Carey Kernodle Anders, MD

• Instructor in the Department of Medicine
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/carey-kernodle-anders-md

Identify the health teaching needs of this patient regarding "stockpiling" (saving) antibiotics anxiety relief tips discount 300 mg wellbutrin overnight delivery. Vital signs: Central line-associated blood stream infections-United States depression definition and description buy wellbutrin without prescription, 2001 depression definition laut who buy wellbutrin with amex, 2008 depression definition free dictionary buy wellbutrin 300 mg on line, and 2009 depression definition icd 10 best wellbutrin 300 mg. Effect of cost sharing on prescription drug use by Medicare beneficiaries prior to the Medicare drug benefit and potential adverse selection in the benefit. Identify the classes of antibiotics that act by inhibiting bacterial protein synthesis. Explain how protein synthesis inhibitors exert selective toxicity toward bacterial, rather than human, cells. Describe means by which bacteria become resistant to protein synthesis inhibitors. Apply the nursing process to care for patients who are receiving pharmacotherapy with bacterial protein synthesis inhibitors. Antibacterial drugs that inhibit this high rate of protein metabolism can either kill the bacterial cell or slow its replication rate. Tetracyclines, macrolides, and a few miscellaneous drugs are bacteriostatic inhibitors of protein synthesis. The importance of protein to a microbe is illustrated by the fact that up to 50% of the dry weight of a bacterial cell consists of protein. For example, the bacterial enzymes required for all biochemical reactions are proteins. Proteins are studded in the plasma membrane and serve as channels, pores, or transporters, assisting substances as they move into and out of cells. Like human proteins, bacterial proteins are composed of long chains of amino acids. Bacterial cells produce protein toxins, which kill other bacteria and can cause serious injury to human cells. The structure of the bacterial cell wall (see Chapter 50) consists of peptidoglycan layers of protein and carbohydrates that protect the bacterium from its environment. From these examples, it is easy to understand cholestatic why proteins are critical to bachepatitis, 865 terial cells. The protein may be active immediately, or it may be processed to its active form in the Golgi body. The finished protein may be used within the bacterial cell (enzymes) or be exported outside (toxins). All cells, including bacteria, are able to quickly increase protein synthesis to meet their growth demands or to respond to environmental challenges. For example, a bacterium may receive a message that other competitive bacteria are in the vicinity. If both humans and bacteria conduct continuous protein synthesis, why are antibiotics that inhibit protein synthesis not also toxic to human cells The answer lies in differences in the structures of the bacterial and human ribosomes. Ribosomes are composed of two subunits, one of which is larger and less dense than the other. The entire bacterial ribosome is called a 70S ribosome (Svedberg units are not additive). Antibiotics that inhibit protein synthesis do so by affecting subunits of the bacterial ribosome. The 80S human ribosome is mostly unaffected by antibiotics that bind to the bacterial 70S ribosome, thus providing a degree of selective toxicity. Interestingly, human mitochondria do contain a 70S ribosome that is affected by several of these antibiotics, thus explaining some of the adverse effects of these drugs. About 20 drugs that affect the synthesis of bacterial proteins have been discovered. Risk factors include age (toddler or adolescent), infrequent travel to developing regions, lack of infection control practices such as hand washing or care in eating or drinking, and daily use of a proton pump inhibitor (de la Cabada Bauche & DuPont, 2011). Travelers can decrease their risk by practicing frequent hand cleansing with hand sanitizers or antiseptic cloths; avoiding beverages with ice, not drinking water that has not been boiled, and not using tap water for teeth brushing; and not consuming raw fruits or vegetables that cannot be peeled because they may be contaminated. The nurse should assess for allergies and provide patient education on when the antibiotic should be used. The nurse should teach that local health authorities should be contacted if the diarrhea worsens, is accompanied by severe abdominal pain or fever, or if blood is present in the stool. The five tetracyclines are effective against a large number of aerobic and anaerobic gram-negative and gram-positive organisms: They have one of the broadest antimicrobial spectrums of any class of antibiotics. They are effective against some species that are resistant to penicillins and other cell wall inhibitors. Because of widespread bacterial resistance, however, they are the drugs of choice for only a few diseases: Rocky Mountain spotted fever, typhus, cholera, Lyme disease, peptic ulcers caused by Helicobacter pylori, and chlamydial infections. In addition, Treponema pallidum (syphilis) responds well to tetracycline therapy for patients who are allergic to penicillin. Although traditionally used for gonorrhea, most strains of Neisseria gonorrhoeae are now resistant to tetracyclines. Once resistance develops to one tetracycline, it usually extends to all drugs in this class. Tetracyclines exert a bacteriostatic effect by selectively inhibiting bacterial protein synthesis. Resistance to tetracyclines develops when bacteria prevent tetracyclines from concentrating inside their cells, or when their ribosome shape is altered so the antibiotic can no longer bind. In addition to having ribosomes with different structures, human cells lack the active transport system required for tetracyclines to enter their cells. All tetracyclines have the same spectrum of antimicrobial activity and similar adverse effects. Photosensitivity is a relatively common adverse reaction to some medications, especially antibiotics. Nurses should counsel patients on the risk of medication-induced photosensitivity and ways to avoid this problem. However, this medication-induced adverse effect can present in two categories: phototoxicity and photoallergic reactions. The more common of the two conditions is phototoxicity, which encompasses both sunburn and reactions caused by chemical photosensitizers such as medications. Both reactions are typically manifested by delayed redness and edema followed by hyperpigmentation. These reactions present as variations of contact dermatitis and are the result of hypersensitivity. In photoallergic reactions, the drug forms an immunogenic complex with cutaneous proteins due to the presence of light energy. Nurses should educate patients about various methods to protect the skin from damage and severe reactions to the sun. The proper use of protective clothing and sunscreens and restrictions on the amount of time spent in direct sunlight are needed to avoid these problems. They are sometimes classified by their duration of action as short acting, intermediate acting, or long acting. Because gastric distress is relatively common with drugs in this class, patients will often take tetracyclines with food. However, these drugs bind metal ions such as calcium and iron, and tetracyclines should not be taken with milk or iron supplements. Food does not interfere with absorption of the longer acting drugs doxycycline and minocycline. Tetracycline-induced diarrhea is common and could indicate toxic effects on normal flora or a bowel superinfection. Caused by Clostridium difficile, this is a rare though potentially severe disorder resulting from therapy with tetracyclines and other classes of antibiotics. When administered parenterally or in high doses, certain tetracyclines can cause hepatotoxicity, especially in patients with preexisting liver disease. Some patients experience photosensitivity during therapy, making their skin especially susceptible to sunburn. Photosensitivity may appear as exaggerated sunburn within minutes to hours of exposure and is often accompanied by a tingling, burning sensation. Because of their broad spectrum, superinfections due to Candida albicans are relatively common. Women who are on oral contraceptives may be more susceptible to vaginal candidiasis. Tetracyclines are usually contraindicated in pregnant or lactating women and in children under the age of 8 because these drugs cause yellow-brown teeth discoloration and may slow the overall growth rate in fetuses or children. Oral and topical preparations are available for treating inflammatory acne vulgaris. The growing amino acid chain is prematurely terminated and protein synthesis is inhibited. Tetracycline is usually considered bacteriostatic, although it can be bacteriocidal at high concentrations. Other frequent adverse effects include nausea, vomiting, epigastric burning, diarrhea, discoloration of the teeth, and photosensitivity. Serious adverse reactions include anaphylaxis; fatty degeneration of the liver, producing jaundice; and exfoliative dermatitis. Although not nephrotoxic, tetracycline can worsen kidney impairment in patients with preexisting disease. As a pregnancy category D agent, tetracycline should not be used during pregnancy. Drug therapy must be monitored carefully in patients with impaired hepatic or renal function, because this drug is excreted by these routes. Drug Interactions: Calcium or iron supplements, magnesiumcontaining laxatives, and antacids reduce the absorption and serum levels of oral tetracycline. Tetracycline eliminates vitamin K­producing bacteria in the intestines; patients taking warfarin may experience an increased anticoagulant effect. Demeclocycline (Declomycin): Approved in 1960, demeclocycline has the same spectrum of action and indications as other drugs in this class. Unrelated to its anti-infective properties, demeclocycline is the only drug in this class that has the ability to stimulate urine flow by blocking the reabsorption of water in the distal renal tubule. Photosensitivity is more severe with demeclocycline than with any other drug in this class. Demeclocycline undergoes extensive enterohepatic recirculation and is excreted in the bile; thus doses should be reduced for patients with hepatic impairment. Doxycycline (Vibramycin, Others): Approved in 1967, doxycycline is the safest tetracycline for patients with impaired renal function because it is excreted primarily by nonrenal routes. It is absorbed well, with or without food, and offers the advantage of once- or twice-daily dosing. Doxycycline is recommended as an alternative to ciprofloxacin for the prophylactic treatment of Bacillus anthracis (anthrax). Adverse effects and contraindications are the same as those of other tetracyclines. Two doxycycline products are available for the treatment of chronic periodontitis in adults. Atridox is administered as a topical, subgingival controlled release product, and Periostat is given as an oral tablet. Approved in 2006, Oracea is a dual-release capsule, containing immediate and delayed release beads for the treatment of inflammatory lesions of the skin associated with rosacea. Minocycline (Minocin, Others): Approved in 1971, minocycline offers the advantage of once or twice a day dosing and may be administered without regard to meals or dairy products. It is the only tetracycline that can cause reversible vestibular toxicity, resulting in dizziness, vertigo, and weakness that can limit therapy. Minocycline is active against some strains of bacteria that are resistant to other drugs in the tetracycline class. Other adverse effects and contraindications are the same as those of other tetracyclines. A microsphere powder formulation, called Arestin, is introduced subgingivally to treat periodontitis. In 2006, Solodyn, an extended release tablet, was approved for the treatment of inflammatory lesions associated with moderate to severe acne vulgaris in patients over 12 years of age. Patient and Family Education: Before application of the topical drug, clean the affected skin area with soap and water, rinse, and dry well. Drugs Similar to Tetracycline (Sumycin, Others) Other tetracyclines include demeclocycline, doxycycline, minocycline, and tigecycline. Nausea and vomiting are the most frequent adverse effects, and these may be severe enough to cause discontinuation of therapy. A slight increase in mortality has been reported with the use of tigecycline, although its cause remains unknown. Hepatic function laboratory values should be monitored during therapy to assess for hepatotoxicity. If antibiotics had been available back then, most of the estimated 200 million people who died would likely have survived after a 10-day treatment with tetracyclines or aminoglycosides (Dufel, 2011). Erythromycin (EryC, Erythrocin, Others), the first macrolide antibiotic, was isolated from Streptomyces organisms in a soil sample in 1952. The name macrolide was chosen for this drug class because they all possess an unusually large 14- to 15-atom ring as part of their chemical structure. Macrolides are considered alternative drugs for patients who are allergic to penicillin. They are widely prescribed although they are the drugs of first choice for relatively few diseases.

Critical Thinking Questions What can the nurse teach the child or adolescent and their family to decrease the risk of developing adverse cardiometabolic effects when an atypical antipsychotic drug has been prescribed Ziprasidone causes less weight gain than other atypical antipsychotics and does not cause agranulocytosis depression symptoms pdf buy 300 mg wellbutrin with amex. From what you learned in Chapter 23 rain depression definition 300 mg wellbutrin purchase mastercard, what two drugs are usually combined with the atypical antipsychotics The balance between these two activities appears to account for the decrease in observed adverse effects anxiety heart rate effective 300 mg wellbutrin, relative to other antipsychotic agents depression definition investopedia discount generic wellbutrin canada. Aripiprazole (Abilify) is the only approved drug in this class at the current time depression definition dsm 4 cheap wellbutrin 300 mg free shipping. It is hoped that this new class will have the same efficacy as other antipsychotic classes, with fewer serious adverse effects. So far this appears to be the case, although the drug is too new and long-term studies are needed. Black Box Warning: this drug is not indicated for the treatment of dementia-related psychosis. Antidepressants increase the risk of suicidal thinking and behavior in children, adolescents, and young adults. Contraindications/Precautions: Lactation, seizure disorders, or hypersensitivity are contraindications to the use of aripiprazole. Precautions must be taken when administering aripiprazole to persons with cardiovascular or cerebrovascular disease or any condition that predisposes them to hypotension. Aripiprazole is generally classified with the atypical antipsychotics because of its ability to control both negative and positive symptoms. Aripiprazole appears to have the same level of effectiveness as other atypical antipsychotics but with a lower incidence of adverse effects. An advantage over other atypical agents is that there is little or no weight gain, hypotension, dysrhythmias, anticholinergic effects, or prolactin release with aripiprazole. In 2007, the drug received approval as an add-on for major depressive disorder in patients whose symptoms were not relieved by antidepressants alone. In 2009, aripiprazole was approved to treat irritability associated with autism spectrum disorder in children. The drug is approved for pediatric patients ages 13 to 17 for schizophrenia, ages 10 to 17 for bipolar disorder, and ages 6 to 17 for autism. Decreased excretion of aripiprazole may occur with the use of drugs such as fluoxetine or paroxetine. Herbal/Food: Grapefruit juice may increase the serum levels of aripiprazole and cause toxicity. Treatment of Overdose: Overdose can cause vomiting, tremor, and drowsiness, but fatalities have not been reported. Nursing Responsibilities: Key nursing implications for patients receiving aripiprazole are included in the Nursing Practice Application for Patients Receiving Antipsychotic Pharmacotherapy on pages 342­344. Lifespan and Diversity Considerations: Assist the older patient to ambulate if dizziness occurs to prevent falls, because these patients are more prone to orthostatic hypotension. Caregivers should assess that the medication is taken as prescribed and report any nonadherence to the provider. Notify the provider of weight gain over 2 kg (5 lbs) in 1 week or as directed by provider. Do not drink alcohol while taking this drug because it may cause excessive drowsiness. Drugs Similar to Aripiprazole (Abilify) There are no other dopamine system stabilizers. Assessment throughout administration: Potential Nursing Diagnoses Disturbed Thought Processes, related to the disease process Disturbed Sensory Perception (Auditory, Visual) Disturbed Personal Identity Anxiety Impaired Verbal Communication Impaired Social Interaction Ineffective Health Maintenance Impaired Home Maintenance Noncompliance Deficient Knowledge (Drug Therapy) Caregiver Role Strain Risk for Self-Directed Violence Risk for Other-Directed Violence Risk for Self-Mutilation Assess for desired therapeutic effects. Because the drugs do not cure the underlying disorder, if regular administration is disrupted, symptoms may return abruptly. Ensure patient safety; monitor ambulation until the effects of the drug are known. For patients who are taking the medications at home or at an outpatient clinic, avoid driving or other activities requiring mental alertness or physical coordination until the effects of the drug are known. Avoid alcohol-based mouthwashes, which are drying to the mucosa and which the patient may drink. Tolerance to anticholinergic effects such as drowsiness usually develops over time. George Watkins is a 47-year-old African American male who was admitted to the psychiatric unit this morning. Although it is summer, he is wearing an overcoat and a winter hat pulled down over his ears. About 3 to 4 weeks before each hospitalization for psychosis, he stopped taking his antipsychotic medication. He has taken different antipsychotic medications over the course of his schizophrenia, but none has proved to be successful over a long period. Both children do well in school, have many friends, and are active in several organizations and sports. As the children get older, they realize that "something is not quite right" with their father. He was active in sports, starred on the high school football team, was an honor student, was a Boy Scout, and had many friends. George is always welcome at family gatherings, but relatives tend to avoid him when his behavior becomes bizarre. They all know he has schizophrenia but do not fully understand the implications of the diagnosis. Prior to discharge, the nurse provides teaching related to adverse effects of phenothiazines to the client and caregivers. The nurse expects that the client experiencing extrapyramidal symptoms during therapy with phenothiazines will be prescribed: 1. She is agitated and paces back and forth in the day room until she is called for dinner. Her agitation escalates until she cannot calm herself down and will not listen to staff. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. Antipsychotic medication in adolescents suffering from schizophrenia: A metaanalysis of randomized controlled trials. Second-generation antipsychotics in major depressive disorder: Update and clinical perspective. Chinese herbal medicine for schizophrenia: Cochrane systematic review of randomised trials. Apply the nursing process to care for patients receiving pharmacotherapy for degenerative diseases of the central nervous system. In nearly all cases, medications are unable to cure or reverse the progressive nature of these disorders, and the symptomatic relief provided by the drugs is only temporary. The etiology of most neurodegenerative diseases is unknown, although the loss of neurons appears to have both genetic and environmental components. It is likely that exposure of neurons to various toxins, genetic predisposition, and normal aging processes all have important roles in the etiology of these disorders. Because of this, neurodegenerative disorders are quite difficult to diagnose in their early stages. With some of them, diagnosis is made only after other neurologic, infectious, cardiovascular, or traumatic etiologies have been ruled out. Approximately 60,000 new cases are diagnosed each year (National Parkinson Foundation, n. Each involves a progressive and irreversible loss of neuron function in the brain or spinal cord, or both. A degenerative disease of the motor neurons characterized by weakness and atrophy of the muscles of the hands, forearms, and legs, spreading to involve most of the body and face; symptoms usually begin during the middle years, with death occurring within 2­5 years. A rare hereditary condition characterized by progressive chorea and mental deterioration resulting in dementia; symptoms usually begin in the 30s­50s with death occurring within 15 years. A chronic debilitating autoimmune disease characterized by fatigue, muscle weakness, difficulty with balance and walking, and vision, hearing and speech abnormalities; symptomatic periods alternate with remissions; symptoms vary depending upon which portion of the nervous system is experiencing inflammation. A debilitating disease characterized by resting tremor, muscle rigidity, hypokinesia, masklike faces, and a slow, shuffling gait. The disease is progressive, with the expression of full symptoms developing over many years. Some patients with idiopathic parkinsonism have a family history of the disorder, and a genetic link is highly probable. Once a patient on antipsychotic therapy shows signs of parkinsonism, the drug is normally discontinued. The patient reports feeling tired and seems to move more slowly, often demonstrating a slight tremor along with fatigue. Many develop thought disturbances, and dementia may occur, especially in those over age 70. These associated health problems often require pharmacologic intervention, which increases the possibility of drug interactions and adverse effects in these patients. Neurotransmitter deficiencies in specific regions of the brain are closely associated with the disease. Involuntary muscle movements are controlled by the basal nuclei (also called basal ganglia), which are clusters of interconnected neurons in several distinct regions of the brain. The basal nuclei are responsible for regulating the flow of information from the cerebral cortex to the motor neurons in the spinal cord. This region helps to synchronize stopping and starting activity such as that which occurs during walking. The student should review the functions of the basal nuclei and associated structures in Chapter 21. The substantia nigra, a dark band of gray matter in the midbrain, is a primary producer of the neurotransmitter dopamine. The dopamine travels through axons along the nigrostriatal pathway to the striatum (also called corpus striatum), where the neurotransmitter is released. Dopamine serves an inhibitory function, slowing the flow of impulses down spinal neurons. When dopamine is present, the normal flow of motor impulses from the striatum helps to produce coordinated, unconscious muscle movement. Should levels of dopamine fall because of the loss of dopamine-producing neurons in the substantia nigra, symptoms of parkinsonism may develop. Remarkably, the body can function normally even when as many as 50% of the neurons stop producing dopamine. A second neurotransmitter modulates the effects of neuronal outflow from the striatum. Under normal conditions, the inhibitory effects of dopamine and the excitatory effects of Ach balance one another and produce smooth, coordinated muscle movement. The hands and head develop a palsy-like, continuous motion or shaking when at rest. The tremors may be so pronounced that the person cannot hold a glass or eating utensils and successfully bring them to his or her mouth. Pill rolling is a common behavior in progressive states, in which patients rub the thumb and forefinger together in a circular motion, resembling the motion of rolling a tablet between two fingers. Changes in facial expression, or a lack of facial expression, are due to rigidity of the facial muscles. This rigidity can lead to chewing and swallowing difficulties if the pharyngeal muscles are involved. Although the symptoms may be less noticeable at first, they progress and become obvious in later years. An involuntary slowness of voluntary movement and speech, bradykinesia is one of the most noticeable of all symptoms and is marked by difficulty chewing, swallowing, or speaking. Patients shuffle their feet without taking normal strides, making walking difficult. From what you learned in Chapter 16, what are the other two major catecholamines found in the nervous system Antiparkinson agents are given to restore the balance between dopamine and Ach in specific regions of the brain. This may be accomplished by directly replacing dopamine, decreasing the breakdown of dopamine, increasing the release of dopamine from neurons, or activating dopamine receptors. Although pharmacotherapy does not cure this disorder, symptoms are dramatically reduced in many patients. Patients receiving prolonged antiparkinson pharmacotherapy may periodically experience a loss of drug effect. Symptoms become worse near the end of the cycle because the concentration of the drug has fallen below the therapeutic level. Adjusting the dosing interval to provide for more frequent dosing may help to reduce this effect. The on-off syndrome occurs when the patient alternates between symptom-free periods (on) and times when the drugs stop working and symptoms abruptly reappear (off). Scheduling doses closer together or using a second, adjunct medication during the off period are strategies used to reduce the on­off syndrome. Symptoms of parkinsonism are major adverse effects of several classes of antipsychotic drugs (see Chapter 24). Recall from Chapter 24 that antipsychotic drugs act through a blockade of dopamine receptors. Again, these treatments may help control symptoms, but they will not cure or prevent the disease from progressing. Drug therapy attempts to restore the functional balance of dopamine and Ach in the striatum of the brain.

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Lurasidone (Latuda): Approved in 2010 anxiety medication order wellbutrin 300 mg on line, lurasidone is one of the newer atypical antipsychotics approved to treat patients with schizophrenia depression explained comic wellbutrin 300 mg low cost. Lurasidone blocks dopamine receptors and its effectiveness is similar to that of other atypical antipsychotics great depression america definition generic 300 mg wellbutrin amex. Common adverse effects are typical of other drugs in this class: somnolence depression gifs 300 mg wellbutrin order free shipping, akathisia mood disorders johns hopkins 300 mg wellbutrin for sale, nausea, agitation, and parkinsonism. It is used to treat both the positive and negative symptoms of schizophrenia, and it is also approved to treat acute agitation and mania associated with bipolar disorder (see Chapter 23). It is also being used experimentally to treat nausea and vomiting in patients with cancer. Weight gain has been reported in up to 25% of patients and is a frequent cause for discontinuation of the drug. Other common adverse effects include dizziness, nervousness, insomnia, headache, and hostility. The risk of patients developing type 2 diabetes mellitus is greater with the use of olanzapine than with other atypical agents. A major Drugs Similar to Risperidone (Risperdal) Other drugs classified as atypical antipsychotics include asenapine, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, and ziprasidone. Aripiprazole (Abilify) is an atypical antipsychotic that is a prototype for a new pharmacologic class (see Section 24. Asenapine (Saphris): One of the newest of the atypical antipsychotics, asenapine was approved in 2009. One unique feature of asenapine is that it is approved to treat both schizophrenia and manic or mixed episodes associated with bipolar disorder. A second advantage is that it is administered by the sublingual route, which bypasses hepatic first-pass metabolism. The types and incidences of adverse effects appear to be similar to those of other drugs in this class. Clozapine (Clozaril): In 1989, clozapine (Clozaril) was the first atypical antipsychotic approved for use in the United States. Clozapine is approved for the management of schizophrenia in patients resistant to standard therapies and to reduce the risk of recurrent suicidal behavior in patients with schizophrenia. Off-label indications include treatment of bipolar disorder, severe obsessive­compulsive disorder, and dementia-related behavioral disorders. Clozapine is available as regular tablets or as oral disintegrating tablets (FazaClo). Because of potentially severe adverse effects, it is generally reserved for schizophrenia symptoms that have not responded favorably to other drugs. Although it occurs in less than 1% of patients taking the drug, agranulocytosis can be fatal. To avoid toxicity, clozapine therapy requires special monitoring and surveillance requirements. Paliperidone (Invega): Approved in 2006, paliperidone is one of the newer antipsychotics approved for the acute and maintenance therapy of schizophrenia. Paliperidone can improve both the positive and negative symptoms of schizophrenia. Paliperidone is the principal active metabolite of risperidone, an agent that is the prototype antipsychotic for this class. The drug is not extensively metabolized in the liver; thus it has less potential for drug­drug interactions than many other antipsychotics. The most common reported adverse effects include restlessness, akathisia, tachycardia, orthostatic hypotension, syncope, increased sensitivity to environmental heat, and sleepiness. It does not cause neutropenia or agranulocytosis and does not appear to lower the seizure threshold. Like other drugs in this class, paliperidone should not be used to treat dementiarelated psychoses in elderly patients because it increases the risk of death due to stroke, heart failure, or infections, especially pneumonia. Quetiapine (Seroquel): Approved to treat both positive and negative symptoms of schizophrenia in 1997, indications were later extended to include the short-term therapy of acute mania associated with bipolar disorder. In 2007, the drug was also approved to treat depression associated with bipolar disorder. It is sometimes used off-label to treat obsessive­ compulsive disorder that is unresponsive to other therapies. Lens changes have occurred during quetiapine use; thus it is recommended for baseline and 6-month eye examinations to be conducted. Other common adverse reactions include weight gain, constipation, postural hypotension, dyspepsia, and xerostomia. Children and adolescents who had not been treated previously with any antipsychotic drug, or had not had over 1 week total lifetime treatment, were included in the study. The drugs used in the study were olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), and aripiprazole (Abilify). At the end of 12 weeks, a statistically significant difference in weight and lipid profiles was noted. There was no difference in these changes related to age; all groups experienced significant changes. The changes in lipid profiles were also found to be greater than changes in glucose, and diabetes or metabolic syndrome was rarely noted during the period of the study. Implications With the rise in childhood obesity rates and the increase in associated adverse effects such as diabetes, metabolic syndrome, hypertension, and lipid-associated cardiovascular risk, any drug that increases the risk of adverse effects on these parameters must be carefully considered when weighing treatment options. Atypical antipsychotic drugs provide benefit to patients diagnosed with psychiatric illness and may be a required component of treatment for children and adolescents who have debilitating illnesses. Research suggests that the atypical antipsychotics may increase the risk of cardiometabolic effects and the nurse plays a pivotal role in patient and family education about these risks and strategies to minimize these effects. Dopamine replacement agents are used to directly increase dopamine levels in this region. Dopamine itself cannot be used for this purpose because it is unable to cross the blood­brain barrier after it is administered. It is connected to a pacemaker-like device that delivers electric currents to interfere with cells that cause tremors. The patient can adjust the settings by using a special magnet placed over the implanted generator. Fetal tissue from either humans or pigs is transplanted into the caudate nucleus of the brain. Expected outcome is that the patient will show a substantial decrease of motor symptoms. When the patient has been sedated, a burr hole is made into the target area and an electrode is inserted. The patient is closely observed for the desired effects of decreased tremor and rigidity. If the desired effect is not seen, or if untoward effects occur, the probe is repositioned until desired effects occur. Lesions are surgically produced within the thalamus, which are thought to decrease tremor and rigidity. This is done only to benefit the side of the body that is most affected because there have been surgical complications from bilateral thalamotomy. Basal nuclei: Caudate nucleus Lenticular nucleus Tremor of hands Head held forward Drooping eyelids, open mouth, drooling Progressive degeneration of and neurons in the nigrostriatal pathway can produce: Antipsychotic dopamineblocking drugs can produce: 25. Slow, shuffling gait, short steps Cholinergic neuron Acetylcholine Benztropine 2 Drug therapy tends to help with symptoms Dopaminergic agents: Precursors to dopamine. Unlike dopamine, however, levodopa easily crosses the blood­brain barrier to reach the affected region. Administration of levodopa directly leads to increased biosynthesis of dopamine within the nerve terminals. Two to three weeks of therapy are needed before improvement is observed, and many patients require several months of therapy for optimum therapeutic outcomes to be achieved. As therapy progresses, however, the beneficial effects of the drug tend to diminish. Carbidopa itself has no therapeutic effects of its own because it cannot cross the blood­brain barrier. The combination of the two drugs allows for much lower doses of levodopa to be prescribed than when levodopa is used alone; 25 mg of levodopa is used as a combination drug versus 125 mg of levodopa when delivered as monotherapy. Carbidopa also decreases dopamine production in peripheral tissues, leading to reduced nausea and vomiting as well as fewer cardiovascular responses to levodopa. Sinemet is available as an immediate release tablet or a sustained release tablet. Parcopa is a preparation of levodopa and carbidopa that dissolves on the tongue and is swallowed with saliva, which is a distinct advantage for patients with swallowing difficulties. The addition of entacapone is believed to create a more consistent level of levodopa in the blood, which can minimize the extent and duration of the wearing-off effect. When metabolized through decarboxylation to dopamine, dopamine levels in the brain increase. Common adverse effects include orthostatic hypotension, nausea, vomiting, anorexia, flatulence, dysphagia, abdominal distress, choreiform and involuntary movements, hand tremors, fatigue, headache, anxiety, twitching, numbness, confusion, agitation, nightmares, and insomnia. Life-threatening adverse effects include agranulocytosis, leukopenia, and hemolytic anemia. Other potential adverse effects are related to the anticholinergic properties of levodopa, including urinary retention and dry mouth. Psychosis develops in up to 20% of patients taking levodopa, and drug therapy with an antipsychotic agent such as clozapine (Clozaril) or quetiapine (Seroquel) may be necessary to control hallucinations and paranoid feelings. Black Box Warning: At least 12 hours should elapse between the last dose of levodopa and initiation of therapy with the carbidopa-levodopa combination drug. Some dystonias such as head bobbing or jaw clenching may be minor adverse effects of levodopa therapy, whereas others such as quick jerking movements may be serious. These dystonias may occur just as the optimum dosage level of levodopa is reached, which is extremely discouraging for patients and their caregivers. To reduce the severity of these dystonias, the dose of levodopa and carbidopa must be reduced. Lifespan and Diversity Considerations: Assist the older adult to ambulate if dizziness occurs to prevent falls related to the muscle rigidity caused by the disease and possible orthostatic hypotension related to the drug. Patient and Family Education: Urine and perspiration may darken in color; this is a normal response to the medication. The drugs do not have to be metabolized to be effective and they are not converted to potentially toxic metabolites. Dietary protein does not interfere with their absorption, so a low-protein diet is not necessary. With long-term use they have a lower incidence of the wearing-off effect and are less likely to cause dyskinesias. Certain adverse effects of dopamine agonists may be more serious than those of levodopa. This Drug Interactions: Although antipsychotic drugs may be used to control psychosis associated with parkinsonism, conventional antipsychotic drugs block dopamine receptors in the brain and can decrease the therapeutic effects of levodopa. Decreased levodopa effects can occur with use of anticholinergics, hydantoins, papaverine, or pyridoxine. Herbal/Food: Food, especially high-protein foods and vitamin-fortified foods containing vitamin B6, decreases the rate and extent of levodopa absorption; however, many persons must take levodopa with food to decrease the nausea and vomiting that may occur. The dopamine agonists are divided into two subclasses: ergot alkaloids and nonergot agents. Bromocriptine (Parlodel) is an ergot alkaloid derived from the ergot fungus that grows on rye wheat. Another use of ergot alkaloids is in the treatment of migraine headaches (see Chapter 29). The nonergot alkaloids include apomorphine (Apokyn), pramipexole (Mirapex), and ropinirole (Requip). Drug Interactions: Dopamine antagonists that may decrease pramipexole levels include phenothiazines, metoclopramide, and the butyrophenones. Drugs that may increase pramipexole levels include levodopa, cimetidine, ranitidine, diltiazem, verapamil, and quinidine. Many patients are able to lower their doses of levodopa when they take pramipexole concurrently. It is also approved for treating moderate to severe symptoms of restless leg syndrome. Several weeks of therapy are necessary for the patient to obtain maximum benefits from pramipexole. Mechanism of Action: Pramipexole is a selective agonist of the D2 subfamily of dopamine receptors at both presynaptic and postsynaptic sites in the striatum. Lifespan and Diversity Considerations: Assist the older adult to ambulate if dizziness occurs to prevent falls related to the rigidity caused by the disease and possible orthostatic hypotension related to the drug. Assess diverse patients frequently to ensure optimal therapeutic effects and minimize adverse effects. Patient and Family Education: Exercise caution with driving and other activities until the effects of the drug are known. Pergolide (Permax) is a dopamine agonist that was discontinued in the United States due to the possible development of valvular heart disease. Apomorphine is structurally related to morphine, but it does not bind to opioid receptors or cause morphinelike effects (see Chapter 29). Life-threatening adverse effects include sleep attacks or acute circulatory failure. The incidence of hallucinations increases with age and may cause discontinuation of therapy in older patients. Orthostatic hypotension occurs in over half the patients taking the drug and may contribute to injury due to falls. Life-threatening adverse effects include sleep attacks, hemolytic anemia, agranulocytosis, and leukopenia. Sleep attacks can occur without warning, regardless of current activity level, and cause accidents.

While nursing responsibilities are similar to those for the anticoagulant drugs depression era recipes best 300 mg wellbutrin, bleeding risk is lessened with the antiplatelet agents bipolar depression nac wellbutrin 300 mg with visa. Lifespan and Diversity Considerations: Monitor for bleeding more frequently in the older adult who is at higher risk for injury and bleeding mood disorder unspecified dsm 5 discount wellbutrin 300 mg fast delivery. Patient and Family Education: Be aware that the effects of the drug may be prolonged for as long as 10 days with an increased risk of bleeding during that time depression test edu cheap wellbutrin 300 mg otc. Any bleeding that does not stop with direct pressure for 15 minutes mood disorder questionnaire age range buy wellbutrin 300 mg free shipping, excessive bruising, or blood in urine or stool should be reported to the provider. Unlike abciximab, the binding of eptifibatide is rapidly reversible and a large amount of unbound drug may circulate in the plasma. Should platelet count decrease to less than 100,000/mm3, legs that worsens with walking or exercise. Pentoxifylline is a unique agent with anticoagulation properties that acts on red blood cells to reduce their viscosity and increase their flexibility, allowing them to enter vessels that are partially occluded and prevent thrombi formation. Cilostazol should be used with care in patients with cardiac disease because it may cause palpitations and tachycardia. The goal of hemostasis has been achieved once a blood clot is formed and the body is protected from excessive hemorrhage. The process of hemostasis, however, is a positive feedback mechanism in which small amounts of clotting lead to additional clotting. Circulation must eventually be restored so that the tissue can resume normal activities. Fibrinolysis is the physiological process that limits clot formation and removes existing clots. During the time a fibrin clot is forming, the surrounding damaged tissue secretes anticoagulant chemicals that limit the spread of the clot to the area of injury. Removal of the clot begins about 24 to 48 hours following clot formation and continues until it is dissolved. Plasmin is an enzyme that attacks the fibrin strands, breaking them into small fragments that are soluble and no longer able to hold the clot together. The body normally regulates fibrinolysis such that unwanted fibrin clots are removed, while fibrin present in wounds is left to maintain hemostasis. It is often mistakenly believed that the purpose of anticoagulants such as heparin or warfarin is to digest clots. In essence, the thrombolytics simply accelerate the normal process of clot removal in the body. The thrombolytics are also called fibrinolytics, owing to their destructive effects on fibrin. The therapeutic outcomes of thrombolytic therapy are strongly dependent on the time frame in which they are administered. They are considerably more effective when given as soon as possible after the clot has formed- preferably within 4 hours. The mechanism of action of the thrombolytics is shown in Pharmacotherapy Illustrated 38. Thrombolytics are nonspecific and have a very narrow margin of safety between dissolving "normal" and "abnormal" clots. Vital signs must be monitored continuously and any signs of bleeding may call for discontinuation of therapy. Patients with recent trauma, active bleeding, or surgery may have "fresh" clots that could be disrupted by the action of these drugs. Thus, they may not be candidates for thrombolytic therapy due to the risk of bleeding. The risks of serious bleeding following drug administration may outweigh the therapeutic benefits. Because these medications are rapidly destroyed in the bloodstream, discontinuing the infusion quickly terminates their thrombolytic activity. After the clot is successfully dissolved with the thrombolytic, anticoagulant therapy with an anticoagulant is initiated to prevent the reformation of clots. Since the discovery of streptokinase, the first drug in this class, there have been several subsequent generations of thrombolytics. Signs of bleeding such as spontaneous ecchymoses, hematomas, or epistaxis should be reported to the health care provider immediately. Whenever possible, parenteral injections of other drugs should be avoided during alteplase therapy to avoid an increased risk of bleeding at the injection site. Although not routinely indicated for treating venous clots, the drug may be used in cases where a limb is at risk of gangrene and possible amputation due to vessel occlusion. Therapy should be initiated only after intracranial hemorrhage has been ruled out. Alteplase does not exhibit the degree of allergic reactions seen with streptokinase. Intravenous nitroglycerin enhances the hepatic degradation of alteplase, reducing its ability to dissolve clots. Herbal/Food: Use with supplements that affect coagulation such as feverfew, green tea, ginkgo, fish oil, ginger, or garlic should be avoided, because they may increase the risk of bleeding. Excessive bleeding may require the administration of blood, blood products, or hemostatics. Nursing Responsibilities: Key nursing implications for patients receiving alteplase are included in the Nursing Practice Application for Patients Receiving Thrombolytic Therapy on pages 683­684. Mechanism of Action: the primary action of alteplase is to convert plasminogen to plasmin, which then dissolves fibrin clots. Alteplase is more fibrin specific than streptokinase, but less so than some of the other thrombolytics. Patient and Family Education: Remain quiet and on bed rest while receiving this medicine. Streptokinase shares the same contraindications and adverse effects with the other thrombolytics. The drug has similar indications, contraindications, and adverse effects to alteplase but has greater fibrin specificity and a longer halflife. This may be responsible for a slightly lower incidence of noncerebral bleeding with tenecteplase. Another advantage is that it can be administered using a single, 5-second bolus injection. Drugs Similar to Alteplase (Activase) Other thrombolytics include reteplase, streptokinase, and tenecteplase. Obtained from human blood donors, urokinase was removed from the market because of the possibility of viral contamination. It has a more rapid onset of action than alteplase, perhaps because reteplase is better able to reach the inside of clots. Like alteplase, it is selective for lysing fibrin and the most serious adverse effect is bleeding. Streptokinase is obtained from beta-hemolytic streptococci and is less fibrin specific than the other drugs in this class; the drug also breaks down fibrinogen and other clotting factors. Although it is much less expensive than other thrombolytics, streptokinase is considered a second-line agent because it is less effective at opening arteries. Allergic reactions such as urticaria, flushing, and headache occur in 1% to 4% of patients, although anaphylaxis is rare. The hemostatics, or antifibrinolytics, have an action opposite to that of anticoagulants: to shorten bleeding time. Although their mechanisms differ, all drugs in this class prevent fibrin from dissolving, thus enhancing the stability of the clot and preventing excessive bleeding. Injection sites should be monitored frequently for thrombophlebitis and extravasation. Assess presence, quality, location of angina, and for presence of dyspnea or chest pain. Assessment throughout administration: Continue frequent assessments for therapeutic effects. Continue to monitor vital signs every 30 min to 1 h for the first 8 h following the infusion. Potential Nursing Diagnoses Pain Ineffective Peripheral Tissue Perfusion Impaired Gas Exchange Impaired Skin Integrity Anxiety Deficient Knowledge, (Drug Therapy) Risk for Injury, related to adverse effects of thrombolytic therapy Planning: Patient Goals and Expected Outcomes the patient will: Experience therapeutic effects dependent on the reason the drug is being given. Healthy lifestyle changes will support and minimize the need for future drug therapy. Frequent assessment for both visible and occult bleeding is necessary to prevent extensive hemorrhage and to start early corrective treatment as appropriate. Bleeding risk is elevated up to 2­4 days post-treatment and if the patient is maintained on anticoagulant or antiplatelet therapy post-thrombolytics. Dysrhythmias may occur postperfusion of the coronary arteries, or may be associated with adverse effects. No treatment for overdose is known, although hemodialysis or peritoneal dialysis may be used to remove the drug. Classification: Therapeutic: Hemostatic/antifibrinolytic Pharmacologic: None Therapeutic Effects and Uses: Aminocaproic acid is prescribed for conditions where there is excessive hemorrhage due to clots being dissolved rapidly or prematurely. Excessive fibrinolysis is associated with conditions such as aplastic anemia, hepatic cirrhosis, postoperative cardiac surgery, and in certain carcinomas. It is most commonly prescribed following surgery to reduce postoperative bleeding. Report fever, myalgia, reddish-brown urine, or decrease in urine output to the health care provider. Monitor vital signs and urine output throughout therapy and for up to 24 hours post-therapy. Lifespan and Diversity Considerations: Monitor renal function labs more frequently with the older adult because normal changes related to aging or the development of myopathy or rhabdomyolysis may increase the risk of renal failure. Patient and Family Education: Immediately report any of the following to the health care provider: difficulty urinating, reddish-brown urine, arm or leg pain, chest pain, difficulty breathing, bleeding, clotting, dizziness, drowsiness, confusion, or convulsions. Myopathy is an uncommon adverse effect that requires monitoring because the drug may lead to rhabdomyolysis. Aminocaproic acid is contraindicated in patients with urinary tract bleeding because the drug promotes the formation of clots in the renal pelvis or ureters that may cause obstruction. Caution must be used when administering the drug to patients with serious renal impairment because the drug may accumulate to toxic serum levels. Drugs Similar to Aminocaproic Acid (Amicar) Other hemostatics include desmopressin, thrombin (recombinant) (Recothrom), and tranexamic acid. Hypercoagulation may occur with concurrent use of estrogens and oral contraceptives. The drug may be given parenterally in acute care scenarios, or by the nasal route (Stimate) for prophylaxis. Because desmopressin inhibits diuresis, caution must be used to prevent water intoxication. Headache and facial flushing are common adverse effects of the intranasal formulation. Tolerance rapidly develops to the actions of desmopressin, although this is usually not a problem when the drug is used to treat hemorrhage because only one to two doses are needed. Desmopressin has uses beyond hemostasis that include the control of excessive or nocturnal urination (enuresis) and polydipsia in patients with diabetes insipidus. Thrombin, topical (Evithrom, Recothrom, Thrombinar): Topical thrombin is applied with a spray or gelatin sponge to areas that are oozing blood and for minor bleeding from capillaries. The drug is not to be used for serious arterial bleeding or bleeding over large areas. Care must be taken not to inject this drug or to allow systemic absorption due to the risk of thrombi formation. Although screened and treated to inactivate viruses, products obtained from human plasma carry a small risk for transmission of infectious agents, such as viruses and the Creutzfeldt-Jakob disease agent. Tranexamic acid (Cyklokapron, Lysteda): Like aminocaproic acid, tranexamic acid produces an antifibrinolytic effect by inhibiting plasminogen and plasmin activity. Because the drug inhibits clot removal, patients must be monitored carefully for signs and symptoms of thromboembolism. Taking Lysteda concurrently with hormonal contraceptives increases the risk of thromboembolic adverse effects. The drug is 8 to 10 times more potent and has a longer halflife than aminocaproic acid. Joint bleeding causes chronic inflammation and may result in permanent deformity and loss of mobility. Some patients have mild forms of hemophilia, exhibiting no symptoms of excessive bleeding until they experience major trauma or surgery. The most severe forms of these disorders, however, are diagnosed shortly after birth and require a lifetime of lifestyle adjustment and pharmacotherapy. Because symptoms associated with the different clotting disorders are nonspecific, diagnosis requires laboratory assays for each of the clotting factors to determine which deficiency is causing the disorder. The pharmacotherapy of hereditary coagulation disorders has resulted in a remarkable change in the life spans of afflicted patients. Prior to 1960, the average life span of a male with severe hemophilia A was 11 years; the life span is now 50 to 60 years. Hereditary disorders of coagulation are relatively rare and may be caused by deficiency in any blood factor in the coagulation cascade. The traditional treatment for hemophilia A is administration of fresh frozen plasma. Plasma obtained from blood donors contains all the necessary components to replace the missing clotting factor(s). Although all donated blood is screened for viral pathogens, fresh frozen plasma is now rarely used to treat hemophilia due to a small risk of viral contamination. A large number of products are available, and trade names include Advate, Alphanate, Bioclate, Helixate, Humate, Hyate, Koate, Kogenate, Monarc, Monoclate, Recombinate, ReFacto, and Xyntha. Most factor concentrates are subjected to dry heat, vapor heat, solvent detergent, or a monoclonal antibody to remove any viruses that may remain.

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