practice. Costs of older drugs are carbe- partial seizures; some of the other drugs are also thought mazepine ($54 to $81), ethosuximide ($105 to $158), to be effective as monotherapy. Adverse drug effects may be the deciding factor in valproate ($80 to $280). Costs of newer drugs are choosing an AED because most types of seizures can gabapentin ($139 to $354), lamotrigine ($196 to $289), be treated effectively by a variety of drugs. The use of levetiracetam ($105 to $315), oxcarbazepine ($97 to carbamazepine and valproic acid increased largely be- $358), tiagabine ($99 to $190), topiramate ($88 to $354), cause they cause less sedation and cognitive and psycho- and zonisamide ($100 to $201). Most of the newer AEDs reportedly cause uninsured clients, choosing less expensive drug ther- fewer adverse effects and are better tolerated than the apy regimens. In general, infants exposed to one AED have a significantly higher Nursing Notes: Apply Your Knowledge risk of birth defects than those not exposed and infants exposed to two or more AEDs have a significantly You are a nurse working in a clinic. His seizures have been well controlled on Drug Dosage phenytoin (Dilantin) 300 mg hs. The dosage of most drugs is determined empirically by ob- servation of seizure control and adverse effects. Usually, larger doses are needed for a single drug than for multiple drugs; for people with a large body mass 2. Periodic measurements of serum drug levels are rec- (assuming normal liver and kidney function); and in ommended, especially when multiple AEDs are being cases involving trauma, surgery, and emotional stress. Smaller doses are usually required when liver disease with particular drug dosages, seizure control, or ad- is present and when multiple drugs are being given. For most drugs, initial doses are relatively low; doses in relation to clinical responses because there are wide are gradually increased until seizures are controlled or variations among clients receiving similar doses, prob- adverse effects occur. Then, doses may be lowered to ably owing to differences in hepatic metabolism. In the minimum effective level, to decrease adverse ef- other words, doses should not be increased or decreased fects. Adverse effects are more likely to occur during solely to maintain a certain serum drug level. In addi- initiation of treatment and, if treatment is started too tion, the timing of blood samples in relation to drug ad- aggressively, clients may be unwilling to continue a ministration is important. For routine monitoring, blood particular medication even if doses are reduced in samples should generally be obtained in the morning, amount or frequency of administration. Several antiseizure drugs have the potential for caus- dosage of the one being added is gradually increased ing blood, liver, or kidney disorders. For this reason, it while the one being discontinued is gradually decreased. When fosphenytoin is substituted for oral phenytoin, the causes include incorrect diagnosis of the type of seizure, same total daily dosage (in PE) may be given IV or IM. For patients receiving carbamazepine or oxcarbazepine drug dosage, and too-frequent changes or premature therapy, either agent may be substituted for the other withdrawal of drugs. Additional causes may include drug without gradual reduction or titration of the dose. For overdoses (eg, theophylline) and severe electrolyte most patients, the equivalent oxcarbazepine dosage is imbalances (eg, hyponatremia) or use of alcohol or 50% higher than the carbamazepine dosage. Duration and Discontinuation of Therapy Antiseizure drug therapy may be discontinued for some Monitoring Antiepileptic Drug Therapy clients, usually after a seizure-free period of at least 2 years. The effectiveness of drug therapy is evaluated primar- drugs should be discontinued, studies indicate that medica- ily by client response in terms of therapeutic or adverse tions can be stopped in approximately two thirds of clients effects. CHAPTER 11 ANTISEIZURE DRUGS 195 Advantages of discontinuation include avoiding adverse drug CNS and cause drowsiness, their combination with any other effects and decreasing costs; disadvantages include recur- CNS depressant drugs may cause excessive sedation and other rence of seizures, with possible status epilepticus. They may also decrease the effects of drugs cannot be stopped completely, periodic attempts to de- numerous other drugs, mainly by inducing drug-metabolizing crease the number or dosage of drugs are probably desirable enzymes in the liver. Discontinuing drugs, chang- drugs are metabolized and eliminated more quickly.

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HERBAL OR DIETARY In women purchase cheap accutane on line skin care heaven, danazol (Danocrine) may be used to prevent or SUPPLEMENTS treat endometriosis or fibrocystic breast disease buy genuine accutane on line skin care 1 month before marriage. Anabolic steroids are more often abused for body-building purposes Androstenedione and DHEA order 30 mg accutane with mastercard anti-acne, androgens produced by the than used for therapeutic effects. They are marketed as safe, natural, alter- cancer and some types of anemia as indications for use, an- native androgens for building muscles. These products, which drogens have largely been replaced by newer drugs for these have weak androgenic activity, act mainly as precursors for purposes. In breast cancer, for example, androgens are second- the production of sex hormones. Androstenedione, for exam- line hormonal agents, after anti-estrogens (eg, tamoxifen). In ple, may be converted to testosterone by way of an enzyme anemia associated with renal failure, synthetic erythropoietin found in most body tissues. In one study, young men with normal serum testosterone levels were given Contraindications to Use an androstenedione supplement for 8 weeks. The researchers found little effect on serum testosterone levels or muscle de- Androgens and anabolic steroids are contraindicated during velopment with resistance training. They also found in- pregnancy (because of possible masculinizing effects on a fe- creased serum levels of estrone and estradiol, which indicate male fetus), in clients with preexisting liver disease, and in men that a significant proportion of the androstenedione was con- with prostate gland disorders. Thus, taking a supplement for masculin- may have additional enlargement, and men with prostatic can- izing effects may produce feminizing effects instead. Although not contraindi- DHEA is available alone as oral capsules or tablets and in cated in children, these drugs must be used very cautiously and a topical cream with vitamins and herbs. Most DHEA prod- Drugs at a Glance: Androgens Routes and Dosage Ranges Generic/Trade Name Hypogonadism Other Testosterone cypionate (Depo-Testosterone) IM 50–200 mg every 2–4 wk Testosterone enanthate (Delatestryl) IM 50–200 mg every 2–4 wk Testosterone gel (Androgel 1%) 5 g (50 mg of drug) once daily to skin of shoulders and upper arms or abdomen Testosterone pellets SC 150–450 mg every 3–6 mo Delayed puberty, SC lower dosage range, for a limited duration (eg, every 3 mo for 2–3 doses) Testosterone transdermal systems Apply two Androderm systems (dose of 5 mg) (Androderm, Testoderm) nightly to back, abdomen, upper arm or thigh; apply Testoderm (one 6-mg system) to scrotal sac daily Testolactone (Teslac) Breast cancer: PO 250 mg four times daily Fluoxymesterone (Halotestin) PO 5–20 mg daily Methyltestosterone (Methitest, others) Cryptorchidism: PO 30 mg daily; buccal tablets, 15 mg daily Danazol (Danocrine) Endometriosis: PO 800 mg daily in two divided doses for 3–9 mo Fibrocystic breast disease: PO 100–400 mg daily in two divided doses for 3–6 mo IM, intramuscular; PO, oral. CHAPTER 29 ANDROGENS AND ANABOLIC STEROIDS 429 ucts of plant origin are produced in Europe and China. They • Noncompliance: Overuse of drugs or dietary supplements are marketed with numerous claims for health benefits, in- • Risk for Injury: Liver disease and other serious adverse cluding inhibition of aging, atherosclerosis, cancer, diabetes drug effects mellitus, and osteoporosis. A few small human studies have been done, most of which used a dose of 50 mg daily. Overall, there Planning/Goals is no conclusive evidence that DHEA supplementation will the client will: prevent or treat such conditions. In addition, long-term effects • Use the drugs for medical purposes only in humans are unknown. Clients older than identified as being at risk (eg, athletes, especially weight 40 years of age should be aggressively screened for hormonally lifters and football players) sensitive cancers before taking DHEA. Whether large doses of the OTC products can produce some of the serious side effects associated with standard anabolic steroids is unknown. Nursing Process • Participate in school or community programs to inform children, parents, coaches, athletic trainers, and others of Assessment the risks of inappropriate use of androgens, anabolic steroids, and related dietary supplements. Before drug therapy is started, clients need a thorough his- tory and physical examination. Evaluation • Assess for conditions in which androgens are used (eg, de- • Interview and observe for compliance with instructions ficiency states). These may be elevated by retention of sodium and water with resultant PRINCIPLES OF THERAPY edema, especially in clients with congestive heart failure. Duration of Therapy • For children, check x-ray reports of bone growth status ini- tially and approximately every 6 months while the drugs Drug therapy with androgens may be short or long term, are being taken. Nursing Diagnoses Effects of Androgens and Anabolic • Disturbed Body Image related to masculinizing effects Steroids on Other Drugs and menstrual irregularities • Deficient Knowledge: Physiologic and psychological Androgens may increase effects of cyclosporine and warfarin, consequences of overuse and abuse of the drugs to enhance apparently by slowing their metabolism and increasing their athletic performance concentrations in the blood. These combinations should be 430 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM CLIENT TEACHING GUIDELINES Androgens General Considerations ✔ Place the tablet between the cheek and gum and ✔ Take the drugs only if prescribed and as prescribed. Rotate sites, with 7 days between appli- ✔ Practice frequent and thorough skin cleansing to de- cations to a site. Wash hands after application and allow sites to ✔ For buccal preparations: dry before dressing. However, if required, serum creatinine and Use in Children cyclosporine levels should be monitored with cyclosporine and prothrombin time or international normalized ratio (INR) with the main indication for use of androgens is for boys with es- warfarin. Because the drugs cause epiphyseal Androgens also increase effects of sulfonylurea anti- closure, hands and wrists should be x-rayed every 6 months diabetic drugs. If required, smaller doses of sulfonylureas may be needed, Stimulation of skeletal growth continues for approximately blood glucose levels should be monitored closely, and clients 6 months after drug therapy is stopped. Danazol in- occurs (precocious sexual development, enlarged penis), the hibits metabolism of carbamazepine and increases risks of drug should be stopped. Scrupulous skin care and other antiacne treatment may be needed, especially in adolescent boys. Use in Older Adults Nursing Notes: Ethical/Legal Dilemma the main indication for use of androgens is a deficiency state in men. Older adults often have hypertension and other cardio- After you discussed the dangers of using anabolic steroids with the vascular disorders that may be aggravated by the sodium and wrestling team, one of the young second-string players comes to water retention associated with androgens and anabolic you to discuss his friend. In men, the drugs may increase prostate size and in- wrestlers on the team and he suspects that his dramatic athletic im- terfere with urination, increase risk of prostatic cancer, and provement over the last year has been because he has used ana- cause excessive sexual stimulation and priapism. Androgens and anabolic steroids are contraindicated in clients Reflect on: with preexisting liver disease. Drug-induced jaundice is reversible when the solve how he might handle the situation? CHAPTER 29 ANDROGENS AND ANABOLIC STEROIDS 431 NURSING Androgens and Anabolic Steroids ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Give intramuscular preparations of testosterone, other an- drogens and anabolic steroids deeply, preferably in the gluteal muscle. With transdermal systems: Correct site selection and application are necessary for therapeu- tic effects. Clients may prefer self-applica- abdomen, once daily, preferably in the morning. Skin should be clean, dry, and intact; hands should be washed after application; and showering and swimming should be avoided for at least 1 hour and preferably 4 to 6 hours after application. When the drug is given for hypogonadism, observe for mas- culinizing effects, such as growth of sexual organs, deepening of voice, growth of body hair, and acne. When the drug is given for anabolic effects, observe for in- creased appetite, euphoria, or statements of feeling better. Virilism or masculinizing effects: (1) In adult men with adequate secretion of testosterone— priapism, increased sexual desire, reduced sperm count, and prostate enlargement (2) In prepubertal boys—premature development of sex organs and secondary sexual characteristics, such as en- largement of the penis, priapism, pubic hair (3) In women—masculinizing effects include hirsutism, deepening of the voice, menstrual irregularities b. Edema More likely in clients who are elderly or who have heart or kidney disease d.

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