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Iron prepara- These women may revert to a nondiabetic state when tions should be given with food to decrease gastric irritation extra super viagra 200 mg on line erectile dysfunction age at onset. A third type is megaloblas- ment of overt diabetes within 5 to 10 years discount extra super viagra 200mg fast delivery erectile dysfunction doctors naples fl. Nausea and Vomiting Constipation Nausea and vomiting often occur, especially during early preg- Constipation often occurs during pregnancy, probably from nancy. Dietary management (eg, eating a few crackers when decreased peristalsis. Preferred treatment, if effective, is to awakening and waiting a few minutes before arising) and increase exercise and intake of fluids and high-fiber foods. Meclizine, 25 to 50 mg daily, and dimenhydrinate, (eg, docusate) or an occasional saline laxative (eg, milk of 50 mg every 3 to 4 hours, are thought to have low teratogenic magnesia) may also be used. If used, rec- because it interferes with absorption of fat-soluble vitamins. Castor oil should be avoided because it can cause Pregnancy-Induced Hypertension uterine contractions. Strong laxatives or any laxative used in excess may initiate uterine contractions and labor. Pregnancy-induced hypertension includes preeclampsia and eclampsia, conditions that endanger the lives of mother and fetus. Preeclampsia is most likely to occur during the last Gastroesophageal Reflux Disease 10 weeks of pregnancy, during labor, or within the first Gastroesophageal reflux disease (GERD), of which heartburn 48 hours after delivery. It is manifested by edema, hypertension, (pyrosis) is the main symptom, often occurs in the later and proteinuria. It develops when increased abdominal or labetalol for blood pressure control and magnesium sulfate pressure and a relaxed esophageal sphincter allow gastric for prevention or treatment of seizures. Eclampsia, charac- acid to splash into the esophagus and cause irritation, dis- terized by severe symptoms and convulsions, occurs if pre- comfort, and esophagitis. Delivery of the fetus is the Nonpharmacologic interventions include eating small only known cure for preeclampsia or eclampsia. For women meals; not eating for 2 to 3 hours before bedtime; avoiding at risk of developing preeclampsia, aspirin 60 mg daily, from caffeine, gas-producing foods and constipation; and sitting in 24 to 28 weeks of gestation until onset of labor, may be used an upright position. During late pregnancy, urinary tract fetus, and the hormonal changes of pregnancy have diabeto- infections (UTIs) or amnionitis may occur. Some delivery, endometritis, bacteremia, or wound infection may women first show signs of diabetes during pregnancy (gesta- occur. Still others, already insulin dependent, are tion with group B streptococci, pregnant women should have likely to need larger doses as pregnancy advances. For biotics given at this time may not provide coverage during diabetic women who become pregnant, maintaining normal labor and delivery. Treatment should be initiated during labor, or near-normal blood sugar levels is required for successful often with ampicillin 2 g intravenously (IV) as a loading dose, outcomes because poor glycemic control increases the risks then 1 g IV every 4 hours until delivery. Recommendations for management include Human immunodeficiency virus (HIV) infection and ac- the following: quired immunodeficiency syndrome (AIDS) can be trans- • If oral antidiabetic drugs are taken by a woman of child- mitted to the fetus and neonate, and treatment is needed to bearing potential, they should be discontinued before reduce transmission. Oral zidovudine (AZT) monotherapy conception, if possible (eg, for a planned pregnancy has been used for several years, after 14 weeks of gestation. After deliv- antidiabetic drugs are contraindicated in pregnancy, ery, the infant should be given AZT for 6 weeks, with or mainly because of fetal hypoglycemia. Increasingly, highly active dation may change in the future, because acarbose, antiretroviral therapy (HAART) is being used for pregnant miglitol, and metformin are thought to have little risk women. Glyburide has been used in some women a nucleoside reverse transcriptase inhibitor (eg, zidovudine, after 11 weeks of gestation. However, its use is not rec- lamivudine, or didansoine), a non-nucleoside reverse tran- ommended during the last few weeks of pregnancy.

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Moreover extra super viagra 200 mg on line impotence after robotic prostatectomy, they are often used concomitantly buy 200 mg extra super viagra with amex erectile dysfunction drugs sales, which ing cases, investigating contacts of newly diagnosed cases, and increases risks of hepatotoxicity. To detect hepatotoxicity as promoting efforts to manage tuberculosis effectively. CHAPTER 38 DRUGS FOR TUBERCULOSIS AND MYCOBACTERIUM AVIUM COMPLEX (MAC) DISEASE 573 NURSING Antitubercular Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Give isoniazid (INH), ethambutol, and rifampin in a single A single dose with the resulting higher blood levels is more effec- dose once daily, twice a week, or 3 times a week. Also, less frequent administration is more convenient for clients and more likely to be completed. Give INH and rifampin on an empty stomach, 1 h before or Food delays absorption. Give parenteral INH by deep IM injection into a large mus- To decrease local pain and tissue irritation. Give IV rifampin by infusion, over 1 to 3 h, depending on For a 600-mg dose, reconstitute with 10 mL sterile water for in- dose and volume of IV solution. Give rifapentine on an empty stomach when possible; may Usually given twice weekly for 2 mo, with 72 h between doses, give with food if GI upset occurs. See drug literature for These drugs are used only to treat TB infection caused by organ- specific instructions. Observe for therapeutic effects Therapeutic effects are usually apparent within the first 2 or 3 wk of drug therapy for active disease. With active disease, observe for clinical improvement (eg, decreased cough, sputum, fever, night sweats, and fatigue; increased appetite, weight, and feeling of well-being; negative sputum smear and culture; improvement in chest radiographs). Nausea, vomiting, diarrhea These symptoms are likely to occur with any of the oral antituber- cular drugs. Neurotoxicity: (1) Eighth cranial nerve damage—vertigo, tinnitus, hear- A major adverse reaction to aminoglycoside antibiotics ing loss (2) Optic nerve damage—decreased vision and color dis- The major adverse reaction to ethambutol crimination (3) Peripheral neuritis—tingling, numbness, paresthesias Often occurs with INH but can be prevented by administering pyridoxine (vitamin B6). Hepatotoxicity—increased serum ALT, AST, and biliru- May occur with INH, rifampin, and pyrazinamide, especially if the bin; jaundice; and other symptoms of hepatitis (eg, anorexia, client already has liver damage. Report these symptoms to the pre- nausea, vomiting, abdominal pain) scribing physician immediately, to prevent possible liver failure and death. Nephrotoxicity—increased blood urea nitrogen and serum A major adverse reaction to aminoglycosides creatinine, cells in urine, oliguria (continued) 574 SECTION 6 DRUGS USED TO TREAT INFECTIONS NURSING ACTIONS RATIONALE/EXPLANATION e. Hypersensitivity—fever, tachycardia, anorexia, and malaise Hypersensitivity reactions are more likely to occur between the are early symptoms. If the drug is not discontinued, exfoliative third and eighth weeks of drug therapy. Early detection and drug dermatitis, hepatitis, renal abnormalities, and blood dyscrasias discontinuation are necessary to prevent progressive worsening of may occur. Miscellaneous—rifampin, rifabutin, and rifapentine can The color change is harmless, but clients should avoid wearing cause: soft contact lenses during therapy. Drugs that increase effects of antitubercular drugs: (1) Other antitubercular drugs Potentiate antitubercular effects and risks of hepatotoxicity. These drugs are always used in combinations of two or more for treat- ment of active tuberculosis. Drugs that increase effects of INH: (1) Alcohol Increases risk of hepatotoxicity, even if use is stopped during INH therapy (2) Carbamazepine Accelerates metabolism of INH to hepatotoxic metabolites and in- creases risk of hepatotoxicity (3) Stavudine Increases risk of peripheral neuropathy; avoid the combination if possible c. Drug that decreases effects of INH: Decreases risk of peripheral neuritis (1) Pyridoxine (vitamin B6) d. Drug that decreases effects of rifampin: (1) Ketoconazole May decrease absorption Nursing Notes: Apply Your Knowledge Review and Application Exercises 1. How do tuberculosis infections differ from other bacte- Answer: First, it is important that you hear Ms.

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How does cardiogenic shock differ from hypovolemic shock purchase 200 mg extra super viagra fast delivery erectile dysfunction my age is 24, and how will this affect management? What symptoms would likely occur when a client is experiencing cardiogenic shock? OVERVIEW Types of Shock Shock is a clinical syndrome characterized by decreased There are three general categories of shock that are based on blood supply to body tissues buy extra super viagra 200 mg without a prescription erectile dysfunction under 40. These mechanisms are the degree of impaired perfusion of vital organs (eg, brain, intravascular volume, the ability of the heart to pump, and heart, and kidneys). Most, but not all, people in shock are hypoten- volume that may be due to actual blood loss or relative loss sive. In a previously hypertensive person, shock may be from fluid shifts within the body. An additional consequence of inadequate blood flow to Distributive or vasogenic shock is characterized by severe, tissues is that cells change from aerobic (oxygen-based) to generalized vasodilation, which results in severe hypotension anaerobic metabolism. Distributive shock is further metabolism leads to generalized metabolic acidosis and even- divided into anaphylactic, neurogenic, and septic shock. In an emergency, the drugs may be used to main- maintains sufficient vascular tone (ie, a small amount of tain adequate perfusion of vital organs until sufficient fluid vasoconstriction) to support adequate blood circulation. Neurogenic shock may occur with depression of the va- Adrenergic drugs with beta activity may be relatively con- somotor center in the brain or decreased sympathetic traindicated in shock states precipitated or complicated by car- outflow to blood vessels. Beta-stimulating drugs also should be used • Septic shock can result from almost any organism that cautiously in cardiogenic shock after myocardial infarction be- gains access to the bloodstream but is most often asso- cause increased contractility and heart rate will increase myo- ciated with gram-negative and gram-positive bacterial cardial oxygen consumption and extend the area of infarction. Individual drugs are described in the following section; in- It is important to know the etiology of shock because man- dications for use and dosage ranges are listed in Drugs at a agement varies among the types. INDIVIDUAL DRUGS ANTISHOCK DRUGS Dopamine is a naturally occurring catecholamine that func- Drugs used in the management of shock are primarily the tions as a neurotransmitter. Dopamine exerts its actions by adrenergic drugs, which are discussed more extensively in stimulating alpha, beta, or dopaminergic receptors, depend- Chapter 18. In this chapter, the drugs are discussed only in ing on the dose being used. In addition, dopamine acts indi- relation to their use in hypotension and shock. In these con- rectly by releasing norepinephrine from sympathetic nerve ditions, drugs with alpha-adrenergic activity (eg, norepi- endings and the adrenal glands. Peripheral dopamine recep- nephrine, phenylephrine) are used to increase peripheral tors are located in splanchnic and renal vascular beds. Some drugs have both accepted that stimulation of dopamine receptors by low alpha- and beta-adrenergic activity (eg, dopamine, epi- doses of exogenous dopamine produces vasodilation in the nephrine). In many cases, a combination of drugs is used, renal circulation and increases urine output. More recent studies indicate that low-dose dopamine enhances renal function only when cardiac function is improved. At doses greater than 3 mcg/kg/min, dopamine binds to beta and alpha TABLE 54–1 Types of Shock receptors and the selectivity of dopaminergic receptors is lost beyond 10 mcg/kg/min. At doses that stimulate beta receptors Clinical Types of Shock Possible Causes Manifestations (3 to 20 mcg/kg/min), there is an increase in heart rate, myo- cardial contractility, and blood pressure. At the highest doses Hypovolemic Trauma Hypotension (20 to 50 mcg/kg/min), beta activity remains, but increasing Gastrointestinal bleed Tachycardia alpha stimulation (vasoconstriction) may overcome its actions. Ruptured aneurysms Cool, clammy skin Third spacing Dopamine is useful in hypovolemic and cardiogenic shock. Diaphoresis Dehydration Pallor Adequate fluid therapy is necessary for the maximal pressor Oliguria effect of dopamine.

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