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The results of this test determine your below 130 mg/dL; weight reduction if overweight; control daily dose of warfarin proscar 5mg sale. Once the blood test and the war- of blood pressure if hypertensive; avoidance of smoking; farin dose stabilize order 5 mg proscar, the blood tests are done less often stress reduction techniques; and regular exercise. If superficial bleeding oc- such as wearing tight clothing; crossing the legs at the curs, apply direct pressure to the site for 3 to 5 minutes knees; prolonged sitting or standing; and bed rest. Too little medication increases your is uncommon with the small doses used for antiplatelet risk of problems from blood clot formation; too much effects. Do not crush or chew coated tablets (long-acting medication can cause bleeding. The blood after morning and evening meals for better absorption tests can help your health care provider regulate drug and effectiveness. If ex- or treatments are begun; and keep all appointments for cessive bruising occurs at the injection site, rubbing an ice continuing care. Helen Innes is admitted to your medical unit for management of bacterial pneumonia. She has been on oral antibiotics for 7 days but her respiratory condition has not improved. In addition to her in- Thrombolytic Therapy travenous antibiotics, you administer her usual dose of Coumadin that she takes for a history of pulmonary emboli. Thrombolytic therapy should be performed only by ex- ment the medications given, you notice that her international nor- perienced personnel in an intensive care setting with malized ratio (INR) is 6. All of the available agents are effective with recom- Use in Older Adults mended uses. Thus, the choice of a thrombolytic agent depends mainly on risks of adverse effects and costs. Older adults often have atherosclerosis and thrombotic dis- All of the drugs may cause bleeding. Alteplase may act orders, including myocardial infarction, thrombotic stroke, more specifically on the fibrin in a clot and cause less and peripheral arterial insufficiency, for which they receive systemic depletion of fibrinogen, but this agent is very an anticoagulant or an antiplatelet drug. Streptokinase, the least expensive agent, than younger adults to experience bleeding and other com- may cause allergic reactions because it is a foreign pro- plications of anticoagulant and antiplatelet drugs. Combination therapy (eg, with alteplase and strep- ple, aspirin or clopidogrel is commonly used to prevent tokinase) may also be used. Two or 3 hours after in older adults with renal impairment and the drugs should be thrombolytic therapy is started, the fibrinogen level can used cautiously. They should also be used with caution in be measured to determine that fibrinolysis is occurring. Major factors in decreasing risks of bleeding are select- who take an NSAID daily may not need low-dose aspirin for ing recipients carefully, avoiding invasive procedures antithrombotic effects. Also, many drugs interact with warfarin does occur, it is most likely from a venipuncture or in- to increase or decrease its effect, and older adults often take vasive procedure site, and local pressure may control it. Starting or stopping any drug may require If bleeding cannot be controlled or involves a vital that warfarin dosage be adjusted. Aminocaproic acid or tranexamic acid may also Use in Renal Impairment be given. When the drugs are used in acute myocardial infarction, 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.

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Fallot should not be given this drug with water be- cause she has difficulty swallowing and is at risk for aspiration discount proscar 5 mg mastercard. This is not the case with lansoprazole buy proscar 5mg with amex, because most likely reason for this is the concurrent use of cimetidine the protective granules within the capsule can be preserved if given because both cimetidine and carbamazepine are metabolized by with acidic foods such as applesauce or yogurt. When a dispute regarding medications probably want to draw a blood level to confirm this is the cause arises, it is wise to consult a drug resource or a pharmacist. Ellen needs to be cautioned to check with her health care provider before using over-the counter medications because drug interactions can occur. The provider may switch Ellen to a proton pump inhibitor or a different histamine-2 recep- tor antagonist, such as famotidine (Pepcid) or ranitidine (Zantac) because these drugs are not metabolized through the P450 sys- tem and will not interact with her antiseizure medication. How do the various drug groups heal ulcers or prevent disease management, 7th ed. Compare H2RAs and PPIs in indications for use and for acid peptic disorders. Philadelphia: with peptic ulcer disease, how would you explain that Lippincott Williams & Wilkins. Compare and contrast peptic ulcer disease and GERD in terms of risk factors, drug therapy, and client teaching needs. Discuss bulk-forming laxatives as the most cording to effects on the gastrointestinal tract. Discuss possible reasons for and hazards of use from those of chronic use. Discuss rational choices of laxatives for se- lected client populations or purposes. Critical Thinking Scenario Elmer Wong, a 67-year-old teacher, fractured his hip when he fell on a patch of ice. He is scheduled for hip surgery to repair the fracture; this will be followed by a period of rehabilitation as he regains his mobility. Reflect on: Factors that increase his risk for constipation during the postoperative period. Expectation for postoperative bowel elimination, considering his history. Nonpharmacologic interventions that can promote normal bowel function during the postoperative period. OVERVIEW causes strong peristalsis, deep breathing, closure of the glot- tis, contraction of abdominal muscles, contraction of the Laxatives and cathartics are drugs used to promote bowel rectum, relaxation of anal sphincters, and expulsion of the elimination (defecation). The term cathar- The cerebral cortex normally controls the defecation re- tic implies strong effects and elimination of liquid or semi- flex so defecation can occur at acceptable times and places. Because the different effects depend more on Voluntary control inhibits the external anal sphincter to allow the dose than on the particular drug used, the terms often are defecation or contracts the sphincter to prevent defecation. When the external sphincter remains contracted, the defeca- tion reflex dissipates, and the urge to defecate usually does not recur until additional feces enter the rectum or several DEFECATION hours later. In people who often inhibit the defecation reflex or fail to Defecation is normally stimulated by movements and re- respond to the urge to defecate, constipation develops as the flexes in the gastrointestinal (GI) tract. Constipation is the infrequent and painful ex- and duodenum are distended with food or fluids, gastrocolic pulsion of hard, dry stools. Although there is no normal and duodenocolic reflexes cause propulsive movements number of stools because of variations in diet and other fac- in the colon, which move feces into the rectum and arouse tors, most people report more than three bowel movements the urge to defecate. Normal bowel elimination should produce a soft, tum are stimulated by the fecal mass, the defecation reflex formed stool without pain. Laxatives and cathartics are somewhat arbitrarily classified as Polyethylene glycol–electrolyte solution (eg, NuLytely) bulk-forming laxatives, surfactant laxatives or stool softeners, is a nonabsorbable oral solution that induces diarrhea within saline cathartics, stimulant cathartics, lubricant or emollient 30 to 60 minutes and rapidly evacuates the bowel, usually laxatives, and miscellaneous. It is a prescription drug used for bowel Drugs at a Glance: Laxatives and Cathartics. Polyethylene glycol solution (MiraLax) is an oral laxative Bulk-Forming Laxatives that may be used to treat occasional constipation. It is a prescription drug and should not be Bulk-forming laxatives (eg, polycarbophil, psyllium seed) taken longer than 2 weeks. The added bulk or size of the fecal mass stimulates peri- stalsis and defecation. The substances also may act by pulling Stimulant Cathartics water into the intestinal lumen.

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To that end I hope that readers will send me their comments purchase 5 mg proscar free shipping, including suggestions for new items to be covered in the next edition discount proscar 5mg overnight delivery, and other pieces of advice and comment. Finally I would like to thank all those who have helped, in their various ways, with this book. These are Gordon Macpherson, Harvey Marcovitch, Pete Moore, Geoff Watts, Geert-Jan van Daal, Don Rowntree, Margaret Hallendorff, Mary Banks and Michèle Clarke. The person who has suffered most for my art, as always, has been my wife Barbara, to whom I offer my special thanks. Proponents argue that this is inevitable; it reflects the increasing specialization of medicine and saves valuable space for yet more papers. The initials CIA are identified so closely with US spies that it may be difficult to remember that they also stand for common iliac arteries. The confusion intensifies when the abbrevia- tions disappear for a while, only to resurface after an absence of several paragraphs when you have completely forgotten what they stand for. For this reason, and because they are in upper case, they slow the reader down. If you do insist on using abbreviations, make sure that you spell out the words in full at their first appearance, and try to use no more than two sets per document (see acronyms; political writing). There are those that stand on their own, as a means of securing an invitation to present at a conference. I call these conference abstracts and they have an entry to themselves (see below). The other type are those that appear at the start of a scientific paper, summarizing the information contained in that paper. In some respects they are a marketing tool, 1 THE A–Z OF MEDICAL WRITING enabling potential readers to decide whether they should read the paper in detail. With the development of electronic databases, they now have a role as a stand-alone unit of scientific knowledge. Approach writing an abstract in the same way as you would approach any other writing task (see process of writing). Journals will make it absolutely clear in the Instructions to Authors how they like their abstract to appear, and it is senseless to ignore these requirements. A modern trend is the structured abstract, which has carefully defined sections to complete. Study the instructions carefully, and look at abstracts in your target journal. One of the most commonly flouted require- ments is length: if they say 300 words they mean 300 words; any more may be cut and your work could become meaningless. It is not hard to find examples of submitted (and sometimes published) articles where details in the abstract simply do not appear in the article itself. This danger is particularly acute when the abstract has been written first. By the time the paper has been written and the co-authors have agreed, all kind of subtle changes have been made. Acceptance The supreme moment when something you have written is accepted for publication. Naming people in this way assumes that they endorse the contents, so you must have their written permission. Journals will vary in their approach to this (see Instructions to Authors). The number is exploding, so if you want to use one, make sure it has not already been taken. Many newspapers and magazines adopt the style that, if you can pronounce an acronym, you write it with one initial capital only. This explains why, although AIDS seems to be the preferred style in medical journals, most other publications style it Aids. Action lists These are beginning to take over from the more traditional minutes as the preferred way of recording the activities of a committee. They are based on the principle that recording the deci- sions is fairly straightforward; the hard thing is ensuring that they are carried out. To produce an action list, write down in clear active language, what has to be done, by whom, and by when.

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