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Normally purchase amitriptyline 75 mg on-line pain treatment for abscess tooth, there is a balance be- tween heat production and heat loss so that a constant body Aspirin purchase amitriptyline 25mg overnight delivery georgia pain treatment center, NSAIDs, and acetaminophen inactivate cyclooxy- temperature is maintained. When there is excessive heat pro- genases, the enzymes required for prostaglandin formation duction, mechanisms to increase heat loss are activated. Two forms of cyclooxygenase, called COX-1 result, blood vessels dilate, more blood flows through the and COX-2, have been identified. Aspirin and traditional skin, sweating occurs, and body temperature usually stays NSAIDs inhibit both COX-1 and COX-2 enzymes. When fever occurs, the heat-regulating COX-1 is normally synthesized continuously and present in center in the hypothalamus is reset so that it tolerates a higher all tissues and cell types, especially platelets, endothelial cells, body temperature. Fever may be produced by dehydration, the gastrointestinal (GI) tract, and the kidneys. Prostaglandins inflammation, infectious processes, some drugs, brain injury, produced by COX-1 are important in numerous homeostatic or diseases involving the hypothalamus. Prostaglandin for- functions and are associated with protective effects on the mation is stimulated by such circumstances and, along with stomach and kidneys. In the stomach, they decrease gastric bacterial toxins and other substances, prostaglandins act as acid secretion, increase mucus secretion, and regulate blood pyrogens (fever-producing agents). In the kidneys, these prostaglandins help to main- Inflammation is the normal body response to tissue dam- tain adequate blood flow and function. In the cardiovascu- age from any source and it may occur in any tissue or organ. Local manifestations are redness, Drug-induced inhibition of these prostaglandins results in the heat, edema, and pain. Redness and heat result from vasodila- adverse effects associated with aspirin and related drugs, tion and increased blood supply; edema results from leakage especially gastric irritation, ulceration, and bleeding. Inhibition of blood plasma into the area; and pain occurs when pain of COX-1 activity in platelets may be more responsible for receptors on nerve endings are stimulated by heat, edema, GI bleeding than inhibition in gastric mucosa. Systemic manifestations include leukocytosis, bone, kidneys, GI tract, and the female reproductive system). When tissue cells are dam- cellular microorganisms, such as viruses and rickettsiae. When Histamine is formed (from the amino acid histidine) and stored the WBCs die, they release enzymes that activate kinins. The in most body tissue, with high concentrations in mast cells, ba- activated kinins increase and prolong the vasodilation and sophils, and platelets. Mast cells, which are abundant in skin increased vascular permeability caused by histamine. They and connective tissue, release histamine into the vascular sys- also cause pain by stimulating nerve endings for pain in the tem in response to stimuli (eg, antigen–antibody reaction, area. Thus, bradykinin may aggravate and prolong the ery- tissue injury, and some drugs). Once released, histamine is thema, heat, and pain of local inflammatory reactions. It also highly vasoactive, causing vasodilation (increasing blood flow increases mucous gland secretion. More specifi- effects include contracting smooth muscles in the bronchi cally, complement destroys cell membranes of body cells (producing bronchoconstriction and respiratory distress), (eg, red blood cells, lymphocytes, platelets) and pathogenic gastrointestinal (GI) tract, and uterus; stimulating salivary, microorganisms (eg, bacteria, viruses). The system is initi- gastric, bronchial, and intestinal secretions; stimulating sen- ated by an antigen–antibody reaction or by tissue injury. Histamine is the vated in a cascade type of reaction in which each component first chemical mediator released in the inflammatory response becomes a proteolytic enzyme that splits the next component and immediate hypersensitivity reactions (anaphylaxis). Activation yields products with profound in- When histamine is released from mast cells and basophils, flammatory effects. C3a and C5a, also called anaphylatox- it diffuses rapidly into other tissues.

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In relation to drugs for weight loss and obesity generic amitriptyline 75mg with amex pain treatment lupus, little infor- • Serum triglyceride levels should be measured before IV mation is available about their use in clients with hepatic im- fat emulsions are given effective amitriptyline 50mg pain treatment center llc. Because sibutramine is metabolized in the liver, it hypertriglyceridemia, which would be worsened by fat is contraindicated in clients with severe hepatic impairment. In relation to drugs for weight loss and obesity, little in- formation is available about their use in clients with renal Use in Critical Illness impairment. With sibutramine, dosage reductions are not rec- ommended with mild to moderate impairment because the Critically ill clients often have organ failures that alter their drug and its active metabolites are eliminated by the liver. Thus, their 448 SECTION 5 NUTRIENTS, FLUIDS, AND ELECTROLYTES nutritional needs vary with the type and extent of organ im- • With enteral nutrition, concentrated products (eg, 1. In addition to renal and hepatic impairments, which 2 kcal/mL) provide more calories and help with fluid were discussed, clients with pulmonary failure, cardiac fail- restrictions. Excessive amounts of sodium and fluid or rapid administration may precipitate or worsen heart failure and should be avoided. Pulmonary Impairment If IV fat emulsions are used, they should be given over • In clients with chronic obstructive pulmonary disease 24 hours because faster infusion may depress myocardial (COPD), major concerns are weight loss and decreasing function. However, increasing caloric in- Multiple Organ Dysfunction Syndrome take in these clients must be done cautiously because overfeeding leads to increased carbon dioxide (CO2) pro- • Clients with MODS, who are usually in critical care duction, increased work of breathing, and perhaps respi- units, require nutritional support because they have ratory acidosis. Thus, excessive carbohydrate in enteral high rates of metabolism and tissue breakdown (ca- or parenteral feedings may cause respiratory failure. However, nutritional support is complex • Enteral nutrition is preferred if the GI tract is functional because a client may have a combination of renal, he- and accessible. Nutrivent and Pulmocare are enteral patic, pulmonary, and cardiac impairments. Thus, it products for clients with COPD or respiratory failure must be individualized according to the type and ex- and mechanical ventilation. Moderate amounts (1 to Clients with oliguric ARF or ARDS as part of their 1. However, many piratory distress syndrome (ARDS), pulmonary edema, clients may not be able to tolerate this amount because or other conditions requiring fluid restriction. For example, clients with ARF • Parenteral nutrition is often needed because clients with and dialysis or severe hepatic failure usually have pro- pulmonary failure from severe pneumonia or septicemia tein intake restricted. As with enteral feedings, excessive car- ergy, should provide 20% to 30% of calories. Some clients with MODS • Intravenous fat emulsions should be infused slowly, already have high serum triglyceride levels and are at over 24 hours. Rapid infusion may lead to pulmonary risk for development of acute pancreatitis and further vasoconstriction. In these clients, IV fat emulsions are • Excessive amounts of sodium and fluids should be usually avoided until serum triglyceride levels are less avoided with both enteral and parenteral nutrition be- than 300 mg/dL. In clients with MODS who receive IV cause they may worsen impaired pulmonary function. Cardiac Impairment • Undernutrition may lead to decreased cardiac output Home Care and stroke volume, with resultant hypotension and bradycardia. The home care nurse is involved with nutritional matters in • Excessive amounts of nutrients or fluids may worsen almost any home care setting. Because nutrition is so important heart failure by increasing cardiac workload. Health promotion albumin may decrease edema and prevent or treat con- may involve assessing the nutritional status of all members of gestive heart failure, which commonly occurs in clients the household, especially children, older adults, and those with with impaired cardiac function. Also, loop diuretics are obvious deficiencies or excesses, and providing counseling or often given to increase excretion of sodium and water. CHAPTER 30 NUTRITIONAL SUPPORT PRODUCTS AND DRUGS FOR OBESITY 449 For clients receiving tube feedings at home, the home from a pharmacy, home health agency, or independent com- care nurse may teach about the goals of treatment, adminis- pany. The home care nurse may not be involved in the initial tration, preparation or storage of solutions, equipment (eg, ob- setup but is likely to participate in ongoing client care, mon- taining, cleaning), and monitoring responses (eg, weight, itoring of client responses, and supporting caregivers. NURSING Nutritional Products and Drugs for Obesity ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. For oral supplemental feedings: (1) Chill liquids or pour over ice and give through a straw, Chilling (or freezing) may improve formula taste and decrease from a closed container, between meals. A straw directs the formula toward the back of the throat and decreases its contact with taste buds. For intravenous (IV) feedings: (1) Administer fluids at the prescribed flow rate.

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This effort has been less than successful—all the synthetic drugs produce atropine-like ad- verse effects when given in sufficient dosage purchase 25mg amitriptyline mastercard pain treatment after root canal. One group of synthetic drugs is used for antispasmodic Acetylcholine effects in GI disorders buy amitriptyline 50 mg fast delivery knee pain laser treatment. They balance the rel- drug receptor ative cholinergic dominance that causes the movement dis- orders associated with parkinsonism. Effector target organ Indications for Use Figure 21–1 Mechanism of action of anticholinergic drugs. Anti- Anticholinergic drugs are used for disorders in many body cholinergic (antimuscarinic) blocking agents prevent acetylcholine from interacting with muscarinic receptors on target effector organs, thus systems. Clinical indications for use of anticholinergic drugs blocking or decreasing a parasympathetic response in these organs. They also are Contraindications to Use used before surgery and bronchoscopy. Drugs at a Glance: Selected Anticholinergic Drugs describes the therapeutic use, Contraindications to the use of anticholinergic drugs include dosage and route of administration of selected anticholiner- any condition characterized by symptoms that would be ag- gic medications. Some of these are prostatic hypertrophy, • GI disorders in which anticholinergics have been used myasthenia gravis, hyperthyroidism, glaucoma, tachyarrhyth- include peptic ulcer disease, gastritis, pylorospasm, di- mias, myocardial infarction, and heart failure unless bradycar- verticulitis, ileitis, and ulcerative colitis. They should not be given in hiatal hernia or other tions are often characterized by excessive gastric acid conditions contributing to reflux esophagitis because the drugs and abdominal pain because of increased motility and delay gastric emptying, relax the cardioesophageal sphincter, spasm of GI smooth muscle. The drugs are weak inhibitors of gastric acid secretion even in maximal doses (which INDIVIDUAL usually produce intolerable adverse effects). Although ANTICHOLINERGIC DRUGS they do not heal peptic ulcers, they may relieve abdom- inal pain by relaxing GI smooth muscle. Belladonna Alkaloids and Derivatives Anticholinergics may be helpful in treating irritable colon or colitis, but they may be contraindicated in Atropine, the prototype of anticholinergic drugs, produces chronic inflammatory disorders (eg, diverticulitis, ulcer- the same effects, has the same clinical indications for use, and ative colitis) or acute intestinal infections (eg, bacterial, has the same contraindications as those described earlier. Other drugs are used to decrease diarrhea addition, it is used as an antidote for an overdose of choliner- and intestinal motility in these conditions. It is usually prepared as atropine sulfate, a salt that infections such as cystitis, urethritis, and prostatitis, the is very soluble in water. It is well absorbed from the GI tract drugs decrease the frequency and pain of urination. It crosses the blood–brain drugs are also given to increase bladder capacity in barrier to enter the CNS, where large doses produce stimulant enuresis, paraplegia, or neurogenic bladder. Atropine is • In ophthalmology, anticholinergic drugs are applied also absorbed systemically when applied locally to mucous topically for mydriatic and cycloplegic effects to aid membranes. They are also used to treat macologic effects are of short duration except for ocular some inflammatory disorders. It is most often used in GI disorders for anti- • In respiratory disorders characterized by bronchocon- spasmodic effect. Homatropine may be preferable to • In cardiology, atropine may be given to increase heart atropine because ocular effects do not last as long. It has the same for their central effects in decreasing salivation, spas- effects as other atropine-like drugs. They are used mainly in clients who Ipratropium (Atrovent) is an anticholinergic drug chemi- have minimal symptoms, who do not respond to lev- cally related to atropine. When given as a nasal spray, it is use- odopa, or who cannot tolerate levodopa because of ad- ful in treating rhinorrhea due to allergy or the common cold. An additional use When given as an inhalation treatment or aerosol to patients of anticholinergic drugs is to relieve Parkinson-like with chronic obstructive pulmonary disease (COPD), it is ben- symptoms that occur with older antipsychotic drugs. An advantage of administration of • Before surgery, anticholinergics are given to prevent anticholinergic drugs by the respiratory route over systemic ad- vagal stimulation and potential bradycardia, hypoten- ministration is less thickening of respiratory secretions and re- sion, and cardiac arrest. CHAPTER 21 ANTICHOLINERGIC DRUGS 311 Drugs at a Glance: Selected Anticholinergic Drugs Routes and Dosage Ranges Generic/Trade Name Use Adults Children Belladonna Alkaloids and Derivatives Atropine Systemic use PO, IM, SC, IV 0. Antidote for cholinergic poisoning IV titrate large doses of 2–3 mg as needed until signs of atropine toxicity appear and cholinergic crisis is controlled. Ophthalmic atropine (Isopto-Atropine) Mydriatic/cycloplegia/ For refraction: Instill 1–2 drops For refraction: Instill 1–2 drops inflammation of uveal tract of 1% solution into eye(s) 1 h of 0. Homatropine (Homapin) Mydriatic/cycloplegia/ For refraction: Instill 1–2 drops For refraction: Instill 1 drop of inflammation of uveal tract of 2% solution or 1 drop 2% solution into eye before 5% solution into eye before procedure. For uveitis: 5–10 min intervals as Instill 1 drop of 2% solution needed.

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This increases blood levels decreasing production of cholesterol 10mg amitriptyline visa pain medication for dogs after neuter, these drugs decrease total of HDL effective amitriptyline 75mg interventional spine and pain treatment center nj. They reduce LDL cholesterol within 2 weeks and In addition to numerous other benefits, HDL levels are reach maximal effects in approximately 4 to 6 weeks. Studies indicate that these drugs can reduce management includes efforts to achieve desirable body the blood levels of C-reactive protein (CRP) that is associated weight, ingest low amounts of saturated fat and choles- with severe arterial inflammation that leads to heart attacks terol, exercise regularly, stop smoking, and reduce al- and strokes. The incidence of coronary artery disease is re- cohol intake, if indicated. The goal is to reduce serum duced by 25% to 60% and the risk of death from any cause triglyceride levels to 200 mg/dL or less. They also reduce the risk of angina • Unless lipid levels are severely elevated, a minimum of pectoris and peripheral arterial disease as well as the need for 6 months of intensive diet therapy and lifestyle modifi- angioplasty and coronary artery grafting to increase or restore cation should be undertaken before drug therapy is con- blood flow to the myocardium. CHAPTER 58 DRUGS FOR DYSLIPIDEMIA 855 Drugs at a Glance: Dyslipidemic Agents Routes and Dosage Ranges Clinical Indications Generic/Trade Name (Type of Dyslipidemia) Adults Children HMG-CoA Reductase Inhibitors (Statins) Atorvastatin (Lipitor) Types IIa and IIb PO 10–80 mg daily in a single dose Fluvastatin (Lescol, Types IIa and IIb PO 40–80 mg daily in 1 or 2 doses Lescol XL) Lovastatin (Mevacor, Types IIa and IIb PO 10–80 mg daily in 1 or 2 doses <10 y: not recommended Altocor) 10–17 y: 10–40 mg daily Pravastatin (Pravachol) Types IIa and IIb PO 40–80 mg once daily Elderly, PO 10 mg once daily Simvastatin (Zocor) Types IV and V (hyper- PO 5–80 mg once daily in the evening triglyceridemia) Elderly, PO 5–20 mg once daily in the evening Fibrates Fenofibrate (Tricor) Types IV, V (hyper- PO 67 mg daily, increased if necessary triglyceridemia) to a maximum dose of 201 mg daily Gemfibrozil (Lopid) Types IV, V (hyper- PO 900–1500 mg daily, usually 1200 mg triglyceridemia) in 2 divided doses, 30 min before morning and evening meals Bile Acid Sequestrants Cholestyramine (Questran) Type IIa PO tablets 4 g once or twice daily ini- 240 mg/kg/d in 3 divided doses tially, gradually increased at monthly intervals to 8–16 g daily in 2 divided doses. LDL cholesterol levels de- extensive first-past metabolism by the liver, which results in crease within a week of starting these drugs and reach maxi- low levels of drug available for general circulation. When the drugs are stopped, lism occurs in the liver with 80% to 85% of drug metabolites pretreatment LDL cholesterol levels return within a month. These drugs are used mainly to reduce LDL cholesterol Statins are usually well tolerated; the most common further in clients who are already receiving a statin drug. The adverse effects (nausea, constipation, diarrhea, abdominal inhibition of cholesterol synthesis by a statin makes bile cramps or pain, headache, skin rash) are usually mild and acid–binding drugs more effective. More serious reactions include rare occurrences of tion increases HDL cholesterol and can further reduce the hepatotoxicity and myopathy. Bile acid sequestrants (eg, cholestyramine) bind bile These drugs are not absorbed systemically and their main acids in the intestinal lumen. This causes the bile acids to adverse effects are abdominal fullness, flatulence, and be excreted in feces and prevents their being recirculated to constipation. Loss of bile acids stimulates hepatic synthesis of more medications (eg, digoxin, folic acid, glipizide, propranolol, bile acids from cholesterol. As more hepatic cholesterol is tetracyclines, thiazide diuretics, thyroid hormones, fat-soluble 856 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM How Can You Avoid This Medication Error? Gribble, a 79-year-old nursing home resident, likes to take all of her medications together. You monitor her pulse and blood pressure before administration and they are within normal cular disease. What, if any, additional precautions should be used when • Identify risk factors: Questran is administered? Other drugs should be taken at least • Obesity 1 hour before or 4 hours after cholestyramine or colestipol. In • Inadequate exercise addition, dosage of the interactive drug may need to be changed • Cigarette smoking when a bile acid sequestrant is added or withdrawn. The • Signs and symptoms depend on the specific problem: drugs increase the oxidation of fatty acids in liver and muscle • Dyslipidemia is manifested by elevated serum cho- tissue and thereby decrease hepatic production of triglycerides, lesterol (>240 mg/100 mL) or triglycerides (>200 mg/ decrease VLDL cholesterol, and increase HDL cholesterol. These are the most effective drugs for reducing serum triglyc- • Coronary artery atherosclerosis is manifested by eride levels, and their main indication for use is high serum myocardial ischemia (angina pectoris, myocardial in- triglyceride levels (>500 mg/dL). In clients with coro- • Cerebrovascular insufficiency may be manifested nary artery disease, management with gemfibrozil is associated by syncope, memory loss, transient ischemic attacks with regression of atherosclerotic lesions on angiography. Impairment of blood flow to the These drugs are well absorbed following oral administra- brain is caused primarily by atherosclerosis in the tion. Metabolism occurs in the liver and excretion is by uri- carotid, vertebral, or cerebral arteries. The main adverse effects are gastrointestinal • Peripheral arterial insufficiency is manifested by im- discomfort and diarrhea, which may occur less often with paired blood flow in the legs (weak or absent pulses; fenofibrate than with gemfibrozil. The drugs may also in- cool, pale extremities; intermittent claudication; leg pain crease cholesterol concentration in the biliary tract and cause at rest; and development of gangrene, usually in the toes gallstones. For clients receiving warfarin, warfarin dosage because they are most distal to blood supply). This con- should be substantially decreased because fibrates displace dition results from atherosclerosis in the distal abdomi- warfarin from binding sites on serum albumin.

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