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People using these devices still need to insert the needle for each injection; however symptoms ms women cytotec 200 mcg amex, they do not need to carry insulin bottles or to draw up insulin before each injection treatment eating disorders cheap 200mcg cytotec with visa. These pens are convenient for those who admin- Chapter 41 Assessment and Management of Patients With Diabetes Mellitus 1169 A B C D E meals medications after stroke cheap cytotec 200mcg line, exercise medications not covered by medicare buy discount cytotec 200 mcg on line, and travel) and, for many patients, improved blood glucose control. Hypoglycemia may occur with insulin pump therapy; however, this is usually related to the lowered blood glucose levels many patients achieve rather than to a specific problem with the pump itself. The tight diabetic control associated with using an insulin pump may increase the incidence of hypoglycemia unawareness because of the very gradual decline in serum glucose level from levels greater than 70 mg/dL (3. Some patients find that wearing the pump for 24 hours each day is an inconvenience. However, the pump can easily be disconnected, per patient preference, for limited periods (eg, for showering, exercise, or sexual activity). Insulin pump candidates must be willing to assess blood glucose levels multiple times daily while on pump therapy. In addition, they must be psychologically stable and open about having diabetes, because the insulin pump is often a visible sign to others and a constant reminder to the patient that he or she has diabetes. Most important, patients using insulin pumps must have extensive education in the use of the insulin pump and in selfmanagement of blood glucose and insulin doses. They must work closely with a team of health care professionals who are experienced in insulin pump therapy-specifically, a diabetologist/ endocrinologist, a dietitian, and a certified diabetes educator. Many insurance policies cover the cost of pump therapy; if it is not covered, the extra expense of the pump and associated supplies may be a deterrent for some patients. In addition, there is research into the development of implantable devices that both measure the blood glucose level and deliver insulin as needed. Methods of administering insulin by the oral route (oral spray or capsule), skin patch, and inhalation are undergoing intensive study. One main issue regarding pancreatic transplantation is weighing the risks of antirejection medications against the advantages of pancreas transplantation. This latter approach involves a less extensive surgical procedure and a potentially lower incidence of immunogenic problems. However, thus far, independence from exogenous insulin has been limited to 2 years after transplantation of islet cells. A recent study of patients with islet cell transplants using less toxic antirejection drugs has shown promise (Shapiro et al. In the United States, oral antidiabetic agents include the sulfonylureas, biguanides, alpha glucosidase inhibitors, thiazolidinediones, and meglitinides (Table 41-6). Sulfonylureas and meglitinides are considered insulin secretagogues because their action increases the secretion of insulin by the pancreatic beta cells. Therefore, a functioning pancreas is necessary for these agents to be effective, and they cannot be used in patients with type 1 diabetes. These agents improve insulin action at the cellular level and may also directly decrease glucose production by the liver. The sulfonylureas can be divided into first- and second-generation categories (see Table 41-6). Hypoglycemia may occur when an excessive dose of a sulfonylurea is used or when the patient omits or delays meals, reduces food intake, or increases activity. Because of the prolonged hypoglycemic effects of these agents (especially chlorpropamide), some patients need to be hospitalized for treatment of oral agent-induced hypoglycemia. Another side effect of chlorpropamide is a disulfiram (Antabuse) type of reaction when alcohol is ingested (see section on alcohol consumption for more information). Some medications may directly interact with sulfonylureas, potentiating their hypoglycemic effects (eg, sulfonamides, chloramphenicol, clofibrate, phenylbutazone, and bishydroxycoumarin). In addition, certain medications may independently affect blood glucose levels, thereby indirectly interfering with these agents. Medications that may increase glucose levels include potassium-losing diuretics, corticosteroids, estrogen compounds, and diphenylhydantoin (Dilantin). Medications that may cause hypoglycemia include salicylates, propranolol, monoamine oxidase inhibitors, and pentamidine. Second-generation sulfonylureas have the advantage of a shorter half-life and excretion by both the kidney and the liver. This makes these medications safer to use in the elderly, in whom accumulation of the medication can cause recurring hypoglycemia.

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A scan is performed to detect ventilation abnormalities in patients who have regional differences in ventilation symptoms nerve damage buy 100 mcg cytotec with amex. It may be helpful in the diagnosis of bronchitis symptoms whiplash discount cytotec online visa, asthma medicine 666 colds purchase generic cytotec canada, inflammatory fibrosis medicine examples order generic cytotec line, pneumonia, emphysema, and lung cancer. A gallium scan is a radioisotope lung scan used to detect inflammatory conditions, abscesses, adhesions, and the presence, location, and size of tumors. It is used to stage bronchogenic cancer and record tumor regression after chemotherapy or radiation. Gallium is injected intravenously, and scans are taken at 6, 24, and/or 48 hours to evaluate gallium uptake by the pulmonary tissues. The purposes of diagnostic bronchoscopy are: (1) to examine tissues or collect secretions, (2) to determine the location and extent of the pathologic process and to obtain a tissue sample for diagnosis (by biting or cutting forceps, curettage, or brush biopsy), (3) to determine if a tumor can be resected surgically, and (4) to diagnose bleeding sites (source of hemoptysis). Therapeutic bronchoscopy is used to: (1) remove foreign bodies from the tracheobronchial tree, (2) remove secretions obstructing the tracheobronchial tree when the patient cannot clear them, (3) treat postoperative atelectasis, and (4) destroy and excise lesions. The fiberoptic bronchoscope is a thin, flexible bronchoscope that can be directed into the segmental bronchi. Because of its small size, its flexibility, and its excellent optical system, it allows increased visualization of the peripheral airways and is ideal for diagnosing pulmonary lesions. Fiberoptic bronchoscopy allows biopsy of previously inaccessible tumors and can be performed at the bedside. It also can be performed through endotracheal or tracheostomy tubes of patients on ventilators. It is used mainly for removing foreign substances, investigating the source of massive hemoptysis, or performing endobronchial surgical procedures. Possible complications of bronchoscopy include a reaction to the local anesthetic, infection, aspiration, bronchospasm, hypoxemia (low blood oxygen level), pneumothorax, bleeding, and perforation. The nurse explains the procedure to the patient to reduce fear and decrease anxiety and administers preoperative medications (usually atropine and a sedative or opioid) as prescribed to inhibit vagal stimulation (thereby guarding against bradycardia, dysrhythmias, and hypotension), suppress the cough reflex, sedate the patient, and relieve anxiety. The examination is usually performed under local anesthesia, but general anesthesia may be needed for rigid bronchoscopy. A topical anesthetic such as lidocaine (Xylocaine) may be sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea to suppress the cough reflex and minimize discomfort. Sedatives or opioids are administered intravenously as prescribed to provide moderate sedation. After the procedure, it is important that the patient takes nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing for several hours. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The nurse assesses for confusion and lethargy in the elderly, which may be due to the large doses of lidocaine given during the procedure. Bronchoscopy permits the clinician not only to diagnose but also to treat various lung problems. The patient is not discharged from the recovery area until adequate cough reflex and respiratory status are present. The nurse instructs the patient and family caregivers to report any shortness of breath or bleeding immediately. Thoracoscopy Thoracoscopy is a diagnostic procedure in which the pleural cavity is examined with an endoscope. Small incisions are made into the pleural cavity in an intercostal space; the location of the incision depends on the clinical and diagnostic findings. After any fluid present in the pleural cavity is aspirated, the fiberoptic mediastinoscope is inserted into the pleural cavity, and its surface is inspected through the instrument. After the procedure, a chest tube may be inserted, and the pleural cavity is drained by negative-pressure water-seal drainage. Thoracoscopy is primarily indicated in the diagnostic evaluation of pleural effusions, pleural disease, and tumor staging. Thoracoscopic procedures have expanded with the availability of video monitoring, which permits improved visualization of the lung.

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Suctioning assists in removal of secretions that the patient may be unable to cough up severe withdrawal symptoms 200 mcg cytotec with mastercard, thereby assisting with maintaining a patent airway medications quit smoking order cytotec online from canada. In the immediate postoperative period medicine with codeine cytotec 100 mcg visa, place the stethoscope over the trachea to assess for stridor medicine 3601 cheap cytotec online. Place the patient in a sitting position and support the neck area with both hands. Instruct the patient in preoperative and postoperative oral hygiene using slightly alkaline solutions such as 8 oz of water mixed with 1 teaspoon of baking soda, or normal saline solution, every 4 hours. Oral care decreases oral bacteria, thereby decreasing the risk of bacterial infection postoperatively. Hydrogen peroxide should not be used, because it may break down fresh granulation tissue. Suction drainage negates the need for pressure dressings because the skin flaps are pulled down tightly. If portable wound suction is not used, pressure dressings may be applied to obliterate dead spaces and provide immobilization. Assess for any possible constrictions that would affect respirations or decrease blood flow to graft. Use aseptic technique to cleanse skin around the drains; change the dressings as ordered by surgeon (usually the second through fifth postoperative days). Assess for symptoms of infection: chills, diaphoresis, altered level of consciousness. Nursing Diagnosis: Impaired skin integrity Goal: Maintenance of intact skin and viability of graft 1. Poor nutritional status preoperatively impairs wound healing and increases potential for infection. A nasogastric tube may be in place for several days to administer enteral feedings. Passage of food may be tolerated better when the head is tilted to the unaffected side. Self-feeding difficulties may cause embarrassment and interfere with intake quantity. Develop nonverbal ways to communicate (eg, finger-tapping, sign language, sign board). Consult support groups such as New Voice Club through the American Cancer Society. Provide information on clothing/cosmetics to deemphasize physical defects (offer information on "Look Good, Feel Better" program through American Cancer Society). Communication with head movement may be impossible because of incisional pain and need to maintain position of neck for graft. A speech/language therapist may assist with other forms of communication, such as esophageal speech or electrolarynx. Damage to the hypoglossal nerve will result in excessive drooling and decreased ability to swallow. Management the patient should be instructed to eat slowly and to drink fluids with meals. As a temporary measure, calcium channel blockers and nitrates have been used to decrease esophageal pressure and improve swallowing. Injection of botulinum toxin (Botox) to quadrants of the esophagus via endoscopy has been helpful because it inhibits the contraction of smooth muscle. If these methods are unsuccessful, pneumatic (forceful) dilation or surgical separation of the muscle fibers may be recommended (Streeter, 1999; Annese et al. Achalasia may be treated conservatively by pneumatic dilation to stretch the narrowed area of the esophagus.

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Any break in these loops of communication (for example schedule 8 medications victoria cytotec 100mcg lowest price, an upper or lower neuron lesion symptoms 8 months pregnant discount cytotec 100mcg on-line, spinal stenosis treatment 3rd metatarsal stress fracture cytotec 100 mcg overnight delivery, or bladder outlet obstruction) can cause some degree of urinary dysfunction medicine knowledge cheap 100 mcg cytotec. Depending on the location of the insult, both incontinence and incomplete bladder emptying can occur. Anatomic integrity of the upper and lower urinary system must be intact; otherwise, urine extravasation into the peritoneal or perivesical cavity (as seen in acute trauma) or extraurethral incontinence (as seen in some forms of congenital malformations) will occur. Genitourinary fistula formation between the bladder wall and other areas, such as the vagina, will result in extraurethral incontinence. When voiding dysfunction occurs in adults, it may affect only the lower urinary system (eg, the bladder and urethra); when voiding dysfunction occurs in children, it commonly involves damage to the upper urinary system (ie, the ureters and kidneys) as well. Many congenital anomalies are discovered early in utero because of prenatal care measures such as ultrasound. The urinary system begins developing days after conception, and anomalies can be seen on a sonogram as early as 20 weeks. Because the urinary system may be only one of several organ systems that are abnormal due to genetic disorders, any defects not noted during gestation should be immediately apparent at birth. Such anomalies include renal agenesis (complete absence of one or both kidneys), ectopic ureter, and Eagle-Barrett syndrome (also known as prune-belly syndrome), with exstrophy of the bladder. On the other hand, voiding dysfunction can be discovered insidiously (for example, during toilet training). At times congenital anomalies, such as posterior urethral valves, typically seen only in males, may escape detection until early adolescence or adulthood, when the voiding dysfunction or its sequelae cause the individual to seek a urologic evaluation. Although pediatric in nature, these disorders may affect urinary tract function when the patient becomes an adult. The micturition (voiding) process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying (see Chap. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction (such as benign prostatic hyperplasia), causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelves. Clinical Manifestations: Types of Incontinence Stress incontinence is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure (sneezing, coughing, or changing position). It predominately affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly bladder wall irritability (Reilly, 2001; Sueppel et al. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction (Chancellor, 1999). Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. This commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness of the need to void. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder. Both neurologic abnormalities (eg, spinal cord lesions) and factors that obstruct the outflow of urine (eg, tumors, strictures, and prostatic hyperplasia) can cause overflow incontinence (Reilly, 2001). Iatrogenic incontinence refers to the involuntary loss of urine due to extrinsic medical factors, predominantly medications. In some individuals with an intact urinary system, these agents adversely affect the alpha receptors responsible for bladder neck closing pressure; the bladder neck relaxes to the point of incontinence with a minimal increase in intra-abdominal pressure, thus mimicking stress incontinence. As soon as the medication is discontinued, the apparent incontinence resolves (Reilly, 2001). Only with appropriate recognition of the problem, assessment, and referral for diagnostic evaluation and treatment can the outcome of incontinence be determined.

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Administer and monitor effects of prescribed treatment for nausea symptoms 3 months pregnant order cytotec 100 mcg on-line, vomiting medications kidney patients should avoid buy 100mcg cytotec fast delivery, and delayed gastric emptying medicine cabinets discount 100mcg cytotec overnight delivery. Assess and modify environment to eliminate unpleasant odors and other factors that cause nausea schedule 6 medications discount cytotec 100mcg with amex, vomiting, and anorexia. Remove items that may reduce appetite (soiled tissues, bedpans, emesis basins, clutter). Reduce the focus on "balanced" meals; offer the same food as often as the patient desires it. For example, add dry milk powder to milk, and use this fortified milk to prepare cream soups, milkshakes, and gravies. Allow and encourage the patient to eat when hungry, regardless of usual meal times. Eliminate or reduce noxious cooking odors, pet odors, or other odors that may precipitate nausea, vomiting, or anorexia. Encourage adequate fluid intake, dietary fiber, and use of bowel program to prevent constipation. Administer and monitor effects of topical and systemic treatment for oropharyngeal pain. Recent research links cytokines produced by the body in response to a tumor to a complex inflammatory-immune response present in patients whose tumors have metastasized, leading to anorexia, weight loss, and altered metabolism. Eating, feeding, and sharing meals are important social activities in families and communities, and food preparation and enjoyment are linked to happy memories, strong emotions, and hopes for survival. For the patient with serious illness, food preparation and mealtimes often become battlegrounds where well-meaning family members argue, plead, and cajole to encourage the ill person to eat. It is not unusual for seriously ill patients to lose their appetites entirely, to develop strong aversions for foods they have enjoyed in the past, or to crave a particular food to the exclusion of all other foods. Although nutritional supplementation may be an important part of the treatment plan in early or chronic illness, unintended weight loss and dehydration are expected sequelae of progressive illness. As illness progresses, patients, families, and clinicians may believe that without artificial nutrition and hydration, the terminally ill patient will "starve," causing profound suffering and hastened death. However, starvation should not be viewed as the failure to implant tubes for nutritional supplementation or hydration of terminally ill patients with irreversible progression of disease. Studies have demonstrated that terminally ill patients who were hydrated had neither improved biochemical parameters nor improved states of consciousness (Waller, Hershkowitz & Adunsky, 1994). Similarly, survival was not increased when terminally ill patients with advanced dementia received enteral feeding (Meier, Ahronheim, Morris et al. Further, in patients who are close to death there are beneficial effects to withholding or withdrawing artificial nutrition and hydration, such as decreased urine output and incontinence, decreased gastric fluids and emesis, decreased pulmonary secretions and respiratory distress, and decreased edema and pressure discomfort (Zerwekh, 1987). Nurses should instruct the family how to separate feeding from caring by demonstrating love, sharing, and caring by being with the loved one in other ways. Preoccupation with appetite, feeding, and weight loss diverts energy and time that the patient and family could use in other meaningful activities. Spiritual intervention, music therapy, gentle massage, and therapeutic touch may provide some relief. Reducing environmental stimuli, avoiding harsh lighting or very dim lighting (which may produce disturbing shadows), the presence of familiar faces, and gentle reorientation and reassurance are also helpful. Depression Clinical depression should not be accepted as an inevitable consequence of dying, nor should it be confused with sadness and anticipatory grieving, which are normal reactions to the losses associated with impending death. Emotional and spiritual support and control of disturbing physical symptoms are appropriate interventions for situational depression associated with terminal illness. The psychological sequelae of cancer pain have been linked to suicidal thought and less frequently to carrying out a planned suicide (Ripamonti, Filiberti, Totis et al. Cancer patients with advanced disease are especially vulnerable to delirium, depression, suicidal ideation, and severe anxiety (Roth & Breitbart, 1996). Higher levels of debilitation predict higher levels of pain and depressive symptoms, and the presence of pain doubles the likelihood of developing major psychiatric complications of illness (Roth & Breitbart, 1996). Patients and their families must be given space and time to experience sadness and to grieve, but patients should not have to endure untreated depression at the end of their lives. Add dry milk powder to milkshakes and cream soups to increase protein and calorie content.