By T. Dargoth. Irvine University College of Law. 2018.

It may also be systemic and involve other pergillus organisms (80% to 90%) enter the body through the res- organs propranolol 40 mg without prescription, especially the skin and bone generic propranolol 80 mg fast delivery. Skin lesions (eg 80 mg propranolol, pustules buy propranolol 80mg mastercard, piratory system, and pulmonary aspergillosis is acquired by ulcerations, abscesses) may progress over a period of years and inhalation of the spores. Other potential entry sites include dam- eventually involve large areas of the body. Bone invasion, with aged skin (eg, burn wounds, intravenous catheter insertion sites), arthritis and bone destruction, occurs in 25% to 50% of clients. Blastomycosis can occur in healthy people with sufficient ex- Aspergillosis in hospitalized patients has long been attributed posure but is usually more severe and more likely to involve to entry of outside air containing aspergillus spores into hospital multiple organ involvement and CNS disease in immunocom- ventilation systems. However, it infrequently occurs in patients with cused on removing aspergillus spores from the air and preventing HIV infection. Specific recommendations are to place HEPA filters where suppressant drug therapy. Candida organisms are found in soil, on outside air enters patient rooms; position air intake and exhaust inanimate objects, in hospital environments, and in food. In the ports so that room air enters from one side of the room, flows human body, they are found on diseased skin and along the entire across the room, and exits on the opposite side; and maintain room gastrointestinal (GI) tract, in sputum, along the female genital air pressure above that of the corridor so that corridor air cannot tract, and in the urine of patients with indwelling bladder catheters. In addition, monitor filtration systems (eg, regular Most infections arise from the normal endogenous organisms, preventive maintenance and checking of pressures and airflow) often from the GI tract or skin, and are caused by Candida albi- and construct windows, doors, and air entry and exit ports to seal cans. Despite the use of the above measures, the incidence of as- • Oral candidiasis (thrush) is characterized by painless white pergillosis continued to increase and researchers began looking for plaques on oral and pharyngeal mucosa. It often occurs in (continued) 598 SECTION 6 DRUGS USED TO TREAT INFECTIONS BOX 40–1 SELECTED FUNGAL INFECTIONS (Continued) newborn infants who become infected during passage organism-filled cavities in the lung. In a few cases, and adults, thrush may occur as a complication of diabetes severe, disseminated disease occurs, either soon after the primary mellitus, as a result of poor oral hygiene, or after taking an- infection or after years of chronic pulmonary disease. It may also occur as an early nated coccidioidomycosis may produce an acute or chronic menin- manifestation of AIDS. Most clients with primary infection recover a large part of the normal flora of the intestine. The main without treatment; clients with disseminated disease require pro- symptom is diarrhea. The infection may produce who live in endemic areas are highly susceptible to this infection. The organism is difficult to eradicate, and many Cryptococcosis is caused by inhalation of spores of Crypto- women have recurrent infections. They have also been isolated from nonavian also may cause diaper rash and perineal rashes. When cryptococcosis occurs in healthy people, the primary in- • Systemic or invasive candidiasis occurs when the organism fection is localized in the lungs, is asymptomatic or produces mild gets into the bloodstream and is circulated throughout the symptoms, and heals without treatment. However, pneumonia may body, with the brain, heart, kidneys, and eyes as the most com- occur and lead to spread of the organisms by the bloodstream. It often occurs as a nosocomial infec- cryptococcosis occurs in immunocompromised people, it is likely tion in clients with serious illnesses or drug therapies that to be more severe and to become disseminated to the CNS, skin, and suppress their immune systems and may be fatal. People with AIDS are highly susceptible and fections may be present in any organ and may produce such cryptococcosis is the fourth most frequent opportunistic infection in disorders as urinary tract infection, endocarditis, and menin- this population. It is usually diagnosed by positive cultures of blood or Cryptococcal pneumonia in patients with AIDS has a mortality rate tissue. Cryptococcal meningitis, the most common mani- fection and the organs affected. Clinical manifestations include headache, dizziness, and neck cent years, in part because of increased numbers of neutropenic stiffness, and the condition is often mistaken for brain tumor. In addition, the frequent use of symptoms include coma, respiratory failure, and death if the menin- strong, broad-spectrum antibiotics leads to extensive candidal col- gitis is not treated effectively. People who use intravenous chicken houses, bird roosts, and caves inhabited by bats. Exposure drugs also develop invasive candidiasis because the injections in- to spores may result from activities such as demolishing or re- oculate the fungi directly into the bloodstream.

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SELECTED REFERENCES Plan follow-up with Gwen and her family at a later time to Allen buy 80 mg propranolol, D cheap propranolol 80 mg without a prescription. Assess potential triggers that may have contributed to this able: Journal of the American Medical Association buy 80 mg propranolol amex, 285(20) generic propranolol 80mg line, and historical perspective. National Institutes of Health, National Heart, Lung, and Blood Institute, Fulco, P. Leukotriene receptor antagonists in the treatment of cotherapy: A pathophysiologic approach, 5th ed. Clinical considerations in the use of inhaled corti- ticosteroids in patients with persistent asthma: A randomized con- costeroids for asthma. Discuss allergic rhinitis, allergic contact for use, adverse effects, and nursing process dermatitis, and drug allergies as conditions implications. Critical Thinking Scenario You are working at the college health center. John, a freshman, comes to the clinic complaining of seasonal pollen allergies that have worsened significantly since his relocation at college. He has been self-treating with over-the-counter (OTC) medications a friend in the dorms gave him. Antihistamines are drugs that antagonize the action of his- Histamine is discharged from mast cells and basophils in tamine. Thus, to understand the use of these drugs, it is nec- response to certain stimuli (eg, allergic reactions, cellular in- essary to understand histamine and its effects on body tissues, jury, extreme cold). Once released, it diffuses rapidly into characteristics of allergic reactions, and selected conditions other tissues, where it interacts with histamine receptors on for which antihistamines are used. H1 receptors are located mainly on smooth muscle cells in blood vessels and the res- piratory and GI tracts. When histamine binds with these re- HISTAMINE AND ITS RECEPTORS ceptors and stimulates them, effects include: • Contraction of smooth muscle in the bronchi and bron- Histamine is the first chemical mediator to be released in im- chioles (producing bronchoconstriction and respiratory mune and inflammatory responses. It is synthesized and stored distress) in most body tissues, with high concentrations in tissues ex- • Stimulation of vagus nerve endings to produce reflex posed to environmental substances (eg, the skin and mucosal bronchoconstriction and cough surfaces of the eye, nose, lungs, and gastrointestinal [GI] • Increased permeability of veins and capillaries, which tract). In allows fluid to flow into subcutaneous tissues and form these tissues, histamine is located mainly in secretory granules edema 715 716 SECTION 8 DRUGS AFFECTING THE RESPIRATORY SYSTEM • Increased secretion of mucous glands. They and increased nasal mucus produce the nasal congestion produce direct damage to the cell surface. Serum creased secretion of gastric acid and pepsin, increased rate sickness, the prototype of these reactions, occurs when and force of myocardial contraction, and decreased immuno- excess antigen combines with antibodies to form immune logic and proinflammatory reactions (eg, decreased release of complexes. The complexes then diffuse into affected tis- histamine from basophils, decreased movement of neu- sues, where they cause tissue damage by activating the trophils and basophils into areas of injury, inhibited T- and complement system and initiating the inflammatory re- B-lymphocyte function). If small amounts of immune complexes are de- ceptors causes peripheral vasodilation (with hypotension, posited locally, the antigenic material can be phagocytized headache, and skin flushing) and increases bronchial, intesti- and digested by white blood cells and macrophages nal, and salivary secretion of mucus. If large amounts are de- posited locally or reach the bloodstream and become deposited in blood vessel walls, the lysosomal enzymes HYPERSENSITIVITY released during phagocytosis may cause permanent tis- (ALLERGIC) REACTIONS sue destruction. That is, the person is hypersensitive antigen to cause inflammation mediated by release of or allergic to the substance (called an antigen or allergen). Allergic reactions may result from specific antibodies, sen- sitized T lymphocytes, or both, formed during exposure to an antigen. Allergic Rhinitis Allergic rhinitis is inflammation of nasal mucosa caused by a Types of Allergic Reactions type I hypersensitivity reaction to inhaled allergens. It is a very common disorder characterized by nasal congestion, • Type I (also called immediate hypersensitivity because itching, sneezing, and watery drainage. Itching of the throat, it occurs within minutes of exposure to the antigen) is an immunoglobulin E (IgE)-induced response that eyes, and ears often occurs as well. Seasonal disease ample, anaphylaxis is a type I response that may be mild (often called hay fever) produces acute symptoms in response (characterized mainly by urticaria, other dermatologic to the protein components of airborne pollens from trees, manifestations, or rhinitis) or severe and life threaten- grasses and weeds, mainly in spring or fall.

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In ad- Histamine-2 Receptor dition discount 40mg propranolol with mastercard, ranitidine causes fewer drug interactions than cimeti- Antagonists (H2RAs) dine generic 40mg propranolol overnight delivery. Oral ranitidine reaches peak blood levels 1 to 3 hours after administration cheap propranolol 40mg without a prescription, and is metabolized in the liver; approx- Histamine is a substance found in almost every body tissue imately 30% is excreted unchanged in the urine buy propranolol 40 mg with visa. Parenteral and released in response to certain stimuli (eg, allergic reac- ranitidine reaches peak blood levels in about 15 minutes; CHAPTER 60 DRUGS USED FOR PEPTIC ULCER AND ACID REFLUX DISORDERS 873 65% to 80% is excreted unchanged in the urine. Famotidine Omeprazole, esomeprazole, lansoprazole, pantoprazole, and nizatidine are similar to cimetidine and ranitidine. Omeprazole was the first Compared with cimetidine, the other drugs cause similar and is still widely used. It is well absorbed after oral adminis- effects except they are less likely to cause mental confusion tration, highly bound to plasma proteins (about 95%), metab- and gynecomastia (antiandrogenic effects). In addition, they olized in the liver, and excreted in the urine (about 75%) and do not affect the cytochrome P450 drug-metabolizing system bile or feces. Acid-inhibiting effects occur within 2 hours and in the liver and therefore do not interfere with the metabolism last 72 hours or longer. Omeprazole (Prilosec) Proton Pump Inhibitors is expected to be approved for over-the-counter sales for treat- ing heartburn. If heartburn is not improved within 14 days of PPIs are strong inhibitors of gastric acid secretion. These treatment, clients should be evaluated by their health care drugs bind irreversibly to the gastric proton pump (ie, the en- provider. Prescription omeprazole has been very expensive; zyme H+, K+-ATPase) to prevent the pumping or release of with nonprescription use, the cost should be much less. Inhibition of the proton pump suppresses gastric acid secretion in re- Prostaglandin sponse to all primary stimuli, histamine, gastrin, and acetyl- choline. Thus, the drugs inhibit both daytime (including Naturally occurring prostaglandin E, which is produced in mu- meal-stimulated) and nocturnal (unstimulated) acid secretion. It also inhibits are usually the drugs of choice for treatment of duodenal and the mucosal damage produced by gastric acid, aspirin, and gastric ulcers, GERD with erosive esophagitis, and Zollinger- NSAIDs. Compared with H2RAs, PPIs suppress sion and ulceration of gastric mucosa may occur. This effect mechanism by which aspirin and other NSAIDs are thought to provides faster symptom relief and faster healing in acid- cause gastric and duodenal ulcers (see Chap. For example, healing of duodenal and gas- Misoprostol is a synthetic form of prostaglandin E approved tric ulcers after 2 weeks is similar to the healing after 4 weeks for concurrent use with NSAIDs to protect gastric mucosa of H2RA therapy. The PPIs and H2RAs are similarly effective from NSAID-induced erosion and ulceration. It is indicated in maintenance therapy of peptic ulcer disorders, with similar for clients at high risk of GI ulceration and bleeding, such as rates of ulcer recurrence. In clients with GERD, PPIs usually those taking high doses of NSAIDs for arthritis and older abolish symptoms within 1 to 2 weeks and heal esophagitis adults. The drugs are also effective in maintenance tial, unless effective contraceptive methods are being used, therapy to prevent recurrence of esophagitis. Nausea, diarrhea, and headache are the most frequently reported adverse effects. However, long-term consequences of profound gastric acid Sucralfate suppression are unknown. Sucralfate is a preparation of sulfated sucrose and aluminum hydroxide that binds to normal and ulcerated mucosa. It is effective Nursing Notes: Apply Your Knowledge even though it does not inhibit secretion of gastric acid or pepsin and it has little neutralizing effect on gastric acid. Its Ellen Jones, a 54-year-old homemaker with a seizure disorder mechanism of action is unclear, but it is thought to act locally that has been well controlled on carbamazepine (Tegretol), on the gastric and duodenal mucosa. Possible mechanisms in- comes to the clinic complaining of ataxia, slurred speech, and clude binding to the ulcer and forming a protective barrier be- lethargy. You obtain a history and the only significant change for tween the mucosa and gastric acid, pepsin, and bile salts; Ellen over the last few weeks is an episode of severe heartburn.

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Most drugs given to a client with hypothy- It is usually continued until the client is euthyroid for 6 to roidism have a prolonged effect because drug metabolism in 12 months purchase 40 mg propranolol. Diagnostic tests to evaluate thyroid function or the liver is delayed and the glomerular filtration rate of the kid- a trial withdrawal then may be implemented to determine neys is decreased generic propranolol 80 mg with visa. Also purchase 40 mg propranolol free shipping, drug absorption from the intestine or whether the client is likely to remain euthyroid without further a parenteral injection site may be slowed 80mg propranolol sale. If the drug is to be discontinued, this is usually of many other drugs should be reduced, including digoxin and done gradually over weeks or months. In addition, people with hypothyroidism are especially likely to experience respiratory depression and myxedema coma with opioid analgesics and other sedating drugs. However, when Iodine preparations and thioamide antithyroid drugs are con- necessary, they are given very cautiously and in dosages of traindicated during pregnancy because they can lead to goiter approximately one third to one half the usual dose. Once thyroid replacement therapy is started and stabilized, Hyperthyroidism and the Metabolism the client becomes euthyroid, has a normal rate of metabo- of Other Drugs lism, and can tolerate usual doses of most drugs if other influ- encing factors are not present. On the other hand, excessive Treatment of hyperthyroidism changes the rate of body me- doses of thyroid drugs may produce hyperthyroidism and a tabolism, including the rate of metabolism of many drugs. In this instance, larger During the hyperthyroid state, drug metabolism may be very doses of most other drugs are necessary to produce the same rapid, and higher doses of most drugs may be necessary to effects. Rather than increasing dosage of other drugs, how- achieve therapeutic results. When the client becomes euthy- ever, dosage of thyroid drugs should be reduced so the client roid, the rate of drug metabolism is decreased. Duration of Replacement Therapy Iodine Ingestion and Hyperthyroidism Thyroid replacement therapy in the client with hypo- thyroidism is lifelong. Medical supervision is needed fre- Iodine is present in foods (especially seafood) and in contrast quently during early treatment and at least annually after the dyes used for gallbladder and other radiologic procedures. Adrenal Insufficiency Use in Children When hypothyroidism and adrenal insufficiency coexist, the For hypothyroidism in children, replacement therapy is re- adrenal insufficiency should be treated with a corticosteroid quired because thyroid hormone is essential for normal growth 362 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM and development. Therefore, a thorough physical examina- choice in children and dosage needs may change with growth. To monitor drug effects on be increased in clients receiving bronchodilators or other growth, height and weight should be recorded and compared cardiac stimulants. To decrease adverse effects, the drugs with growth charts at regular intervals. Adverse drug effects should be given in small initial dosages (eg, 25 mcg/day) are similar to those seen in adults, and children should be mon- and increased by 25 mcg/day at monthly intervals until itored closely. For hyperthyroidism in children, propylthiouracil or me- Periodic measurements of serum TSH levels are indicated thimazole is used. Potential risks of adverse effects are simi- to monitor drug therapy, and doses can be adjusted when lar to those in adults. For hyperthyroidism, propylthiouracil or methimazole may be used, but radioactive iodine is often preferred because it is Use in Older Adults associated with fewer adverse effects than other antithyroid drugs or surgery. Clients should be monitored closely for Signs and symptoms of thyroid disorders may mimic those of hypothyroidism, which usually develops within a year after other disorders that often occur in older adults (eg, conges- receiving treatment for hyperthyroidism. NURSING Thyroid and Antithyroid Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. With thyroid drugs: (1) Administer in a single daily dose, on an empty stomach Fasting increases drug absorption; early administration allows (eg, before breakfast). If the rate Tachycardia or other cardiac dysrhythmias may indicate adverse is over 100 per minute or if any changes in cardiac rhythm cardiac effects. Dosage may need to be reduced or the drug stopped are noted, consult the physician before giving the dose. The crushed tablet may also be sprinkled on a small amount of food (eg, cereal or applesauce). All these drugs have rather short half-lives and must be given fre- quently and regularly to maintain therapeutic blood levels.

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