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As a result of these bewildering products order super levitra 80mg online impotence natural treatments, tinue to be used and some people report beneficial effects buy 80 mg super levitra amex erectile dysfunction doctors in san fernando valley, 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.

Therapy may be limited to a short list of and shying away from paternalism buy super levitra 80 mg on line erectile dysfunction doctor miami. Patients and families must come to un- tional outcome measures such as the FIM purchase 80 mg super levitra thyroid erectile dysfunction treatment. The cilities often ask their patients about satisfac- ethical challenge for the providers of therapies tion with their experiences. Table 5–1 poses is to come to an agreement with the client some commonly asked questions of patients at about realistic medical, functional, and quality- the time of discharge from inpatient care that of-life goals. Agreement is especially important also get at the responsibilities of each member since the team, not the patient and family of the team. This decision is individual leadership must be taken to manage often made under some pressure by the health the medical, neurophysiologic, functional, cog- care insurer to halt services that are not med- nitive, psychologic, social, educational, and vo- ically necessary. Studies of inpatient stroke rehabilitation sup- port the approach primarily as an efficient means to organize services for patients with PHYSICIANS functional disabilities. Sample Patient Satisfaction Questions for Inpatient Rehabilitation Answered on a Likert Scale 1. Did the program enable you to take better care of yourself and train the family in your care? He had his ataxic patients, primary care doctor the indications for med- many with tabes dorsalis, practice upper ex- ications, measures for secondary prevention of tremity coordination and walking tasks and in- complications, management of risk factors for corporated parallel bars into gait training. His recurrence or exacerbation of the disease, and methods gained adherents in the United the type and duration of rehabilitative inter- States9 and led to the first hospital gymnasium ventions. In a study of disagreements between at the Salpétrière in Paris, the most famous physicians and patients about their encounters, neurology department of its day. Physiatrists evolved from the need for so that patients can obtain equipment, services, a rehabilitation discipline after World War II and pertinent disability reports. Thus, cilitators of the team, especially on an inpatient from their roots in syphilis, polio, and war- service. Here, the physician leads a weekly related trauma, neurologists and physiatrists are team conference that reviews the progress of most likely to participate with an inpatient team. The conference allows the team Physicians are especially responsible for antic- to share notes and thoughts about each patient ipating and managing the medical complica- and to solve lingering problems. A physician tions and rehabilitation needs of their patients leader articulates, mobilizes, and persuades the (see Chapter 8). In addition, physicians who patient, family, and team of therapists toward specialize in neurologic rehabilitation educate goals that they come to share. Team meetings and journal clubs with pain and disability and the present degree may be used to discuss new and relevant re- of disability. These issues include interference impairments will affect rehabilitation potential. Is in- functional activities, physical fitness, mood, somnia associated with anxiety or depression, and lifestyle. These elements will impact reha- a noisy roommate, and pain at rest or with cer- bilitation care and goal-setting. Although neuroimaging point to a urinary tract infection, phlebitis or studies cannot themselves predict impairments aspiration, as well as caloric and fluid intake, and prognosis, tests such as computerized to- short-term therapy goals, how the patient and mography (CT) and magnetic resonance imag- family are coping with unexpected burdens, ing (MRI) offer useful insights. During daily rounds, the physician that reveals an old, silent lacuna in the right encourages patients to spend more time out of basis pontis, however, offers insight into the bed, reiterates specific exercises for improving cause of a pseudobulbar palsy and alters the endurance, motor control, and skills that can prognosis. Families and people with neurologic dis- pably tender musculoligamentous tissue cause eases are quick to check for experimental and pain or limit movement? Does a medication or alternative treatments on the Internet and in episodic orthostatic hypotension lessen atten- articles. The physician needs to put animal re- tion span and endurance for exercise? Is hy- search results, ongoing clinical trials, uncon- ponatremia or anemia having negative clinical trolled use of substances that include much consequences? Does a muscle group show in- hype by the seller, and alternative medicine ap- creased paresis with a few repetitive contrac- proaches into perspective. Nor does the com- problems related only to the cerebral injury, or pulsive clinician ever disregard the insights of does a metabolic abnormality, a medication or, the rest of the team. A modest decline in at- in an older person, an underlying dementia tention span or exercise tolerance noted by the 218 Common Practices Across Disorders speech therapist or occupational therapist may should insist on definable interventions.

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He had found a system that worked for him—giving a diagnosis safe 80 mg super levitra erectile dysfunction pills at gas stations, no matter how far-fetched purchase super levitra 80 mg without prescription erectile dysfunction blood pressure medications side effects, was for him the best way to handle these patients with multiple symptoms. Diagnoses Without Diseases 35 Fortunately, I could avoid the conflict with Dr. He soon returned to his practice, and I had accepted an appointment on the faculty at the University of Alabama at the School of Medi- cine in Birmingham. Returning to academic medicine for me was like oxygen to a winded runner or water to a man lost in a desert. Teaching and see- ing complex clinical problems was what I wanted to do. My official job at the School of Medicine at the University of Alabama was to run the N. Clinical Research Center, set up a system to review research applications, and provide clinical care and oversight to the patients in the research center. I spent most of my time teaching medical students, residents, and fellows in endo- crinology and seeing patients referred to the medical center with possible endocrine problems. Tere were only four trained endocrinologists in the entire state of Alabama, and we were all at the medical center in Birming- ham. Together we saw examples of every conceivable endocrine disease known at that time. Tere was no such specialty then as pediatric endocrinology, so we saw the full spectrum of life—ba- bies, children, and adults. Within a few years, I had seen examples of not only every recognized endocrine disorder but also nearly every known variation. Tis was the era when subspecialists ex- isted only in large academic medical centers. In the years to follow, other endocrinologists moved into clinical practice and built their own private practices, eventually diluting the population that was referred to the medical center. Endocrinology was one of the first specialties in medicine to become truly scientific. We lived during the transition from urine measurements using animal/mice assays, or analyses, to very precise direct measurements of hormones in blood. Te advent of highly sensitive radioimmunoassays and paper chromatography expanded our ability to measure very small quantities of nearly ev- ery hormone. Tese new tools allowed us to measure at the nano- gram level, an astounding nine decimal places out from one gram— 0. In a short time, the exact definitions for diagnosing low and high levels of hormones were rewritten. Making a diagnosis of an endocrine disorder became extraor- dinarily precise. We could measure not only the level of hormones but also the pituitary-stimulating hormones that regulated many of the hormone levels and secretions. Te negative feedback system then permitted extremely refined definitions of excesses or defi- ciencies of the major hormones. Excesses shut off, and deficien- cies produced, high levels of the pituitary-stimulating hormones. Medicine could not get too scientific for me, and I was living and practicing on the cutting edge of clinical science. As we took these new ideas and tools out into our talks to the county medical societies, our referral practice at the medical cen- ter mushroomed. As soon as we described and taught the doctors across the state what to look for, we began to see referred examples in Birmingham. We began to publish reports of individual cases, collections of patients, and unusual examples of the various endo- crine disorders. Along with all the endocrine and metabolic disorders we saw in the referred patients, there was a steady stream of patients who had no endocrine or metabolic disorder.

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Similarly buy 80 mg super levitra with amex impotence world association, decreased elimination by the liver and should be used cautiously discount 80 mg super levitra with visa thyroid causes erectile dysfunction. Tiagabine is cleared more slowly in kidneys may lead to drug accumulation, with subsequent risks clients with liver impairment. Increased plasma levels of un- of dizziness, impaired coordination, and injuries due to falls. For example, with carbamazepine, they may duced or given at less frequent intervals. Topiramate may also develop hyponatremia, especially if they also take sodium- be cleared more slowly even though it is eliminated mainly losing diuretics (eg, furosemide, hydrochlorothiazide), or through the kidneys and does not undergo significant hepatic cardiac dysrhythmias, especially if they have underlying metabolism. With valproic acid, older adults may develop cated with levetiracetam, oxcarbazepine, or zonisamide. The tremor is often dose-related and reverses when Use in Critical Illness the drug is reduced in dosage or discontinued. Most of these potential problems can be averted or mini- Phenytoin is often used to prevent or treat seizure disorders in mized by using AEDs very cautiously in older adults. Pheny- general, small initial doses, slow titration to desired doses, toin therapy can best be monitored by measuring free serum and small maintenance doses are needed. Using controlled- phenytoin concentrations, but laboratories usually report the release formulations, when available, to minimize peak plasma total serum drug concentration. In addition, frequent phenytoin level may still be therapeutic and a dosage increase assessment of clients for adverse effects and periodic moni- is not indicated. The occurrence of nystagmus (abnormal toring of serum drug levels, liver function, and kidney function movements of the eyeball) indicates phenytoin toxicity; the are indicated. Because phenytoin is extensively metabo- lized in the liver, clients with severe illnesses may metabolize Use in Renal Impairment the drug more slowly and therefore experience toxicity. For clients in critical care units for other disorders, a his- Phenytoin is often used to prevent or treat seizure disorders tory of long-term AED therapy may be a risk factor for in seriously ill clients. With renal impairment, protein bind- seizures, including status epilepticus, if the drug is stopped ing is decreased and the amount of free, active drug is higher abruptly. At the same time, continuing an AED may compli- than in clients with normal renal function. The use of phe- cate drug therapy of other conditions because of adverse CHAPTER 11 ANTISEIZURE DRUGS 197 effects and potential drug–drug interactions. For example, dosage and determine whether the chosen drug is effective in phenytoin decreases the effects of dopamine, a drug often controlling seizures. The nurse can play an important role by used to treat hypotension and shock in critical care units. In clinical assessment of the client, interviewing the family addition, phenytoin decreases ventricular automaticity and about the occurrence of seizures (a log of date, time, duration, should not be used in critically ill clients with sinus brady- and characteristics of seizures can be very helpful), ensuring cardia or heart block. With long-term use of the drugs, the nurse Home Care must monitor the client for therapeutic and adverse drug effects, especially with changes in drugs or dosages. With any evi- The home care nurse must work with clients and family dence that the client is not taking medication as directed, the members to implement and monitor AED therapy. When an nurse may need to review the potential loss of seizure control AED is started, a few weeks may be required to titrate the and potential for status epilepticus. NURSING Antiseizure Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Give most oral antiseizure drugs after meals or with a full Most antiseizure drugs cause some gastric irritation, nausea, or glass of water or other fluid; levetiracetam, oxcarbazepine, top- vomiting. Taking the drugs with food or fluid helps decrease gastro- iramate, and zonisamide may be taken with or without food. To give phenytoin: (1) Shake oral suspensions of the drug vigorously before In suspensions, particles of drug are suspended in water or other pouring and always use the same measuring equipment. Shaking the container is necessary to distribute drug parti- cles in the liquid vehicle. If the contents are not mixed well every time a dose is given, the liquid vehicle will be given initially, and the concentrated drug will be given later. That is, underdosage will occur at first, and little if any therapeutic benefit will result. Over- dosage will follow, and the risks of serious toxicity are greatly in- creased. Calibrated medication cups or measuring teaspoons or tablespoons are acceptable.

An electromechani- Accessible Telecommunications generic super levitra 80mg amex erectile dysfunction medicine name in india, Information and cal gait trainer for restoration of gait in hemiparetic Healthcare Technologies: IEEE Press discount super levitra 80 mg with visa erectile dysfunction remedies pump, 2002. Biol Cybern 1991; 65:147– environment training improves motor performance in 159. PART II COMMON PRACTICES ACROSS DISORDERS Chapter 5 The Rehabilitation Team THE TEAM APPROACH designations mean something different in The Rehabilitation Milieu every program of inpatient or outpatient care. PHYSICIANS Intensive does not imply a particular intensity Responsibilities of practice. Intensive may mean that a patient Interventions is assigned to 3 hours a day with therapists. In NURSES reality, the patient may actively participate in Responsibilities therapy for considerably less time. Compre- Interventions hensive may mean that most disciplines are PHYSICAL THERAPISTS represented, not that their activities aim to re- Responsibilities store a broad range of functions. To the pa- Interventions for Skilled Action tient, comprehensive care may mean satisfying OCCUPATIONAL THERAPISTS all health-related needs. Responsibilities Inpatient and outpatient therapy are con- Interventions for Personal Independence strained by the costs of care. The duration and SPEECH AND LANGUAGE THERAPISTS intensity of rehabilitation is also constrained by Responsibilities the ability of a therapist or a team to articulate Interventions for Dysarthria and Aphasia the value of continuing to work on an aspect NEUROPSYCHOLOGISTS of disability and to offer an evidence-based SOCIAL WORKERS practice to enhance gains. The length of inpa- RECREATIONAL THERAPISTS tient rehabilitation stays has been declining in OTHER TEAM MEMBERS the United States since 1985. This trend may SUMMARY continue with the institution of a Prospective Payment System under Medicare and Medic- aid (www. The oppor- and personal needs, require a team of profes- tunities to offer patients therapy beyond lim- sionals who partner in inpatient and outpatient ited compensatory skills for basic activities of settings. I will refer to the team of rehabilita- daily living (ADLs) depends upon research that tion specialists, such as nurses, physical thera- demonstrates evidence-based interventions. To- THE TEAM APPROACH gether, they practice the experiential art and science of the possible. In a Rehabilitationists provide what many pro- multidisciplinary model, each member with grams call intensive and comprehensive neu- specialty training treats particular disabilities. For example, training procedures for health care goals still take a back seat in most motor and cognitive learning or behavioral deliberations. Rehabilitationists, in contrast, modification are reinforced by all members, us- seek both short-term and long-term goals that ing agreed upon strategies. Patients come to be understood in the con- the impediments to a return to a usual role in text of their cultures and values, their senses, daily life activities. In the medical model, team as a group and of its member specialists the physician controls the action and nearly all depends more on interpersonal and interpro- communication with a patient. The patient pas- fessional skills than on a specific model of in- sively awaits amelioration or cure. Rehabilitation services are not a col- professionals play limited, transient roles. Just as tension ing rehabilitation, an imperious physician may exists between the elements of harmony, do harm by failing to listen and to act upon the melody, and rhythm in the structure of a jazz concerns and strategies of the team and the composition, tensions within the elements of client. Rehabilitation of patients, humility, humor, perseverance, services try to quell the anxieties associated creative thinking, and hypothesis-making and with a sudden, debilitating illness and its threat testing. Everyone performs in real time and of death or permanent loss of functional inde- each performance challenges the members of pendence. The team can help patients break a team to play the role that best brings out the from this terrifying link by educating them and mode of learning and cooperation best suited by sharing stories of their own lives and the to each patient. Most important to the team lives of other patients who recovered and re- approach, patients and their families are con- turned home after rehabilitation. A repository of life ex- periences and intuitions from meeting chal- The rehabilitation team helps its clients artic- lenges in the past resides in every patient. The life stories of peo- ers who serve as caregivers play a critical col- ple also offer new textures in a familiar world laborative role in setting and revamping goals that help rehabilitation clinicians enjoy their and in carrying out supportive and therapeutic work and empathize with their clients. Patients must be taught that their team must also monitor how patients see them- active participation drives the possibility of selves through the course of rehabilitation and gains. Rehabilitationists do not possess holy wa- how spouses and other caregivers view them. Reading and discussing stories The Rehabilitation Team 215 from the literature of medicine, from the per- best serve short-term functional goals and on- spectives of patients, families, doctors, and oth- going medical and rehabilitative care pose ers, can help the team examine and find a con- complex design problems.

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