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Several studies have noted that the incidence of pressure ulcers among black Americans and among white Americans may differ heart attack during sex purchase 40mg inderal amex. Whether this can be attributed to arrhythmia treatment algorithm order inderal online pills structural skin changes or socioeconomic factors is unknown because of the paucity of pressure-ulcer research among patients in U heart attack jack order inderal canada. When a pressure ulcer is present and there is aerobic or anaerobic bacteremia, or both, the pressure ulcer is most often the primary source of the infection. Additional complications of pressure ulcers include localized infection, cellulitis, and osteomyelitis. Several studies have noted the association of pressure-ulcer development and mortality in both the hospital and nursing-home settings. In fact, the mortality rate has been noted to be as high as 60% for those older persons who develop a pressure ulcer within 1 year of hospital discharge. However, any disease process that renders an elderly person immobile for an extended period of time will increase the risk for pressure-ulcer development. There are intrinsic factors and extrinsic factors that determine the tolerance of soft tissue to the adverse affects of pressure. Intrinsic risk factors are physiologic factors or disease states that increase the risk for pressure-ulcer development (eg, age, nutritional status, and decreased arteriolar blood pressure). Extrinsic factors are external factors that damage the skin (eg, friction and shear, moisture, and urinary or fecal incontinence, or both). Variables that appear to be predictors of pressure-ulcer development include age $70 years, impaired mobility, current smoking history, low body mass index, altered mental status (eg, confusion), urinary and fecal incontinence, malnutrition, restraints, malignancy, diabetes mellitus, stroke, pneumonia, congestive heart failure, fever, sepsis, hypotension, renal failure, dry and scaly skin, history of pressure ulcers, anemia, lymphopenia, and hypoalbuminemia. The Braden Scale (see the Appendix) and the Norton Scale are probably the most widely used tools for identifying elderly patients who are at risk for developing pressure ulcers. The Braden Scale has a sensitivity of 83% to 100% and a specificity of 64% to 77%; the Norton Scale has a sensitivity of 73% to 92% and a specificity of 61% to 94%. The Guidelines recommend that bed- and chairbound patients or those with impaired ability to be repositioned should be assessed upon admission to the hospital or the nursing home for additional factors that increase the risk for developing pressure ulcers. A systematic risk assessment can be accomplished by use of a validated risk-assessment tool, such as the Braden Scale or the Norton Scale. Pressure-ulcer risk should also be reassessed at periodic intervals and when there is a change in level of activity or mobility. Studies have demonstrated that the incorporation of systematic risk-assessment tools has significantly reduced the incidence of pressure ulcers. To date, the Braden Scale is the only tool to be validated in nonwhite populations. It is important to note that the use of risk-assessment tools will not guarantee that all elderly persons at risk for pressure ulcers will be identified. These clinical practice guidelines (Pressure Ulcers in Adults: Prediction and Prevention, published in May 1992) provide an excellent approach to evidenced-based pressure-ulcer prevention. The goal of skin care after identifying the older person at risk for pressure ulcers is to maintain and improve tissue tolerance to pressure in order to prevent injury. All older persons at risk should have a systematic skin inspection at least once a day, with emphasis on the bony prominences. The skin should be cleansed with warm water and a mild cleansing agent to minimize irritation and dryness of the skin. Every effort should be made to minimize environmental factors leading to skin drying, such as low humidity (less than 40%) and exposure to cold. Decreased skin hydration has been found to result in decreased pliability, and severely dry skin has been noted to damage the stratum corneum. Previously, it was believed that massaging the bony prominences promoted circulation. However, postmortem biopsies found degenerated tissue in those areas exposed to massage but no degenerated tissue on those areas that were not massaged. All efforts to avoid exposing the skin to urine and fecal matter resulting from incontinence, to perspiration, and to wound drainage should be undertaken.

Treatment for retinoblastoma usually involves the removal of the affected eye(s) (enucleation) blood pressure medication infertility discount inderal uk, followed by radiation blood pressure qof purchase generic inderal on line. Diagnostic blood pressure 200 over 100 buy inderal 80 mg with mastercard, Symptomatic, and Related Terms 473 Diagnostic, Symptomatic, and Related Terms this section introduces diagnostic, symptomatic, and related terms and their meanings. Eversion, or outward turning, of the edge of the lower eyelid Normal condition of the eye in refraction in which, when the eye is at rest, parallel rays focus exactly on the retina Inversion, or inward turning, of the edge of the lower eyelid Abnormal overflow of tears Epiphora is sometimes caused by obstruction of the tear ducts. Protrusion of one or both eyeballs Common causes of exophthalmos include hyperactive thyroid, trauma, and tumor. Inability to see well in dim light; also called night blindness Common causes of nyctalopia include cataracts, vitamin A deficiency, certain medications, and hereditary causes. Involuntary eye movements that appear jerky and may reduce vision or be associated with other, more serious conditions that limit vision Edema and hyperemia of the optic disc usually associated with increased ocular pressure resulting from intracranial pressure; also called choked disc Unusual intolerance and sensitivity to light Photophobia commonly occurs in such diseases as meningitis, inflammation of the eyes, measles, and rubella. Loss of accommodation of the crystalline lens associated with the aging process During the aging process, proteins in the lens become harder and less elastic and muscle fibers surrounding the lens lose strength. Hearing loss should not be confused with anacusis, which refers to the complete inability to hear and is commonly congenital. Disorder of the labyrinth that leads to progressive loss of hearing Mйniиre disease is characterized by vertigo, sensorineural hearing loss, and tinnitus. Impairment of hearing resulting from old age; also called presbyacusia In presbyacusis, patients are generally able to hear low tones but ability to hear higher tones is lost. This condition usually affects speech perception, especially in the presence of background noise, as in a restaurant or a large crowd. Perception of ringing, hissing, or other sounds in the ears or head when no external sound is present Tinnitus may be caused by a blow to the head, ingestion of large doses of aspirin, anemia, noise exposure, stress, impacted wax, hypertension, and certain types of medications and tumors. Hallucination of movement, or a feeling of spinning or dizziness Vertigo may be caused by a variety of disorders, including Mйniиre disease and labyrinthitis. Test that uses different temperatures to assess the vestibular portion of the nerve of the inner ear (acoustic nerve) to determine if nerve damage is the cause of vertigo In the caloric stimulation test, cold and warm water are separately introduced into each ear while electrodes, placed around the eye, record nystagmus. Eyes move in a predictable pattern when the water is introduced, except with acoustic nerve damage. Method of assessing and recording eye movements by measuring the electrical activity of the extraocular muscles In electronystagmography, electrodes are placed above, below, and to the side of each eye. The electrodes record eye movement relative to the position of the ground electrode. Measurement of the blood pressure of the retinal vessels Ophthalmodynamometry is a screening test used to determine reduction of blood flow in the carotid artery. Evaluation of intraocular pressure by measuring the resistance of the eyeball to indentation by an applied force Tonometry is used to detect glaucoma. The applanation method of tonometry uses a sensor to depress the cornea and is considered the most accurate method of tonometry. Part of an eye examination that determines the smallest letters that can be read on a standardized chart at a distance of 20 Visual acuity is expressed as a fraction. The top number refers to the distance from the chart (usually 20) and the bottom number indicates the distance at which a person with normal eyesight could read the same line. For example 20/40 indicates that the patient correctly read letters at 20 that could be read by a person with normal vision at 40. Evaluation of refractive errors of the eye by projecting a light into the eyes and determining the movement of reflected light rays Retinoscopy is especially important in determining errors of refraction in babies and small children who cannot be refracted by traditional methods. Assesses blood vessels and their leakage in and beneath the retina by injecting a colored dye (fluorescein) and allowing it to circulate while photographs of the intraocular circulation are recorded Fluorescein angiography facilitates the in vivo study of the retinal circulation and is particularly useful in the management of diabetic retinopathy and macular degeneration, two leading causes of blindness. Removal of the contents of the eye while leaving the sclera and cornea Evisceration is performed when the blind eye is painful or unsightly. Method of treating cataracts by using ultrasonic waves to disintegrate the cloudy lens, which is then aspirated and removed Surgical formation of an opening in the sclera Sclerostomy is commonly performed in conjunction with surgery for glaucoma. Reconstruction of the eardrum, commonly due to a perforation; also called myringoplasty Pharmacology Disorders of the eyes and ears are commonly treated with instillation of drops onto the surface of the eye or into the cavity of the ear. The eyes and ears are commonly irrigated with liquid solution to remove foreign objects and to provide topical applications of medications. Pharmacological agents used to treat eye disorders include antibiotics for bacterial eye infections, beta blockers and carbonic anhydrase inhibitors for glaucoma, and ophthalmic 480 15 · Special Senses decongestants and moisturizers for irritated eyes. Mydriatics and miotics are used, not only to treat eye disorders but also to dilate (mydriatics) and contract (miotics) the pupil during eye examinations.

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Most hospitals and clinics require that nurses receive specialized training and standardized educational preparation before they are permitted to arrhythmia game inderal 80 mg on line administer antineoplastic drugs arrhythmia while sleeping buy 80mg inderal mastercard. The Oncology Nursing Society has developed guidelines and educational tools for credentialing nurses for certification in administering chemotherapy arrhythmia effects discount 40mg inderal with amex. If guidelines are not provided, it is important for the nurse to review the drugs being given before their administration. The nurse consults appropriate references to obtain information regarding the preparation and administration of a particular drug, the average dose ranges, all the known adverse reactions, and the warnings and precautions given by the manufacturer. Most oral drugs are well absorbed when the gastrointestinal tract is functioning normally. Antineoplastic drugs such as melphalan, busulfan, and chlorambucil are usually given orally. The section on "Educating the Patient and Family" provides information to include in a teaching plan. When an antineoplastic drug is administered orally, the nurse must handle the drug safely. Gloves are considered acceptable if physical contact with the tablet or capsule is necessary. It is important for the nurse to take precautions to prevent accidental spilling or spraying of the drug into the eyes or onto unprotected areas of the skin. The nurse thoroughly washes the hands before and after preparing and administering an antineoplastic drug. Special directions for administration, stated by either the primary health care provider or manufacturer, are also important. The intravenous route of drug delivery is these drugs are given orally, others are given by the parenteral route. Antineoplastic drugs may be administered subcutaneously, intramuscularly, and intravenously. If the injections are given frequently, the sites should be rotated and charted appropriately. Goserelin (Zoladex), a hormonal antineoplastic drug used to treat breast cancer, is administered subcutaneously in an unusual way. The drug is contained in a dry pellet that is implanted in the soft tissue of the abdomen, where it is gradually absorbed during a period of 1 to 3 months. After a local anesthetic, such as lidocaine, is administered, a large needle (usually 16 gauge) is used to insert the pellet. It is most important to follow the directions of the manufacturer or primary health care provider regarding the type of solution to be used for dilution or administration. When preparing an antineoplastic drug for parenteral administration, the nurse wears disposable plastic gloves. Some of these drugs can be absorbed through the skin of the individual preparing these drugs. Because antineoplastic drugs are highly toxic and can have an effect on many organs and systems of the body, nurses must use measures to prevent the most common and most reliable method of drug delivery. Intravenous administration may be accomplished using a vascular access device, an Angiocath, or a butterfly needle. Selection of the device depends on the type of therapy the patient is to receive, the condition of the veins, and how long the treatment regimen is to be continued. Instructions for monitoring the administration of intravenous antineoplastic drugs are given by the physician. Nurses who are certified in chemotherapy drug administration administer these drugs, but any nurse may be involved in monitoring patients receiving antineoplastic drugs. If administration guidelines are not provided by the primary health care provider or the hospital, the nurse checks with the appropriate authorities (physician, pharmacist) regarding the administration of a specific antineoplastic drug. The nurse must read thoroughly the package insert supplied with the drug before the drug is prepared and administered. Antineoplastic drugs are potentially toxic drugs that can cause a variety of effects during and after their administration. Display 55-2 summarizes important points to keep in mind when administering an antineoplastic drug.

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There is an increased risk of xanthine toxicity when the drugs are administered with influenza vaccination blood pressure medication can you stop purchase 40 mg inderal with visa, oral contraceptives heart attack 50 years buy discount inderal line, glucocorticoids blood pressure classification buy genuine inderal, -adrenergic blockers, cimetidine, macrolides, thyroid hormones, or allopurinol. Additional information concerning the xanthine derivatives is found in the Summary Drug Table: Bronchodilators. During the inflammatory process, large amounts of histamine are released from the mast cells of the respiratory tract, causing symptoms such as increased mucous production and edema of the airway and resulting in bronchospasm and inflammation. With asthma the airways become narrow, the muscles around the airway tighten, the inner lining of the bronchi swell, and extra mucus clogs the smaller airways. These include corticosteroids, leukotriene formation inhibitors, leukotriene receptor agonists, and mast cell stabilizers. A multidrug regimen allows smaller dosages of each drug, decreasing the number and severity of adverse reactions. Vanceril is contraindicated for the relief of symptoms that can be controlled by a bronchodilator and other nonsteroidal medications and in the treatment of nonasthmatic bronchitis. The corticosteroids are used cautiously in patients with compromised immune systems, glaucoma, kidney or liver disease, convulsive disorders, or diabetes, those taking systemic corticosteroids, and during pregnancy (Pregnancy Category C) and lactation. With increased sensitivity of the 2-receptors, the 2-receptor agonist drugs are more effective. Leukotriene receptor antagonists include montelukast sodium (Singulair) and zafirlukast (Accolate). Additional information concerning these drugs is found in the Summary Drug Table: Antiasthma Drugs. Although the result is the same, montelukast and zafirlukast work in a manner slightly differently from that of zileuton. Montelukast and zafirlukast are considered leukotriene receptor antagonists because they inhibit leukotriene receptor sites in the respiratory tract, preventing airway edema and facilitating bronchodilation. When used to manage chronic asthma, the corticosteroids are most often given by inhalation. Adverse reactions to the corticosteroids are less likely to occur when the drugs are given by inhalation rather than taken orally. Occasionally, patients may experience throat irritation causing hoarseness, cough, or fungal infection of the mouth and throat. See Chapter 50 for adverse reactions after oral administration of the corticosteroids. A more complete listing of the adverse reactions associated with the corticosteroids is found in the Summary Drug Table: Antiasthma Drugs. Montelukast is used in the prophylaxis and treatment of chronic asthma in adults and in children older than 2 years. Montelukast (Singulair) administration may cause headache, dizziness, dyspepsia, flu-like symptoms, cough, abdominal pain, and fatigue. These elevations may continue to rise, remain unchanged, or resolve with continued therapy. Montelukast, zafirlukast, and zileuton are not used in the reversal of bronchospasm in acute asthma attacks. The drugs are used cautiously in patients with hepatic dysfunction and during pregnancy (zafirlukast and montelukast are Pregnancy Category B drugs, and zileuton is Pregnancy Category C) and lactation. Administration of zafirlukast and aspirin increases plasma levels of zafirlukast, When zafirlukast is administered with warfarin, there is an increased effect of the anticoagulant. Administration of zafirlukast and theophylline or erythromycin may result in a decreased level of zafirlukast. Administration of montelukast with other drugs has not revealed any adverse responses. A prothrombin blood test should be done regularly in the event dosages of warfarin need to be decreased. When the mast cell stabilizers are used in conjunction with other antiasthma drugs, a reduction in dosage of the drugs may be possible after using the mast cell stabilizer for 3 or 4 weeks. These drugs may be given by nebulization, aerosol spray, or as an oral concentrate. These drugs may cause nasal or throat irritation when given intranasally or by inhalation.

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