By D. Zuben. Lenoir-Rhyne College. 2018.
Such mg milligram an action allows the full dose to be absorbed immediately and mL milliliter constitutes an overdose buy dilantin 100 mg lowest price, with potential organ damage or death buy cheap dilantin 100 mg online. These medications are slowly absorbed from the skin patches over varying periods of time (eg buy dilantin 100 mg line, 1 week for cloni- ac before meals dine and estrogen) generic 100 mg dilantin with visa. Pump delivery systems may be external or ad lib as desired implanted under the skin and reﬁllable or long acting without bid twice daily hs bedtime reﬁlls best 100mg dilantin. Pumps are used to administer insulin order dilantin 100mg online, opioid analgesics, pc after meals antineoplastics, and other drugs. PRN when needed Solutions, ointments, creams, and suppositories are applied qd every day, daily topically to skin or mucous membranes. They are formulated q4h every four hours for the intended route of administration. For example, several qid four times daily qod every other day drugs are available in solutions for nasal or oral inhalation; they stat immediately are usually self-administered as a spray into the nose or mouth. Commonly used combina- *Because of errors made with the abbreviations, some authorities recommend spelling out the site (eg, right eye). CHAPTER 3 ADMINISTERING MEDICATIONS 33 TABLE 3–2 Drug Dosage Forms Dosage Forms and Their Routes of Administration Characteristics Considerations/Precautions Tablets Regular: PO, GI tube (crushed • Contain active drug plus binders, dyes, preservatives 8 oz of water recommended when taken orally, to and mixed with water) • Dissolve in gastric ﬂuids promote dissolution and absorption Chewable: PO Colorful and ﬂavored, mainly for young children who Colors and ﬂavors appeal to children; keep out of are unable to swallow or who refuse regular tablets reach to avoid accidental overdose. Enteric coated: PO Dissolve in small intestine rather than stomach; Do not crush; instruct clients not to chew or crush. Solutions Oral: PO, GI tube • Absorbed rapidly because they do not need to be Use of appropriate measuring devices and accurate dissolved measurement are extremely important. Parenteral: IV, IM SC, • Medications and all administration devices must Use of appropriate equipment (eg, needles, syringes, intradermal be sterile IV administration sets) and accurate measurement • IV produces rapid effects; SC is used mainly for in- are extremely important. Insulin syringes should sulin and heparin; IM is used for only a few drugs; always be used for insulin and tuberculin syringes intradermal is used mainly to inject skin test ma- are recommended for measuring small amounts of terial rather than therapeutic drugs. Suspensions PO, SC (NPH and • These are particles of active drug suspended in Drug particles settle to the bottom on standing. If Lente insulins) a liquid; the liquid must be rotated or shaken not remixed, the liquid vehicle is given rather than before measuring a dose. Dermatologic Creams, Lotions, Ointments Topically to skin • Most are formulated for minimal absorption Formulations vary with intended uses and are not through skin and local effects at the site of appli- interchangeable. Solutions and Powders for • Oral inhalations are used mainly for asthma; nasal Several research studies indicate that patients often Oral or Nasal Inhalation, sprays for nasal allergies (allergic rhinitis) do not use MDIs correctly and sometimes are in- Including Metered Dose • Effective with less systemic effect than oral drugs correctly taught by health care providers. Correct Inhalers (MDIs) • Deliver a speciﬁed dose per inhalation use is essential to obtaining therapeutic effects and avoiding adverse effects. Eye Solutions and Ointments • Should be sterile Can be systemically absorbed and cause systemic • Most are packaged in small amounts, to be used adverse effects by a single patient Throat Lozenges • Used for cough and sore throat Ear Solutions • Used mainly for ear infections (continued) 34 SECTION 1 INTRODUCTION TO DRUG THERAPY TABLE 3–2 Drug Dosage Forms (continued) Dosage Forms and Their Routes of Administration Characteristics Considerations/Precautions Vaginal Creams and • Formulated for insertion into the vagina Suppositories • Commonly used to treat vaginal infections Rectal Suppositories • Formulated for insertion into the rectum Effects somewhat unpredictable because absorption and Enemas • Suppositories may be used to administer seda- is erratic tives, analgesics, laxatives • Medicated enemas are used to treat inﬂammatory bowel diseases (eg, ulcerative colitis) PO, oral; GI, gastrointestinal; IV, intravenous; IM, intramuscular; SC, subcutaneous. CALCULATING DRUG DOSAGES animal tests (ie, the amount of drug required to produce a particular response). For ex- When calculating drug doses, the importance of accuracy ample, concentrations of insulin and heparin are both ex- cannot be overemphasized. Accuracy requires basic skills in pressed in units, but there is no relation between a unit of mathematics, knowledge of common units of measurement, insulin and a unit of heparin. These drugs are usually ordered and methods of using data in performing calculations. Milliequivalents express the ionic ac- The most commonly used system of measurement is the met- tivity of a drug. Drugs such as potassium chloride are ordered ric system, in which the meter is used for linear measure, the and labeled in the number of milliequivalents per dose, tablet, gram for weight, and the liter for volume. The apothecary system, now obsolete and rarely used, has units called grains, minims, drams, ounces, pounds, pints, Mathematical Calculations and quarts. The household system, with units of drops, tea- spoons, tablespoons, and cups, is infrequently used in health Most drug orders and labels are expressed in metric units of care agencies but may be used at home. If the amount speciﬁed in the order is the same alent measurements within and among these systems.
Szpalski M purchase dilantin 100 mg mastercard, Gunzburg R (1998) The loid deposits in spinal canal stenosis buy 100mg dilantin overnight delivery. Gill GG dilantin 100mg online, Manning JG discount 100mg dilantin mastercard, White HL Surg Br 32:325–333 tol 12:141–159 (1955) Surgical treatment of spondy- 19 proven dilantin 100 mg. J Bone (1988) Lumbar disc degeneration: cor- tom from developmental narrowing of Joint Surg Am 37:493–520 relation with age buy cheap dilantin 100mg line, sex and spine levels the lumbar vertebral canal. Spine 13: Joint Surg Br 36:230–237 al (2003) Clinical and psychofunc- 173–178 33. Miyamoto S, Takaoka K, Yonenobu K influence of occupation on lumbar de- compression surgery for lumbar spinal et al (1992) Ossification of the liga- generation. Videman T, Nurminen M, Troup JDG Eur Spine J 12:197–204 phogenic protein. Gutwirth P (2000) Distinguishing vas- 74:279–283 daveric material in relation to history cular disease from lumbar spinal steno- 21. Newman PH (1963) The aetiology of of back pain, occupation and physical sis. Wiltse LL, Rothman SLG (1996) Lum- Williams & Wilkins, Philadelphia, 22. Porter RW (2000) Vascular compres- bar and lumbosacral spondylolisthesis. Computed tomography after laminec- pincott Williams & Wilkins, Philadel- Saunders, Philadelphia, pp 621–654 tomy for lumbar spinal stenosis. Porter RW, Ward D (1992) cauda equina stenosis–Result of surgical treatment. Herno A, Saari T, Suomalainen O et al dysfunction: the significance of multi- J Westn Pac Orthopaedic Assoc 29: (1999) The degree of decompressive ple level pathology. Postacchini F Gumina S, Cinotti G et come in patients undergoing surgery al (1994) Ligamenta flava in lumbar for lumbar spinal stenosis. Spine 19:917–922 REVIEW Robert Gunzburg The conservative surgical treatment Marek Szpalski of lumbar spinal stenosis in the elderly Abstract Canal stenosis is now the which preserves a maximum of bony most common indication for lumbar and ligamentous structures. De- principle of surgical treatment is in- generative disc disease is by far the terspinous process distraction This most common cause of lumbar spinal device is implanted between the spin- stenosis. It is generally accepted that ous processes, thus reducing exten- surgery is indicated if a well-con- sion at the symptomatic level(s), yet ducted conservative management allowing flexion and unrestricted ax- fails. It lim- ture showed on average that 64% of its the further narrowing of the canal surgically treated patients for lumbar in upright and extended position. In spinal stenosis were reported to have accordance with the current general R. In re- tendency towards minimally invasive Department of Orthopaedics, Eeuwfeestkliniek, cent years, however, a growing ten- surgery, such techniques, which pre- Harmoniestraat 68, dency towards less invasive decom- serve much of the anatomy, and the 2018 Antwerp, Belgium pressive surgery has emerged. Szpalski the vertebra above and below the Department of Orthopaedics, stenotic level combined with a par- Keywords Lumbar spinal stenosis · Hôpitaux Iris Sud–Molière Longchamp, 142 rue Marconi, tial arthrectomy at that level. It can Surgery 1190 Brussels, Belgium be performed through an approach row but not stenotic. Degenerative disc disease is by Introduction far the most common cause of lumbar spinal stenosis. A bulging degenerated intervertebral disc anteriorly, com- Increasing numbers of patients, particularly the elderly, bined with thickened infolding of ligamenta flava and hy- are undergoing surgery for lumbar stenosis. Indeed, canal pertrophy of the facet joints posteriorly result in narrow- stenosis is now the most common indication for lumbar ing of the spinal canal. With the aging of the central, lateral or a combination, of the two. As for population the incidence of surgical decompressions will many continuous characteristics, both canal size and dural increase.
Nevertheless in this dilantin 100 mg low price, and for the majority of clinical trials order 100 mg dilantin, it is clearly important to monitor INTERIM ANALYSIS AND EARLY the accumulating data purchase 100mg dilantin visa. It has also been recognised STOPPING RULES that such monitoring should be reviewed (not by the clinical teams involved in entering patients At the planning stage of a clinical trial the design into the trial themselves) but by an independent team will be aware of the need to monitor the DMC buy dilantin 100 mg free shipping. The membership and remit of a DMC will progress of the trial by reports to an IDMSC purchase 100mg dilantin free shipping. On usually depend on the particular trial(s) under these occasions the data centre responsible for the 32 TEXTBOOK OF CLINICAL TRIALS conduct of the trial will expect to prepare reports published and negative studies tend not to be on many aspects of trial progress including published presents a distorted view of the true especially safety and efﬁcacy discount 100 mg dilantin overnight delivery. This approach to reporting is par- often detailed in the trial protocol. The detail may ticularly important for clinical trial overviews specify those aspects that are likely to be of major and meta-analysis where it is clearly impor- concern and also the timing (often expressed in tant to be able to include all relevant stud- terms of patient numbers or events observed) of ies (not just the published ones) in the overall such reports. An interim report may include a formal The second aspect of reporting is the standard (statistical) comparison of treatment efﬁcacy. The most accumulating data for each IDMSC and ﬁnally basic feature that has repeatedly been empha- following the close of the trial once the relevant sised is to give estimates (with conﬁdence inter- data are to hand. These repeated statistical tests vals) of treatment effects and not just p-values. The Con- methods of adjusting for the multiple looks solidation of the Standards of Reporting Trials at the accumulating data have been devised. However, all these meth- Thus a full note has to be provided on those, ods are predicated on obtaining timely and com- for example, who post-randomisation refuse the plete data, very rapid analysis and report writing allocation and perhaps then insist on the competi- and immediate review by the IDMSC. Two examples of how the patient also focus on only one aspect (usually efﬁcacy) ﬂow through a trial is summarised are given in and so do not provide a comprehensive view of Figure 2. These are intended as an important prerequisite to be supplemented by The ﬁrst rule after completing a clinical trial the p-value from the associated hypothesis test. Selective reporting many standard statistical packages as well as the whereby results of positive studies tend to be specialist software of Altman et al. Trial proﬁles following the CONSORT Guidelines INTENTION-TO-TREAT (ITT) B, then the trial is no longer properly ran- domised and the resulting comparison may be As we have indicated, once patients have been seriously biased. On the other hand if patients, once ran- are to be summarised, any analysis including domised, have then to be scheduled for surgery, those patients who were randomised to the drug then there may be considerable delay before ther- but then did not receive it (for whatever reason) apy is activated. This delay may provide a period could seriously underestimate the true levels. If in which the patients change their mind about this is indeed appropriate for such endpoints, consent or indeed in those with life-threatening then the trial protocol should state that such an illness some may die before the scheduled date analysis is intended from the onset. Thus, the number of patients actu- One procedure that used to be in widespread ally starting the protocol treatment allocated may use was, once the protocol treatment and follow- be less than the number randomised to receive up were complete, and all the trial-speciﬁc it. This review would, for example, for analysis whatever occurs, even in situations check that the patient eligibility criteria were where a patient after consent is randomised to satisﬁed and that there had been no important (say) A but then refuses and even insists on protocol deviations while on treatment. The effect of such patients following this review, then found to be a patient is to dilute the estimate of the true dif- ineligible or protocol violators would then, in ference between A and B. However, if such a principle, be set aside and excluded from the patient was analysed as if allocated to treatment trial results. In the meantime the tal and these include the statistical signiﬁcance patient is randomised and treatment commenced test, conﬁdence intervals and analysis adjusted but once the report is returned the patient is for confounding (usually prognostic) variables. The form of these techniques will depend on The above review process would automatically the design and especially the type of endpoint exclude this patient, whereas Freedman and variable under consideration. In are examined in this way as to which treatment is a survival time context, the difference between which.
The goal of treatment is to provide an adequate Evaluation quantity and quality of nutrients to meet tissue needs discount dilantin 100 mg on-line. Re- • Observe undernourished clients for quantity and quality quirements for nutrients vary with age cheap dilantin 100 mg otc, level of activity dilantin 100mg discount, of nutrient intake buy dilantin 100mg without prescription, weight gain buy dilantin 100mg amex, and improvement in lab- level of health or illness generic dilantin 100mg fast delivery, and other factors that must be con- oratory tests of nutritional status (eg, serum proteins, sidered when designing appropriate therapy. High-protein, high- • Observe children for quantity and quality of food intake calorie foods can be included in many diets and given as and appropriate increases in height and weight. If the client cannot ingest • Interview and observe for signs and symptoms of com- enough food and ﬂuid, many of the commercial nutritional plications of enteral and parenteral nutrition. Cold formu- ✔ Nutrition is extremely important in promoting health and las may cause abdominal cramping. For people who are unable to take ✔ Do not take or give more than 1 pint (500 mL) per in enough nutrients because of poor appetite or illness, feeding, including 2 to 3 oz of water for rinsing the nutritional supplements can be very beneﬁcial in improv- tube. This helps to avoid overﬁlling the stomach and ing their nutritional status. With intermittent feedings, rinse all ferent ﬂavors, and trying several different ones may be equipment after each use, and change at least every helpful. Most tube feeding formulas are milk based client does not like, ask for the names of others with com- and infection may occur if formulas become con- parable nutritional value. Water can be mixed with the tube feeding formula, given after the tube feeding, Self- or Caregiver Administration or given between feedings. Be sure to include the amount of water used for rinsing the tube in the total ✔ For oral supplemental feedings: daily amount. When not ✔ Mix powders or concentrated liquid preparations in available, some tablets may be crushed and some cap- preferred beverages, when possible. Some can be sules may be emptied and mixed with 1 to 2 table- mixed with fruit juice, milk, tea, or coffee, which may spoons of water. Ask a health care provider the best way of check- ication to get the medication through the tube and to ing placement for your type of tube. Measures to improve taste may prevent GI atrophy, maintain GI function, and maintain im- include chilling, serving over ice, freezing, or mixing with mune system function. For long-term feedings, a gas- Refer to instructions, usually on the labels, for appropriate trostomy tube may be placed percutaneously (called percuta- diluting and mixing of beverages. Nasointestinal several oral supplements are available and may be preferred tubes are recommended for clients at risk of aspiration from by some clients. Except for gastro- stomy tubes, the tubes should be soft and small bore to decrease Enteral Nutrition: Tube Feedings trauma. First, tube feeding is usually safer, amounts calculated to provide adequate water, protein, 444 SECTION 5 NUTRIENTS, FLUIDS, AND ELECTROLYTES CLIENT TEACHING GUIDELINES Drugs That Aid Weight Loss General Considerations plements when taking a prescription appetite suppres- ✔ In addition to feeling better, health beneﬁts of weight loss sant. The combination can cause serious adverse effects may include reduced blood pressure, reduced blood fats, from excessive heart and brain stimulation. The recommended rate of weight loss is approx- does not cause heart or brain stimulation. Medications to aid weight loss are Self-Administration usually recommended only for people whose health is en- ✔ Take appetite suppressants in the morning to decrease dangered (ie, those who are overweight and have other appetite during the day and avoid interference with sleep risk factors for heart disease and those who are obese). If ✔ Have blood pressure and heart rate checked at regular unclear about any aspect of the information, consult a intervals (the drug increases them). Because these ✔ With orlistat: drugs stimulate the heart and the brain, adverse effects ✔ Take one capsule with each main meal or up to 1 hour may include increased blood pressure, fast heart beat, after a meal, up to 3 capsules daily. If you miss a meal irregular heart beat, heart attack, stroke, dizziness, ner- or eat a non-fat meal, you may omit a dose of orlistat. In addition, prolonged use of prescription drugs (A,D,E, and K) daily, at least 2 hours before or after may lead to psychological dependence.
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