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By B. Fadi. Salem College.

Hypertonic solutions are given in a central caloric intake and increase exercise generic clonidine 0.1mg online. Central parenteral nutri- 2 of 27 kg/m buy clonidine 0.1 mg on-line, treatment is recommended for those with two or tion requires special techniques to increase safety and de- more risk factors (eg, hypertension, dyslipidemia, diabetes) crease complications. For example, a physician must insert or a high waist circumference (central obesity). For people the central IV catheter, and placement must be verified by a 2 with a BMI of 30 kg/m or above, treatment is recommended. Complications include air embolism and pneu- Considerations include the following: mothorax. Peripheral nutrition solutions are less hypertonic • Any weight reduction program needs to include a reduced- because they contains 5% or 10% dextrose. Diets should consist given alone or in combination with oral or enteral feedings to of nutritionally sound foods in balanced meals. These solutions are isotonic and may be given preserve lean body mass during weight loss. When given peripherally, they are help to prevent the decreased metabolic rate that usually coinfused with the nutrition solution. There is Guidelines for administration of central and peripheral strong evidence that weight loss reduces risk factors for parenteral nutrition include the following: cardiovascular disease, including blood pressure, serum • Administer with an infusion pump to control the flow triglycerides, and total and LDL cholesterol. In addition, in overweight and tent rate so nutrients can be used and complications pre- obese people without diabetes, weight loss reduces vented. The initial flow rate is usually 50 mL/hour; flow blood glucose levels and the risk for development of rate is then increased as tolerated to meet nutritional re- type 2 diabetes. For people who already have type 2 di- quirements (approximately 1500 to 3000 mL/day). In general, modest weight losses of only 5 to 10 lbs lower blood pressure and blood lipids and im- prove insulin resistance and glucose tolerance. The Ensure is supplied in 2 • There is increasing consensus that obesity is a chronic 240-cc cans. How will you dilute this formula, and at what rate disease and that obese people should take weight loss will you set the infusion pump? Usually, however, the 446 SECTION 5 NUTRIENTS, FLUIDS, AND ELECTROLYTES medications are recommended only in clients whose Emphasis is being placed on prevention of obesity, espe- health is significantly endangered by obesity. The main • When drug therapy is indicated, a single drug in the elements are a more active lifestyle, a low-fat diet, regular lowest effective dose is recommended. As with most meals, avoidance of snacking, drinking water instead of other drugs, low doses decrease risks of adverse drug calorie-containing beverages, and decreasing the time spent effects. Nutritional Support and • Maximum weight loss usually occurs during the first Obesity in Older Adults 6 months of drug therapy. With most available drugs, use for this long is an unlabeled use of the drug. Older adults are at risk for development of deficits and ex- • After a weight loss regimen of a few months, some ex- cesses in fluid volume. Inadequate intake is common and may perts recommend letting the body adjust to the lower result from numerous causes (eg, impaired thirst mechanism, weight before attempting additional losses. Thus, a impaired ability to obtain and drink fluids, inadequate water weight maintenance program, possibly with continued with tube feedings). Fluid • The National Institutes of Health do not recommend volume excess is most likely to occur with large amounts or combining weight loss medications except in the con- rapid administration of IV fluids, especially in older adults text of clinical trials. Inadequate intake may result from the inability to obtain and prepare food, as well as disease processes that interfere with the ability to digest and Nutritional Support and Obesity in Children use nutrients. When alternative feeding methods (tube feed- ings, IV fluids) are used, careful assessment of nutritional sta- Children in general need increased amounts of water, protein, tus is required to avoid deficits or excesses. Overweight and carbohydrate, and fat in proportion to their size to support obesity are also common among older adults. However, reports of needs are usually decreased, primarily because of slowed me- childhood obesity and inadequate exercise abound and are tabolism and decreased physical activity, most people continue steadily increasing. With the high incidence of atherosclero- is to meet needs without promoting obesity. Anorexiant drugs should the recommended rate of administration is no more than be used very cautiously, if at all, because older adults often 5 mL every 5 to 10 minutes for premature and small infants have cardiovascular, renal, or hepatic impairments that in- and 10 mL/minute for older infants and children. The use of orlistat in tion of formulas, positioning of children, and administration older adults has not been studied.

Hypothyroidism and hyperthy- thyroid gland gradually atrophies and functioning glandular roidism produce opposing effects on body tissues cheap clonidine 0.1 mg mastercard, depending tissue is replaced by nonfunctioning fibrous connective tissue on the levels of circulating thyroid hormone cheap 0.1mg clonidine. Myxedema coma is severe, life-threatening hypothyroidism characterized by coma, hypothermia, cardiovascular collapse, hypoventilation, and severe metabolic disorders such as hypo- Simple Goiter natremia, hypoglycemia, and lactic acidosis. Predisposing factors include exposure to cold, infection, trauma, respiratory Simple goiter is an enlargement of the thyroid gland resulting disease, and administration of central nervous system (CNS) from iodine deficiency. Inadequate iodine decreases thyroid depressant drugs (eg, anesthetics, analgesics, sedatives). To compensate, the anterior pituitary person with severe hypothyroidism cannot metabolize and gland secretes more TSH, which causes the thyroid to enlarge excrete the drugs. If the enlarged gland secretes enough hormone, thyroid function is normal and the main Treatment consequences of the goiter are disfigurement, psychological distress, dyspnea, and dysphagia. If the gland cannot secrete Regardless of the cause of hypothyroidism and the age at enough hormone despite enlargement, hypothyroidism re- which it occurs, the specific treatment is replacement of thy- sults. Simple or endemic goiter is a common condition in roid hormone from an exogenous source. In patients with subclinical largely because of the widespread use of iodized table salt. There is some dif- tions and thyroid hormones to prevent further enlargement and ference of opinion about treatment for TSH values between promote regression in gland size. In patients with symptomatic hypothyroidism, levothyrox- Primary hypothyroidism occurs when disease or destruction ine therapy is definitely indicated. In addition to improve- of thyroid gland tissue causes inadequate production of thy- ment of metabolism, treatment may also improve cardiac roid hormones. Common causes of primary hypothyroidism function, energy level, mood, muscle function, and fertility. Other causes include factors and to support vital functions until the thyroid hormone previous radiation to the thyroid area of the neck and treat- becomes effective, often within 24 hours. CHAPTER 25 THYROID AND ANTITHYROID DRUGS 355 TABLE 25–1 Thyroid Disorders and Their Effects on Body Systems Hypothyroidism Hyperthyroidism Cardiovascular Effects Increased capillary fragility Tachycardia Decreased cardiac output Increased cardiac output Decreased blood pressure Increased blood volume Decreased heart rate Increased systolic blood pressure Cardiac enlargement Cardiac dysrhythmias Congestive heart failure Congestive heart failure Anemia More rapid development of atherosclerosis and its complications (eg, coronary artery and peripheral vascular disease) Central Nervous System Effects Apathy and lethargy Nervousness Emotional dullness Emotional instability Slow speech, perhaps slurring and hoarseness as well Restlessness Hypoactive reflexes Anxiety Forgetfulness and mental sluggishness Insomnia Excessive drowsiness and sleeping Hyperactive reflexes Metabolic Effects Intolerance of cold Intolerance of heat Subnormal temperature Low-grade fever Increased serum cholesterol Weight loss despite increased appetite Weight gain Gastrointestinal Effects Decreased appetite Increased appetite Constipation Abdominal cramps Diarrhea Nausea and vomiting Muscular Effects Weakness Weakness Fatigue Fatigue Vague aches and pains Muscle atrophy Tremors Integumentary Effects Dry, coarse, and thickened skin Moist, warm, flushed skin due to vasodilation and increased Puffy appearance of face and eyelids sweating Dry and thinned hair Hair and nails soft Thick and hard nails Reproductive Effects Prolonged menstrual periods Amenorrhea or oligomenorrhea Infertility or sterility Decreased libido Miscellaneous Effects Increased susceptibility to infection Dyspnea Increased sensitivity to narcotics, barbiturates, and anesthetics Polyuria due to slowed metabolism of these drugs Hoarse, rapid speech Increased susceptibility to infection Excessive perspiration Localized edema around the eyeballs, which produces characteristic eye changes, including exophthalmos Hyperthyroidism secretes excessive TSH. Hyperthyroidism usually involves an enlarged thyroid gland that has an increased number of Hyperthyroidism is characterized by excessive secretion of cells and an increased rate of secretion. As a result, body metabolism is greatly in- functioning thyroid carcinoma, and pituitary adenoma that creased. Specific physiologic effects and clinical manifesta- 356 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM tions of hyperthyroidism are listed in Table 25–1. These Iodine preparations inhibit the release of thyroid hormones effects vary, depending on the amount of circulating thyroid and cause them to be stored within the gland. They reduce hormone, and they usually increase in incidence and severity blood levels of thyroid hormones more quickly than thioamide with time if hyperthyroidism is not treated. Maximal effects are reached in Subclinical hyperthyroidism is defined as a reduced TSH approximately 10 to 15 days of continuous therapy, and this (below 0. The most common cause is excess thyroid hor- include the following: mone therapy. Subclinical hyperthyroidism is a risk factor for • They may produce goiter, hyperthyroidism, or both. Therapeutic benefits are tem- trogen replacement therapy, because it leads to reduced bone porary, and symptoms of hyperthyroidism may reappear mineral density. It also greatly increases the risk of atrial fib- and even be intensified if other treatment methods are rillation in clients over 60 years of age. Thyroid storm or thyrotoxic crisis is a rare but severe • Radioactive iodine cannot be used effectively for a pro- complication characterized by extreme symptoms of hyper- longed period in a client who has received iodine prepa- thyroidism, such as severe tachycardia, fever, dehydration, rations. Even if the iodine preparation is discontinued, heart failure, and coma. It is most likely to occur in clients the thyroid gland is saturated with iodine and does not with hyperthyroidism that has been inadequately treated, attract enough radioactive iodine for treatment to be ef- especially when stressful situations occur (eg, trauma, infec- fective. Also, if radioactive iodine is given later, acute tion, surgery, emotional upsets). Treatment • Although giving a thioamide drug followed by an Treatment of hyperthyroidism depends on the cause. If the iodine preparation is standard preparation for thy- cause is an adenoma or multinodular goiter, surgery or radio- roidectomy, the opposite sequence of administration active iodine therapy is recommended, especially in older is unsafe.

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Excessive sedation and drowsiness Excessive sedation may occur with usual doses of antiemetics and is more likely to occur with high doses clonidine 0.1mg without prescription. Anticholinergic effects—dry mouth order 0.1 mg clonidine overnight delivery, urinary retention These effects are common to many antiemetic agents and are more likely to occur with large doses. Hypotension, including orthostatic hypotension Most likely to occur with phenothiazines; may also occur with 5-HT3 antagonists d. Extrapyramidal reactions—dyskinesia, dystonia, akathisia, These disorders may occur with phenothiazines and metoclo- parkinsonism pramide. With ondansetron and related drugs, observe for headache, These drugs are usually well tolerated, with mild to moderate diarrhea or constipation, dizziness, fatigue, and muscle aches. With dronabinol, observe for alterations in mood, cogni- Tachycardia may be prevented with a beta-adrenergic blocking tion, and perception of reality, dysphoria, drowsiness, dizziness, drug, such as propranolol (Inderal). Drugs that increase effects of antiemetic agents: (1) CNS depressants (alcohol, sedative-hypnotics, anti- Additive CNS depression anxiety agents, other antihistamines or antipsychotic agents) (2) Anticholinergics (eg, atropine) Additive anticholinergic effects. Some phenothiazines and anti- emetic antihistamines have strong anticholinergic properties. Drugs that alter effects of 5-HT3 receptor antagonists: (1) Atenolol and cimetidine increase effects of dolasetron The drugs decrease dolasetron metabolism and clearance. Philadelphia: Lippincott Answer: When giving very emetogenic drugs, it is important to Williams & Wilkins. Springhouse, PA: Springhouse Cor- antiemetics work in different ways, so they can be used in com- poration. Supportive care: Controlling chemotherapy-induced and Review and Application Exercises postoperative nausea and vomiting. Are antiemetics more effective if given before, during, or York: McGraw-Hill. Describe major types of antineoplastic drugs interventions to prevent or minimize adverse in terms of mechanism of action, indications drug effects. Manage or assist clients/caregivers in manag- surgical treatment, and with radiation therapy. Critical Thinking Scenario Georgia Sommers, a 39 year-old mother of 4, is diagnosed with breast cancer that was detected by routine mammography. She is recovering from a modified radical mastectomy when she comes to the clinic to dis- cuss additional treatment with chemotherapy with the oncologist. He explains that she will receive combina- tion therapy with three drugs on a cycle of every 4 weeks. The normal cell cycle is the interval between the birth of a cell and its division into two daughter cells (Fig. Oncology is the study of malignant neoplasms and their treat- The daughter cells may then enter the resting phase (G0) or ment. Drugs used in oncologic disorders include those used to proceed through the reproductive cycle to form more new kill, damage, or slow the growth of cancer cells, and those used cells. Normal cells are also well differentiated in appearance to prevent or treat adverse drug effects. In- ment modality for cancer, along with surgery and radiation stead, they occupy space and take blood and nutrients away therapy. They grow in an uncontrolled fashion characteristics of cancer are described below. They are undifferentiated, which means they have lost the structural and functional character- NORMAL AND MALIGNANT CELLS istics of the cells from which they originated. They are loosely connected, so that cells break off from the primary Normal cells reproduce in response to a need for growth or tumor and invade adjacent tissues. Loose cells also enter tissue repair and stop reproduction when the need has been blood and lymph vessels, by which they circulate through the 913 914 SECTION 11 DRUGS USED IN SPECIAL CONDITIONS mutations of normal growth-regulating genes called proto- G0 oncogenes, which are present in all body cells. Normally, proto-oncogenes are active for a brief period in the cell re- G1 productive cycle. When exposed to carcinogens and genetically altered to oncogenes, however, they may operate continuously and cause abnormal, disordered, and unregulated cell growth. Unregulated cell growth and proliferation increases the prob- ability of neoplastic transformation of the cell. Tumors of the breast, colon, lung, and bone have been linked to activation of oncogenes.

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In all ten drills start with ten repetitions a day and progress as explained in the text buy clonidine 0.1mg otc. If you literally bend back cheap clonidine 0.1mg amex, your movement is limited to a couple of lumbar vertebrae. Instead of hinging it on your lumbar vertebrae alone try to get some motion out of every segment of the spine, from top to bottom. Excessive bending is one hazard; a strong pull of the hip flexors on the spine is another. These psoas muscles originate in the small of your back and run through your stomach to insert in front of your thighs. Unfortunately, instead of stretching they usually tenaciously keep their length and pull hard on the lumbar spine to exaggerate the arch even further. Besides, flexed glutes will semi-relax the psoas and further dampen their powerful pull. According to the neurological phenomenon of reciprocal inhibition, when a muscle is contracting, its antagonist, or the opposite number, relaxes to make the movement more efficient: why press the gas and the brake pedals at the same time? The glutes are hip extensors; they oppose the hip flexors—which include the psoas. That is why it is generally advisable to flex your glutes during back bending exercises. Academician Amosov emphasizes a maximal range of motion in his exercises. This is the simple the key to the effectiveness of his youth-restoring calisthenics. Other, even more complicated routines generally do not pay attention to this vital advice (how about those idiots who tell you not to do full squats? Rotating a joint through its anatomically complete range of motion —or trying to approach that ROM if the joint is damaged—smoothes out the joint surfaces and lubricates them. When doing mobility drills, you generally will not feel much of a stretch, which is fine. A muscle does not always have to be stretched to put a joint through its full range of motion. For example, you will achieve complete hip flexion if you stand upright and bring your knee towards your chest. To stretch one of the muscles that oppose hip flexion, the hamstring, you will have to raise your leg with your knee straight or nearly straight. Unless you are a mutant, you will not succeed in touching your chest or stomach with your knee; your ham will tighten up and stop you long before that. Your hinges need a distinctly different type of workout from your muscles. First is a 100% healthy joint, usually found in a young person: …a person can lift his knees to his stomach and touch his buttocks with his heels; he can flex his spine so his head ends up between his knees and make a full circle with his arms. Twenty reps per joint will suffice for prevention until you are thirty or so according to the Academician. The second stage usually hits by the time you are forty, give or take a few years. The joints already have salt deposits and they speak up with aches and a limited ROM. When this happens, and even if it does not but you hit forty, the man says the numbers must be cranked up to 50–100 per joint. The third stage is when the joint aches almost constantly and actively interferes with your work and life. X-rays show changes, the most common being bone spurs growing between vertebrae. Bad posture, poor body mechanics at work and in the gym, and lack of joint movement are to blame.

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