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I have always thoroughly liked manipulating the biochemistry of the event generic 0.18 mg alesse with amex. It takes a lot of knowledge of physiology and biochem- istry to go through the full and proper treatment of a patient in 124 Te Woman Who Could Not Tell Her Husband Anything 125 diabetic ketoacidosis cheap 0.18mg alesse visa. I had not been called to see Joyce to care for her diabetes but to try to unravel why she was being admitted in coma almost ev- ery month. She had been in the hospital seven times in the past ten months, each time unconscious and in ketoacidosis from un- controlled diabetes mellitus. It never works to pursue directly the possibility that someone stopped taking in- sulin on purpose to go into diabetic acidosis. Even raising the ques- tion with the patient builds resentment and resistance. Te list of other known causes is quite long and includes a number of infec- tious diseases. All had already been either tested for or ruled out on previous admissions. He had no clue why Joyce had such frequent and se- vere recurrences of acidosis. Extensive and exhaustive workups for the known precipitating causes had been negative on all prior ad- missions. He talked a bit about his feelings of failure for not keep- ing Joyce out of trouble. Tere is a belief common among some internists that they are responsible for the total health of their patients in a very direct way, even when the patient is at home. Tis comes from the strict training in hospitals, where indeed the physician bears a heavy re- sponsibility for the health and treatment of the hospitalized pa- tient. Tis sense of responsibility often carries over into the outside 126 Symptoms of Unknown Origin world. She was the young girl at Fort Hood, Texas, who had unregulated diabetes that became well regulated when a little girl and a kitten showed up on the scene. By late afternoon, when I returned to see her, she was talking and taking liquids by mouth. I never fail to get some equivalent of goose bumps every time I witness a completely unconscious patient recover from diabetic coma and begin to talk as though nothing had happened. I had the same feelings when I spoke briefly with Joyce and told her of my reasons for seeing her. Her internist had asked me to see her to try to find out why she had so many episodes of coma. I had found that many patients in hospitals are on the verge of crying almost all the time. Some people have said that hospitals are grieving institutions, and that the number of patients with hidden depression or unresolved grief is very large, even as high as 20 percent. In fact, it can Te Woman Who Could Not Tell Her Husband Anything 127 be counterproductive. I had learned to detect at their earliest stages grief or sadness or whatever other internal states can cause tears. Tere is a dictum that says that for every internal emotional state there is a full and visible external representation of that state, if you have the eyes and ears to detect it (Bandler and Grinder 1982). If I distracted the patient, the signs of near crying quickly changed to the distracted state. As best I can tell, people, for a brief moment, are often not aware that they are about to cry. I tested this in one patient whom I had known and trusted for a long time, and he said he was not aware of any sadness or grief even though I had seen his eyes get quite red and watery and his lower lip quiver before I distracted him. I believe there is a considerable delay in most patients between the time external signs are visible and the onset of conscious awareness of internal feel- ings.

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Aminocaproic acid or tranexamic acid may also Use in Renal Impairment be given alesse 0.18mg amex. When the drugs are used in acute myocardial infarction alesse 0.18mg cheap, Most anticoagulant, antiplatelet, and thrombolytic drugs may cardiac dysrhythmias may occur when blood flow is re- be used in clients with impaired renal function. Therefore, antidysrhythmic drugs should heparin and warfarin can be used in usual dosages, and be readily available. Dosage of LMWHs should be reduced in Use in Children clients with severe renal impairment (creatinine clearance <30 mL/minute) because they are excreted by the kidneys Little information is available about the use of anticoagu- and elimination is slowed. Heparin solutions containing benzyl alco- DVT with LMWHs and warfarin is contraindicated in clients hol as a preservative should not be given to premature with severe renal impairment. Guidelines for the use of other infants because fatal reactions have been reported. Warfarin is given to children after cardiac surgery to pre- • Cilostazol is probably safe to use in clients with mild or vent thromboembolism, but doses and guidelines for safe, moderate renal impairment. Accurate drug ad- pairment alters drug protein binding and increases blood ministration, close monitoring of blood coagulation tests, levels of metabolites. Antiplatelet agents and warfarin are used for long-term pre- • Ticlopidine may be more likely to cause bleeding in vention or management of thromboembolism and are often clients with renal impairment because the plasma drug taken at home. For prevention, antiplatelet agents and warfarin concentration is increased and elimination is slower. Dosage must be reduced INR, and notifies the prescriber, who then prescribes the ap- by approximately 50%. The risk of bleeding has lessened in recent years because of lower doses of warfarin. In addition, bleed- Use in Hepatic Impairment ing during warfarin therapy may be caused by medical condi- tions other than anticoagulation. Little information is available about the use of most anticoag- Heparin may also be taken at home. Standard heparin may ulant, antiplatelet, and thrombolytic drugs in clients with im- be taken subcutaneously, but LMWHs for home management paired liver function. However, such drugs should be used very of venous thrombosis are becoming standard practice. Enoxa- cautiously because these clients may already be predisposed to parin is approved by the Food and Drug Administration for bleeding because of decreased hepatic synthesis of clotting fac- outpatient use. Additional considerations include the following: needed if the client or a family member is unable or unwill- • Warfarin is more likely to cause bleeding in clients with ing to inject the medication. Platelet counts should be done liver disease, because of decreased synthesis of vitamin K. Heparin In addition, warfarin is eliminated only by hepatic me- should be discontinued if the platelet count falls below tabolism and may accumulate with liver impairment. Clients and family members should be educated disease because of high risks of excessive bleeding. When anagrelide is given, blood tests when indicated, and taking safety precautions. In clients should be closely monitored for signs of hepa- addition, assess the environment for risk factors for injury. It should be used the drugs, assisting clients to obtain laboratory tests, and teach- cautiously. CHAPTER 57 DRUGS THAT AFFECT BLOOD COAGULATION 847 NURSING Drugs That Affect Blood Coagulation ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. With standard heparin: (1) When handwriting a heparin dose, write out units This is a safety precaution to avoid erroneous dosage. Underdosage may cause thromboembolism, and overdosage may cause bleeding. In addition, heparin is available in several con- centrations (1000, 2500, 5000, 10,000, 15,000, 20,000, and 40,000 units/mL). To minimize trauma and risk of bleeding (b) Leave a small air bubble in the syringe to follow Locks drug into subcutaneous space and minimizes trauma dose (c) Grasp a skinfold and inject the heparin into it, at a To give the drug in a deep subcutaneous or fat layer, with minimal 90-degree angle, without aspirating. Whatever effective method is to fill the volume-control set method is used, it is desirable to standardize concentration of (eg, Volutrol) with 100 mL of 5% dextrose in water heparin solutions within an institution. Standardization is safer, and add 5000 units of heparin to yield a concentration because it reduces risks of errors in dosage.

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