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Predisposing factors and the health history in the older adult in uence the complexity of care for the patient 1950s medications 100 mg epitol with amex. Pul monary function is limited in the older adult and therefore airway exchange treatment 001 purchase epitol canada, lung elasticity administering medications 7th edition answers epitol 100 mg for sale, and ventilation can be affected medicine youkai watch buy generic epitol 100 mg online. Decreased cardiac function and coronary artery disease increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus or other endocrine disorders present nutritional challenges and require close monitoring. Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team. The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal. Medical Management Four major goals relating to burn management are prevention, institution of life-saving measures for the severely burned person, prevention of disability and dis gurement, and rehabilitation. Nursing Management: Emergent/ Resuscitative Phase Assessment Focus on the major priorities of any trauma patient; the burn wound is a secondary consideration, although aseptic 110 Burn Injury management of the burn wounds and invasive lines con B tinues. Note amount of urine obtained when catheter is inserted (indicates preburn renal function and uid status). Burn Injury 111 Report labored respirations, decreased depth of respirations, B or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies. Maintaining Normal Body Temperature Provide warm environment: use heat shield, space blanket, heat lights, or blankets. Minimizing Pain and Anxiety Use a pain scale to assess pain level (ie, 1 to 10); differen tiate between restlessness due to pain and restlessness due to hypoxia. Provide individualized responses to support patient and family cop ing; explain all procedures in clear, simple terms. Administer uid resuscitation as ordered in response to physical ndings; continue monitoring uid status. Burn Injury 113 Nursing Management: Acute/ B Intermediate Phase the acute or intermediate phase begins 48 to 72 hours after the burn injury. Assessment Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications. Preventing Infection Provide a clean and safe environment; protect patient from sources of crosscontamination (eg, visitors, other patients, staff, equipment). Maintaining Adequate Nutrition Initiate oral uids slowly when bowel sounds resume; record toleranceif vomiting and distention do not occur, uids 114 Burn Injury may be increased gradually and the patient may be advanced B to a normal diet or to tube feedings. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feed ings); note residual volumes. Relieving Pain and Discomfort Frequently assess pain and discomfort; administer analgesic agents and anxiolytic medications, as prescribed, before the pain becomes severe. Assess and document the patients response to medication and any other interventions. Promoting Physical Mobility Prevent complications of immobility (atelectasis, pneumo nia, edema, pressure ulcers, and contractures) by deep breathing, turning, and proper repositioning. When legs are involved, apply elastic pressure bandages before assisting patient to upright position. Strengthening Coping Strategies Assist patient to develop effective coping strategies: Set spe ci c expectations for behavior, promote truthful communi cation to build trust, help patient practice coping strategies, and give positive reinforcement when appropriate. Enlist a noninvolved person for patient to vent feelings without fear of retalia tion. Supporting Patient and Family Processes Support and address the verbal and nonverbal concerns of the patient and family. Assess and consider preferred learning styles; assess ability to grasp and cope with the information; determine barriers to learning when planning and executing teaching. Monitoring and Managing Potential Complications Heart failure: Assess for uid overload, decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 heart sounds. Assess for decrease in tidal volume and lung com pliance in patients on mechanical ventilation. Fas ciotomies may be necessary to relieve swelling and ischemia in the muscles and fascia; monitor patient for excessive blood loss and hypovolemia after fasciotomy. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining uid and electrolyte balance and improving nutrition status continue to be important. Assessment In early assessment, obtain information about patients educational level, occupation, leisure activities, cultural background, religion, and family interactions. Nursing Interventions Promoting Activity Tolerance Schedule care to allow periods of uninterrupted sleep. Monitor fatigue, pain, and fever to determine amount of activity to be encouraged daily. Improving Body Image and Self-Concept Take time to listen to patients concerns and provide real istic support; refer patient to a support group to develop coping strategies to deal with losses. Promote a healthy body image and self-concept by help ing patient practice responses to people who stare or ask about the injury. Burn Injury 119 Teach patient ways to direct attention away from a dis g B ured body to the self within. Monitoring and Managing Potential Complications Contractures: Provide early and aggressive physical and occupational therapy; support patient if surgery is needed to achieve full range of motion. Evaluation Expected Patient Outcomes Demonstrates activity tolerance required for desired daily activities 120 Burn Injury Adapts to altered body image B Demonstrates knowledge of required self-care and follow up care Exhibits no complications For more information, see Chapter 57 in Smeltzer, S. Pathophysiology the abnormal cell forms a clone and begins to proliferate abnormally, ignoring growth-regulating signals in the envi ronment surrounding the cell. The cells acquire invasive char acteristics, and changes occur in surrounding tissues. The cells in ltrate these tissues and gain access to lymph and blood ves sels, which carry the cells to other areas of the body. This phe nomenon is called metastasis (cancer spread to other parts of the body). Cancerous cells are described as malignant neoplasms and are classi ed and named by tissue of origin. The failure of the immune system to promptly destroy abnormal cells permits these cells to grow too large to be managed by normal immune mechanisms. Certain categories of agents or factors implicated in carcinogenesis (malignant transformation) include viruses and bacteria, physical agents, chemical agents, genetic or familial factors, dietary factors, and hormonal agents. Cancer is the second leading cause of death in the United States, with most cancers occurring in men and in people older than 65 years. Clinical Manifestations Cancerous cells spread from one organ or body part to another by invasion and metastasis; therefore, manifesta tions are related to the system affected and degree of dis ruption (see the speci c type of cancer). Assessment and Diagnostic Methods Screening to detect early cancer usually focuses on cancers with the highest incidence or those that have improved sur vival rates if diagnosed early. Examples of these cancers include breast, colorectal, cervical, endometrial, testicular, skin, and oropharyngeal cancers. Patients with suspected can cer undergo extensive testing to Determine the presence and extent of tumor. Tumor Staging and Grading Staging Staging determines the size of the tumor and the existence of local invasion and distant metastasis. Grad ing systems seek to de ne the type of tissue from which the tumor originated and the degree to which the tumor cells retain the functional and histologic characteristics of the tis sue of origin (differentiation). Samples of cells to be used to establish the grade of a tumor may be obtained from tissue scrapings, body uids, secretions, or washings, biopsy, or sur gical excision. This information helps the health care team predict the behavior and prognosis of various tumors. The tumor is assigned a numeric value ranging from 1 (well differentiated) to 4 (poorly differentiated or undifferentiated). Medical Management the range of possible treatment goals may include complete eradication of malignant disease (cure), prolonged survival and containment of cancer cell growth (control), or relief of symptoms associated with the disease (palliation). A variety of therapies may be used, including the following: Surgery (eg, excisions, video-assisted endoscopic surgery, sal vage surgery, electrosurgery, cryosurgery, chemosurgery, or laser surgery). Surgery may be the primary method of treatment or 124 Cancer it may be prophylactic, palliative, or reconstructive.


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Additional helpful strate gies include: Scheduling regular visits with the patient medicine song 2015 order cheapest epitol, initially weekly and then monthly medications zovirax cheap epitol 100mg, to medications or therapy purchase epitol 100mg otc perform a thorough assessment until treatment is completed treatment for hemorrhoids discount 100 mg epitol mastercard. The patient should undergo post-treatment monitoring for a minimum of 2 years to mon itor for relapse. This approach should be based on the patients needs and mutual respect between the patient and the provider. Any toxicity must be quickly identifed, reported, and acted upon (see Chapter 9, Adverse Reactions). Although providing the injectable agent may be daunting, it is important that the patient and staff understand the importance of the injectable agent in the regimen. Alternatively, patients can come into the clinic/provider offce to receive the injection as long as appropriate infection control is in place while the patient is still infec tious. Public health and/or clinic nursing staff may require additional in-service training if they have not had recent experience in providing injections. A major challenge in provid ing infusions is fnding staff to perform the infusion. Typically, public health nurses are not trained to provide infusionsor it falls outside of their scopes of practiceand a home health agency may be needed to provide home-based infusions. Even if the case manager is not directly administering the infusion, it is important that he/ she be aware of and assess for signs of infection. Once a patient is no longer considered infectious, another option is to use an infusion center. Calculating the concentration and volume for administering injectable agents requires careful attention. Education may be provided by physicians, nurses, community health workers, and other health care providers. The case manager will have a key role in providing education, coaching, and support to the patient through out treatment. Health care providers are encouraged to communicate with patients in a manner that is respectful, supportive and helps to build a positive partnership. Providers should avoid talking at patients and refrain from language that is judgmental or punitive. The analogy of preparing for a marathon has been suggested to emphasize the key role the case manager can play in coaching the patient through the various phases of treatment and by setting achievable interim goals. First phase the frst phase spans from diagnosis through the period of time the patient may require airborne infection isolation. If the patients medical needs are not given careful attention during this frst phase, the patient is at higher risk for becoming discouraged. Patients are less likely to comprehend treatment information if they are fearful or preoccupied with worries about their jobs or family members. Second phase Once the patient is stabilized on treatment, the emphasis of education will shift. During this phase, focus on helping the patient manage any side effects, maximizing nutrition and working together to identify barriers to adherence. Drug toxicity can occur at any phase in treatment and should continue to be closely monitored. Third phase If continued clinical response is achieved, the third phase begins when the parenteral agent is discontinued and lasts until the end of treatment. While this may sound much like nearing the home stretch, it is really closer to passing the halfway point. The patient may have another year or more of oral medication to complete before reaching the fnish line. The marathon is over, yet the patient will require clinical monitoring for the next 2 years to ensure that if a relapse occurs, it will be identifed and acted upon quickly. Provide the patient with appropriate referral and contact information as indicated. Most patients will need ongoing social and emo tional support to cope with these challenges. The case manager often plays a key role in providing emotional and social support by listening to the patient, and talking with patient and family to reduce stigma, fear, and misunderstandings about the disease. Do everything possible to get the family to cooperate and support the treatment plan. Assess the patients social support network and the strengths and barriers to adherence. Ensure that plans are in place for addressing issues such as mental illness, substance abuse, and homelessness. Facilitate referral to programs and services that can work with the patient on harm reduction. See Resources at the end of this chapter for tools to monitor for depression and psychosis. A patients cultural background, spiritual tradi tions, prior experiences of treating illness, and history of access to care may impact how he/she views the path towards health. Assessing patients understanding of and beliefs about their diagnoses and treatment plans can provide case managers and providers with important information to negotiate mutually acceptable approaches to treatment. Additional sites contain cultural information that may be helpful to the case manager in anticipating the patients cultural practices and needs. For patients with limited or no health insurance coverage, charges associated with the cost of drugs, diagnostic exams, and surgery may pose an extreme fnancial burden on individuals and families. Many patients experience a period of prolonged unemployment associated with the period of infectiousness and due to employment discrimination. The case manager may intervene and educate employers to help protect a patients job during the period the patient must remain on respiratory isolation. The case manager may also be instrumental in assisting to fnd alternative sources of income and/or other assistance. Addressing any fnancial challenges early in the patients course of treatment will go a long way in establishing a foundation of confdence and trust. The cost of these drugs is also variable, but in general, they are expensive, particularly when you factor in the length of treatment. Enablers such as transportation and food vouchers can be used to address some of the economic hardships experienced during treatment. Additionally, patient motivation commonly wanes once the patient begins to feel better and may affect the patients commitment to the treatment plan. Sim ple interventions geared at making the patients experience easier, as well as that of their family, can go a long way towards gaining commitment to treatment. For more information about incentives and enablers, see Resources section at the end of this chapter. The case manager should be knowledgeable about the process for referring such patients, and must ensure that all lesser restrictive measures that have been employed have been documented. Interjurisdictional transfers If the patient moves out of the case managers jurisdiction, concrete plans for transfer of care need to be in place before the move. Even if the patient moves out of country, an accepting provider and responsible jurisdiction need to be identifed and apprised of the patients disease and treatment history. These programs can work with patients who are considering a move prior to completion of therapy. This program also provides a treatment outcome report to the enrolling site upon case closure. Co-management with private providers If the patient is managed by a private provider: Make an appointment to meet the provider and the offce staff as soon as possible. Anticipate staff needs, such as an audiologist who takes the patients insurance or an interpreter whom the patient trusts. Reach an agreement about how and when important information (sputum and other laboratory results and radiographic results) will be shared between the private provider and public health agency. Below are some areas for special attention: Airborne infection isolation: Patients will require isolation and may not be returned to the general population until they are considered non-infectious (see section: Infection control for suggested criteria). The need for respiratory isolation may require movement to a hospital or different facility and additional coordination to ensure all providers involved know the treatment plan. Occasionally, patients are in isolation for prolonged periods and may require physical and/or occupational ther apy to prevent physical deconditioning and situational depression due to lack of movement and stimulation. Patients cannot be forced to take medications while incarcerated, and staff will need to work closely to address side effects and potential barriers to adherence.

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By adding the adjective extend its application beyond anaphylactic shock to treatment authorization request order epitol online from canada immediate/late or delayed medicine glossary epitol 100mg without prescription, we can both describe the include severe medicine jar paul mccartney purchase epitol with paypal, life-threatening attacks of broncho onset of symptoms and indicate the probable mediating spasm medicine norco purchase epitol once a day. Still other clinicians use it to describe any mechanisms, IgE and lymphocytes (71), respectively. If generalized or systemic allergic reactions, even if we wish to highlight the role of IgE antibody in a hypotension and severe bronchospasm are absent. All propose the following broad de nition: other reactions should be referred to as nonallergic drug hypersensitivity. Such reactions may have identi able Anaphylaxis is a severe, life-threatening, generalized or systemic hypersensitivity reaction. A positive intradermal skin test or a weak the reaction usually develops gradually, most often (<3 mm) skin prick test is not an objective or suf cient starting with itching of the gums/throat, the palms, or measure of an immunologic reaction for example, the soles, and local urticaria; developing to a multiple compare direct mediator release by certain neuropep organ reaction often dominated by severe asthma; and tides and basic secretagogues such as compound 48/80 culminating in hypotension and shock. Hypotension (18) and should not be accepted as the only evidence and severe bronchospasm do not have to be present for for a possible immunologic mechanism. An anaphylactic Acknowledgments reaction mediated by IgE antibodies, such as peanut We thank the following colleagues who have kindly acted as active induced food anaphylaxis or bee venom-induced test panels and discussion partners during the development of this anaphylaxis, may be called IgE-mediated anaphylaxis. The Arnold Oranje, Harald Renz, Timo Reunala, Frank Riedel, Joanna term anaphylactoid should not be used. Clin Rev Allergy dintroduction a letude` des prurigos epitopes in the IgE response of celery Immunol 1997;15:375387. Agents Actions Suppl Allergic disorders and immediate skin nonallergic rhinitis with a symptom 1989;28:233238. Allergy Neuropeptide-induced secretion from the lamina propria and proliferation 1987;42:161167. Studies in and IgE responses to common food placebo-controlled food challenge: a hypersensitiveness. Short-term anaphylactic the immunopathology of extrinsic dermatitis, psoriasis and normal IgG antibodies in human sera. Dietary antigens: uptake and related traits on chromosome 7 classi cation of early disease by humoral immunity in man. Unpublished Allergy Clin Immunol Bakt Parasits Infect I Abt Orig observation, 2001. New developments in the syngeneic bone marrow levels in atopic dermatitis and diagnosis and treatment of transplantation. Blackwell Science, Severe isolated allergy to Ficus prevalence of bronchial asthma and 1996. Atopic disease in outdoor allergens at the age of three immunology of the intrinsic (non seven-year-old children. Int Arch epidemiologische, allergologische cutaneous involvement and course of Allergy 1960;178 (Suppl):1106. Indoor allergen exposure is a risk im Radio-Allergo-Sorbens-Test bei Immunoglobulins in atopic dermatitis. Zur Immunpathologie Derm Venereol (Stock) eosinophilia and serum factors with der Neurodermitis constitutionalis. M ast tion to homing receptors for T lymphocytes that are selective for skin localizations and not for cells of the hum an skin, but not those of oth lung. We hope that the coming years will witness histam ine release from hum an skin m ast cells7. The direct activation of m ast cells cells, IgE antibodies, Langerhans cells, Preventive measures. This finding O pening the Scenario: the Cells O rchestrating dem onstrates that IgE-sensitization is a clear Cutaneous Inflam m ation cut reality. Keratinocytes exert an active im m un tact with allergens, since virgin T cells localize oregulatory role in concert with infiltrating poorly in skin16. Several potent, toxic and roborating the evidence of eosinophil degran cationic proteins, have been observed in the ulation in A D 27. It is therefore tem pting to activation of eosinophils have been dem on speculate that eosinophil cationic proteins, in strated. A lthough peripheral blood addition to noxious effects for the skin, m ay eosinophilia is a com m on feature of A D, ac contribute to the profound im m unologic ab cum ulation of tissue eosinophils is not prom i norm alities described in patients with A D. M ore rec severity38 represents only an indirect m easure ently, it has been studied the eosinophil de of the pathological process taking place in the granulation in hum an skin tissues. A m ajor breakthrough in deposition in the upper derm is, thus pro our understanding of A D pathogenesis oc 97 A. To date no definite m ay predom inate in the infiltrates in A D le consistent association has been found with sions81. A ccordingly, D A, but com plicated by asthm a and/or aller A D is less likely a m onogenic disorder with gic rhinitis (A R)77. In m onozygot increase in trans-epiderm al water loss charac ic (M Z) twins the pairwise concordance rate teristic of A D 93 (biochemical abnormalities). G enetic effects Immune abnormalities m ay account for 33-76% of the variation in li Several lines of evidence suggest that a va ability to atopic diseases, however twin girls riety of qualitative and/or quantitative im have a higher risk of being diagnosed with A D than boys87. G enetic-im m unologic and clinical features of ses the risk of early developm ent of A D (O R A D. In ad Genetic-im m unologic dition, when both parents have atopic disease G enetic background of atopic syndrom e of the sam e sort, the risk of atopic disease in Increased levels of allergen-specific IgE in serum their child is 80%; if parents have different and skin atopic disease the child has a risk of 61% of Norm al serum IgA, IgG and IgM concentrations developing a sim ilar phenotype, and when Preferential expression of allergen-specific Th2 only one parent is atopic the risk at 2 years is lym phocytes 38% 88,89. No univocal results of developing atopic disease com pared with have confirm ed that the T-cell im balance in neonates without fam ily history of atopy117-121. Thus in all likelihood the relevant of IgE, but also to the high IgE levels in 80% expansion of allergen-specific Th2 cells, of the children. A sim ilar im m une dysfunction is dir antigen presentation, such as monocytes and ectly involved in children with W A S or A D 85. H owever, additional eosinophils, 9% neutrophils, and 5% m ono evidence of the role of IgE-m ediated m echa cytes13. These two phases are thus character nism s is indirectly confirm ed by the recent ized by IgE-m ediated hypersensitivity reac dem onstration that: tions. A t 72 hrs epiderm al changes, incl lesion of A D in som e patients, who also ex uding focal spongiosis and m icrovesiculation perience eczem atous flaring following expo were evident along with a significant increase sure to ragweed pollen185. Cohen186 did a very interesting observation, Biopsy specim en of the positive lesions also which definitively showed that pollens can showed m ononuclear cell and neutrophil reach cutaneous m ast cells. Biopsies pollen was blown into the nostrils of 50 nor of the positive test sites revealed an eczem a m al control subjects passively sensitized in tous reaction with epiderm al spongiosis and tracutaneously with serum from a ragweed m icrovesiculation. Im m unostaining of cryo allergic patient and serum from non-atopic stat sections showed derm al cell infiltrates controls. Typical A D lesion oc duce in a patient asthm a and flares of A D curred on non m anipulated skin in 4/13 adults following inhalation of an A lternaria spray. They also dem onstrated the penetration of D er f hypothesized that inhalation of pollen led to (which was linked with ferritin) into the stra sweating, which was linked to the develop tum corneum, the epiderm is and the derm is. H owever, the lesions were present only in Eczem atoid changes developed which persis typical areas and only with previous skin ted for several days188,189. The authors hypothesized that A D, inhalation studies also with A lternaria: sweat rather than being prim ary eruption, is likely ing and pruritus developed within m inutes, to be the result of various repeated stim uli, and changes over 12-24 h developed in skin com bining reactions including type I and type sites, which lasted for 4-5 days190. In fact following halation studies of ragweed and A lternaria the percutaneous challenge with m ite aller provided the first evidence for a pathogenic gen, a type I reaction occurred in the pa role of aeroallergens in patients with A D. H owever, it delayed cutaneous response in 18 patients is of note that m ore than 50 years ago, Rost with A D applying various aeroallergen ex dem onstrated that the skin lesions rem ark tracts (20 w/v in 50% glycerin) on clinically ably im proved when patients with A D were uninvolved and not m anipulated skin. No only (at the gastrointestinal and/or skin lev positive responses were found in atopic pa el) cannot com pletely explain the histology tients without A D or in controls. When the ingested food with antibodies against granular constituents antigens com e into contact with the skin of the eosinophils revealed that infiltrating m ast cells, histam ine and other chem o eosinophils were in an activated state and attractants are released into skin tissue. The repeated in cells of the helper/inducer phenotype have gestion of food allergens was discovered to been observed. The release eosinophil chem otactic factors and finding that IgE m olecules from atopic pa som e of the infiltrating eosinophils becom e tients bind H R F but that IgE antibodies activated50. The role of skin infections and In a subsequent study of ours207, 146 chil bacterial superantigens dren with A D aged 6 m o-10 yr underwent 154 M icrobial pathogens initiate disease challenge tests, 61 of which (42%) were posi through a num ber of pathways. Clinical reactions elicited in 61 children posi ceptibility to a variety of m icrobial agents. R ecently a greatest focus has been con centrated on the significance of Staphy Sym ptom s N of children (%) lococcus aureus colonization and infection to the severity of A D skin lesions210. A D m ight therefore be a con release tumor necrosis factor a which induces sequence of im m une activation during expo endothelial leukocyte adhesion molecule 1. In Ruzicka T, Ring A D is a disease of offsprings of atopic par J, Pryzbilla B, eds.

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Vivek Gupta treatment using drugs is called discount epitol 100mg with visa, Importance of Examination of Tongue in Homeopathic Case Taking treatment 2011 generic 100 mg epitol mastercard, the Friends of Health medications related to the integumentary system order epitol cheap online, March symptoms retinal detachment discount epitol 100 mg with amex, 2015. No part of it may be reproduced, stored in a retrieval system, or transmitted, in any form or by any meanselectronic, mechanical, photocopy, recording, or otherwisewithout prior written permission of the publisher, except for brief quotations embodied in critical articles and reviews and testing and evaluation materials provided by publisher to instructors whose schools have adopted its accompanying textbook. Materials appearing in this book prepared by individuals as part of their of cial duties as U. However, the authors, editors, and publisher are not respon sible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the content of the publication. The authors, editors, and publisher have exerted every effort to ensure that drug selec tion and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant ow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly impor tant when the recommended agent is a new or infrequently employed drug. Perfect for use across multiple health care settings, the Handbook presents need-to-know information on nearly 200 commonly encountered diseases and disorders. The easy to-use, colorful, consistent, and alphabetized outline format enables readers to gain quick access to vital information on Disease (Pathophysiology) Clinical Manifestations Assessment and Diagnostic Methods Medical, Surgical, and Pharmacologic Management Nursing Management according to the Nursing Process For readers requiring more in-depth information, the Handbook is completely cross-referenced to chapters in Brun ner & Suddarths Textbook of Medical-Surgical Nursing, 12th edi tion. Special Features the Handbook places special emphasis on home and com munity-based nursing practice, patient education, and expected outcomes of care. Additional features include the following: Gerontologic ConsiderationsThumbnail descriptions and interventions related to the care of the older adult population, whose health care needs continue to expand at a rapid rate. Nursing AlertsInstant notes focused on priority care issues and hazardous or potentially life-threatening situations. Up-to-date appendices for use in clinicals, on the unit, and at home or in the community. These types of lymphomas are characteristically of a higher grade, indi cating aggressive growth and resistance to treatment. Symptoms include memory de cits, headache, dif culty concentrating, progressive confusion, psychomotor slowing, apathy, and ataxia, and in later stages global cogni tive impairments, delayed verbal responses, a vacant stare, spastic paraparesis, hyperre exia, psychosis, hallucinations, tremor, incontinence, seizures, mutism, and death. Depressive Causes of depression are multifactorial and may include a his tory of preexisting mental illness, neuropsychiatric disturbances, psychosocial factors, or response to the physical symptoms. Medical Management Treatment of Opportunistic Infections Guidelines for the treatment of opportunistic infections should be consulted for the most current recommendations. Other Infections Oral acyclovir, famciclovir, or valacyclovir may be used to treat infections caused by herpes simplex or herpes zoster. Esophageal or oral candidiasis is treated topically with clotri mazole (Mycelex) oral troches or nystatin suspension. Chronic refractory infection with candidiasis (thrush) or esophageal involvement is treated with ketoconazole (Nizoral) or u conazole(Di ucan). Chemotherapy Kaposis Sarcoma Treatment goals are to reduce symptoms by decreasing the size of the skin lesions, to reduce discomfort associated with edema and ulcerations, and to control symptoms associated with mucosal or visceral involvement. Combination chemotherapy and radiation therapy regimens may produce an initial response, but it is usually short-lived. Antidepressant Therapy Treatment of depression involves psychotherapy integrated with pharmacotherapy (antidepressants [eg, imipramine, desipramine, and uoxetine] and possibly a psychostimulant [eg, methylphenidate]). Nutrition Therapy A healthy diet tailored to meet the nutritional needs of the patient is important. Skin and Mucous Membranes Inspect daily for breakdown, ulceration, and infection. Respiratory Status Monitor for cough, sputum production, shortness of breath, orthopnea, tachypnea, and chest pain; assess breath sounds. Neurologic Status Assess mental status as early as possible to provide a base line. Fluid and Electrolyte Status Examine skin and mucous membranes for turgor and dry ness. Use of Alternative Therapies Question patient about the use of alternative therapies. Nursing Interventions Promoting Skin Integrity Assess skin and oral mucosa for changes in appearance, location and size of lesions, and evidence of infection and breakdown; encourage regular oral care. Maintaining Perianal Skin Integrity Assess perianal region for impaired skin integrity and infection. Promoting Usual Bowel Patterns Assess bowel patterns for diarrhea (frequency and consis tency of stool, pain or cramping with bowel movements). Preventing Infection Instruct patient and caregivers to monitor for signs and symptoms of infection. Teach col leagues and other health care workers to apply precautions to blood and all body uids, secretions, and excretions except sweat (eg, cerebrospinal uid; synovial, pleural, peritoneal, pericardial, amniotic, and vaginal uids; semen). Consider all body uids to be potentially hazardous in emergency circum stances when differentiating between uid types is dif cult. Improving Activity Tolerance Monitor ability to ambulate and perform daily activities. Improving Airway Clearance At least daily, assess respiratory status, mental status, and skin color. Coping With Grief Help patients explore and identify resources for support and mechanisms for coping. Monitoring and Managing Potential Complications Inform patient that signs and symptoms of opportunistic infections include fever, malaise, dif culty breathing, nau sea or vomiting, diarrhea, dif culty swallowing, and any occurrences of swelling or discharge. Assist patient and caregivers in tting the medication reg imen into their lives. In each case, a profound imbalance exists between myocardial oxygen supply and demand. These signs and symp toms, which are caused by stimulation of the sympathetic nerv ous system, may be present for only a short time or may persist. Assessment and Diagnostic Methods Patient history (description of presenting symptom; history of previous illnesses and family health history, particularly of heart disease). Previous history should also include infor mation about patients risk factors for heart disease. Medical Management the goals of medical management are to minimize myocardial damage, preserve myocardial function, and prevent complica tions such as lethal dysrhythmias and cardiogenic shock. Acute Coronary Syndrome and Myocardial Infarction 19 A Reduce myocardial oxygen demand and increase oxygen sup ply with medications, oxygen administration, and bed rest. Include history of chest pain or discomfort, dif culty breathing (dyspnea), palpi tations, unusual fatigue, faintness (syncope), or sweating (diaphoresis). Perform a complete physical assessment, which is crucial for detecting complications and any change in status. Nursing Interventions Relieving Pain and Other Signs and Symptoms of Ischemia Administer oxygen in tandem with medication therapy to assist with relief of symptoms (inhalation of oxygen reduces pain associated with low levels of circulating oxygen). Acute Coronary Syndrome and Myocardial Infarction 21 A Assess vital signs frequently as long as patient is experiencing pain. Improving Respiratory Function Assess respiratory function to detect early signs of compli cations. Promoting Adequate Tissue Perfusion Keep patient on bed or chair rest to reduce myocardial oxygen consumption. Reducing Anxiety Develop a trusting and caring relationship with patient; provide information to the patient and family in an hon est and supportive manner. Monitoring and Managing Complications Monitor closely for cardinal signs and symptoms that signal onset of complications. Evaluation Expected Patient Outcomes Experiences relief of angina Has stable cardiac and respiratory status Maintains adequate tissue perfusion Exhibits decreased anxiety Complies with self-care program Experiences absence of complications For more information, see Chapter 28 in Smeltzer, S. Nursing Management Closely monitor the patient; frequently assess effectiveness of treatment (eg, oxygen administration, nebulizer therapy, chest physiotherapy, endotracheal intubation or tracheostomy, mechanical ventilation, suctioning, bronchoscopy). Addisons Disease (Adrenocortical Insuf ciency) 25 A Addisons Disease (Adrenocortical Insuf ciency) Addisons disease occurs when the adrenal cortex function is inadequate to meet the patients need for cortical hormones. Autoimmune or idiopathic atrophy of the adrenal glands is responsible for the vast majority of cases. Other causes include surgical removal of both adrenal glands or infection (tubercu losis or histoplasmosis) of the adrenal glands.

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