Requip

Michael R. Mill, MD

• Professor of Surgery
• Chief, Division of Cardiothoracic Surgery
• Director, Heart-Lung Transplant Program
• Director, UNC Comprehensive Transplant Center
• Program Director, Cardiothoracic Surgery Residency Program
• University of North Carolina School of Medicine
• Chapel Hill, North Carolina

National institutions as well as clinical and forensic to xicology facilities are required not only to analyse seized materials medications 123 buy requip 0.25 mg without a prescription, but also to detect and measure the abused compounds and their metabolites in biological specimens symptoms testicular cancer buy requip overnight delivery. In the clinical environment symptoms of depression buy requip on line amex, to xicologists are usually required to promptly identify drugs and drug metabolites to support the physician in the diagnosis and treatment of acute in to xications symptoms 6 week pregnancy purchase requip 2mg mastercard. As a result of the changes described above medications 319 buy discount requip 1 mg on-line, labora to ries must be able to deal with an ever increasing number of substances and use analytical methods coupling sen sitivity and specifcity with the widest analytical spectrum medications used to treat anxiety discount 2mg requip overnight delivery, assuring both rapid 1 2 Guidelines for testing drugs under international control in hair, sweat and oral fuid response and robust operation at the same time. Taking in to account the analysis of biological specimens, additional challenges must be faced, such as the need for high sensitivity and for high selectivity to wards numerous potential endogenous interfer ences. Furthermore, the rapid decrease of drug concentrations in biological fuids due to the metabolic changes of the parent compounds poses additional problems to the to xicologist. Given the above considerations, it is clear that an effcient exchange of information between labora to ries, as well as between labora to ries and regula to ry agencies at the national and international levels will offer a harmonization of methods, which forms the basis of an effective global control of the phenomenon of drug abuse. In particular, the validation of analytical methods according to international standards. For this purpose, urine testing has been by far the most common to xicological approach because relatively high concentrations of drugs and metabolites are generally present in this biological matrix. However, urine analyses are essentially limited to testing for and reporting on the presence (or the absence) of a drug or its metabolites over a short retrospective period [2]. Blood, in which the presence of many compounds is limited to a few hours, is generally considered the biological sample of choice to detect drugs in the actual phase of biological activity, i. The relatively low concentrations and short half-life of exogenous compounds in the blood places important demands on the analytical techniques, which should be 10 to 100-fold more sensitive than for urine. Even if performed with the most rigorous analytical procedure, an intrinsic weak point of the analysis of drugs in biofuids is the limited detection window (from hours up to a few days) and the prevalence of metabolites versus the parent drug. Therefore, hair analysis is now considered to be the most effcient to ol to investigate drug-related his to ries, particularly when the period of use needs to be tested back to many days or even months before the sampling [6]. On these grounds, following recent suggestions from international associations, such as the Society of Hair Testing, hair analysis can become not only a fundamental to ol in forensic to xicology and medicine, but also a way to fnd traces of illicit drugs in subjects claiming abstinence for months before sampling. As depicted in table 1 [7], these alternate matrices offer different detection windows. In most instances, they show signifcantly different metabolic profles when compared to traditional blood and urine testing. Detection windows for drugs in various biological matrices [7] Specimen Detection window Blood (serum) Several hours to 1-2 days Urine Several hours to 3 days Oral fuid Several hours to 1-2 days (or more for basic drugs) Sweat (patch) Weeks Hair Months/years In addition to differences in metabolism and pharmacokinetics, the various biological matrices show other peculiarities, particularly relevant in the forensic environment. First of all, there are issues with the possibility of urine substitution, dilution, and adulteration during sample collection. These problems are much less likely for hair and the other alternate specimens compared to urine. This advantage has promoted the popularity and use of these specimens for drug testing [3]. Also, in comparison to blood, the alternate matrices have the undoubted advantage of a minimally invasive collection procedure, which can potentially be performed in a non-medical setting. The analysis of drugs in hair was frst reported outside the feld of forensic to xico logy in 1954 [8]. However, only in 1979 [4] was a radioimmunoassay for morphine detection reported and used to document chronic opiate-abuse his to ries. As mentioned above, the major practical advantage of hair testing compared to urine and blood testing for drugs is its larger detection window, ranging from weeks to several months (depending on the length of hair shaft analysed). In practice, by combining the detection windows offered by blood, urine and hair, a 4 Guidelines for testing drugs under international control in hair, sweat and oral fuid to xicologist can gather objective information on drug use/exposure within an extended time frame. Hair analysis has also been used for the determination of a large number of pharmaceutical drugs [11] and chemical compounds [27]. Purpose and use of the Manual the present Manual is focused on the application of up- to -date techniques of ana lytical to xicology to the biological specimens, hair, sweat and oral fuid. These biological matrices, having a different composition to more traditional biofuids, i. The major issues that are still open regarding the interpretation of the qualitative and quantitative results will be discussed the present Manual is one in a series of similar publications dealing with the iden tifcation and analysis of various classes of drugs under international control. In accordance with the overall objective of the series, the present Manual suggests approaches that may assist drug analysts in the selection of methods appropriate for the sample under examination and provide data suitable for the purpose at hand. It should be noted that due to the nature of the analytes and requirements for extrac tion and analysis, the detection of drugs in biofuids generally requires the need for relatively advanced techniques such as gas chroma to graphy-mass spectrometry and liquid chroma to graphy-mass spectrometry. The reader should be aware, however, that there are a number of other methods, including those published in the forensic science literature, which may also produce acceptable results. Comments and suggestions may be addressed to : Labora to ry and Scientifc Section United Nations Offce on Drugs and Crime Vienna International Centre P. Hair is a keratin-containing appendage that grows from a root located in a cavity of the skin called the follicle [28]. The hair follicles extend from the dermis through the epidermis and the stratum corneum at the surface of the skin, and in humans, cover a high percentage of the body surface. At its surface, hair has a thick covering consisting of one or more layers of fat overlapping scale-like structures, collectively called cuticles, that function to protect and anchor the hair shaft to the follicle [29]. The cuticle layers surround the cortex, which contains nearly all the fbre mass and fbrous proteins, consisting of spindle-shaped cells that are aligned longitudinally. The medulla is the fourth structure, which contains the medullar cells and is detectable only in the hairs with a large diameter (in the human beard, the medulla is complex and, in some instances, a double medulla may be observed). Chemically, hair is a cross-linked, partially crystalline-oriented polymeric network, which contains different chemical functional groups, with the potential for binding small molecules. It is composed of approximately 65-95 % proteins, 15-35 % water, 1-9 % lipids and 0. In particular, the lipids are derived mainly from sebum and the secretion of the apocrine glands of the skin and consist of free fatty acids, mono-, di and triglycerides, wax esters, hydrocarbons and alcohols. The colour of the hair is related to the different amount and distribution of hair pigments, principally melanin[29]. There are basic structural similarities between hair of dif ferent colour, ethnic origin and body region. The fundamentals of hair composition, ana to my and physiology have been described in articles by Harkey [29] and Cone and Joseph [6], and are summarized in the following sections. During the anagen stage, the papilla 7 8 Guidelines for testing drugs under international control in hair, sweat and oral fuid promotes the hair growth. It then moves up to the zone of differentiation, where the melanocytes produce the hair pigment, which is incorporated in to each fbre inside the cortical and medullary cells by means of a phagocy to sis-mediated mechanism. The intermediate flament proteins, consisting of helical di-sulphur bond dimers of acidic and basic-neutral flaments (keratins), are the frst proteins synthesized in the differentiating cortical cells. These dimers, at a later stage, pair to form tetramers that combine, becoming pro to flaments (important subunits of the cortex). The cuticle is built higher up in the follicle and consists of cysteine rich proteins. The resulting cell complex, tem porarily tied by desmosomes, tight and gap junctions, is fnally fxed by the cell membrane complex. Cells are in active proliferation in the root, whereas in the hair shaft any residual metabolism is lost. During the catagen stage, the metabolic activity of the root slows down and the base of the bulb migrates upwards in the skin through the epidermal surface. In the telogen phase, growth s to ps, the follicle atrophies and fnally the hair is lost. The length and the rate of growth of hairs depend on the duration of the stages described above. The duration of the stages varies from person to person, between the scalp hair and the hair of other body regions and even between different areas of the scalp of the same person (mosaic pattern growth). Sweat is secreted by eccrine glands on the surface of the body, and can be considered a vehicle for the excretion of drugs. The chemical and physical properties of the compounds affect their susceptibility to incorporation in to the hair structure. In general, small molecular dimensions, high hydrophobicity and the presence of basic ionizable groups tend to favour binding in to the hair structure. Among these, a prominent role is exerted by keratin with its carboxyl, amine, phenol, hydroxyl and sulphydril groups, as well as multiple hydrogen bonds. It may be considered to behave like a weak cationic exchanger and consequently tends to bind basic drugs. Pragst and Balikova report that at 12-15 cm from the root, hair can retain only about 4 % of the original drug concentration (23 different drugs or metabolites were tested) in regularly shampooed hair not exposed to cosmetic treatments [35]. Several publications describe a lower drug concentration for opioids, methadone, cocaine, methamphetamine and cannabinoids in scalp hair compared to other types of hair [35]. Therefore, the biological differences between hair sampled from different locations must be considered for a proper interpretation of the results of hair testing. There are considerable variations of growth rate in the different regions of the scalp. Thus, for the sake of uniformity, sampling from the vertex posterior area is recom mended. Average values for the anagen stage in scalp hairs are 4-6 years, the catagen stage lasts a few weeks and the telogen stage about 4-6 months, with an overall growth rate ranging from 0. Beard hairs are thicker, have bigger follicles and have the slowest growth rate (0. Their follicles are characteristic because the sebaceous gland duct exits from the skin in a channel separate from the channel of the hair shaft; thus beard hair may be somewhat less contaminated by sebaceous secretions. However, as the sample is commonly obtained by shaving, inherently, the specimen can be contaminated by pieces of epidermis. Similarly to scalp hair, beard hair may be contaminated by the external environment. Pubic and axillary hairs are less suitable as specimens, as they are curled rather than straight (thus segmental analysis is more diffcult) and are also exposed to sebum, sweat and apocrine gland secretions (discharged in to the hair follicle). A competent individual, but not necessarily a medical practitioner, should collect hair samples. The collec to r must wear gloves and use clean to ols to avoid any risk of inter individual contamination. Collection site: the posterior vertex region of the head is the preferred sampling site as this region is associated with the smallest variation in growth rate. As an alterna tive, or in addition to scalp hair sampling, pubic, beard or axillary hair can be collected, taking in to account the interpretation issues posed by these differing specimens. Sample amount: to carry out screening and confrma to ry routine tests, and, if required, to repeat the analyses (including counter-analysis by a second labora to ry), the amount of sample collected is critical. This can be avoided by collect ing several smaller samples from multiple sites of the scalp, possibly within the vertex region. Collection procedure: a lock of hair should be tied and cut as close to the skin as possible. Description (depending on the purpose of the test): the case his to ry, relevant anamnesis data, the colour, length, site of collection and any cosmetic treatments should be recorded. S to rage: hair samples must be s to red in a dry, dark environment at room tem perature. S to rage at low temperature is not recommended, as it can result in hair swelling, growth of moulds and drug loss. S to rage in plastic bags must be avoided because of contamination by plastic softeners. A simple procedure for s to rage is to wrap the hair sample in aluminium foil and seal it in a paper envelope. Collection in drug-facilitated crimes Recently, reports on the use of drugs to modify the behaviour of a victim for criminal gain have increased. Typically, victims report forms of amnesia during and after the event, resulting in a delay in the notifcation of the crime. In these instances, the to xicologist may be asked to detect, by means of hair analysis, a single drug exposure having occurred weeks or months before sample collection [15]. This period is adequate to ensure that the hair shaft incorporating the drug emerges from the bulb area in the follicle to a height above the skin surface suffcient for collection. Also, the characteristics of the hair sample should be considered in order to decide the pre-analytical and the analytical strategy. In order to avoid generic screenings, which inherently not only sacrifce sensitivity and selectivity, but also require higher sample quantities, it is generally preferable to focus on one or more targeted drugs and consequently identify the most appropri ate analytical methods.

Stress importance of avoiding exposure to smoke treatment 10 order requip 2mg mastercard, air pollu Protects lung(s) from irritation and reduces risk of infection medications listed alphabetically generic requip 2mg amex. Suggest increasing protein Meeting cellular energy requirements and maintaining good and use of high-calorie snacks as appropriate symptoms gerd purchase requip with visa. Weakness and fatigue should decrease as lung heals and respi ra to ry function improves during recovery period treatment xdr tb guidelines cheap 1mg requip fast delivery, especially if cancer was completely removed medications like zoloft discount 0.5mg requip otc. If cancer is advanced medicine 3605 v purchase requip, it is emotionally helpful for client to be able to set realistic activity goals to achieve optimal independence. Evaluate availability and adequacy of support system(s) and General weakness and activity limitations may reduce necessity for assistance in self-care and home management. Encourage alternating rest periods with activity and light tasks Generalized weakness and fatigue are usual in the early recovery with heavy tasks. Emphasize avoidance of heavy lifting and period but should diminish as respira to ry function improves isometric or strenuous upper body exercise. Note: Strenuous use of arms can place undue stress on incision because chest muscles may be weaker than normal for 3 to 6 months following surgery. Recommend s to pping any activity that causes undue fatigue or Exhaustion aggravates respira to ry insufficiency. Review expectations for Healing begins immediately, but complete healing takes time. Underlying tissue may look bruised and feel tense, warm, and lumpy (resolving hema to ma). Suggest wearing soft cot to n shirts and loose-fitting clothing; Reduces suture line irritation and pressure from clothing. Support incision with butterfly bandages as needed when Aids in maintaining approximation of wound edges to promote sutures and staples are removed. Secondary spontaneous pneumothorax space volumes and reduced lung capacity, causing respira c. Iatrogenic pneumothorax to ry distress and gas exchange problems and producing ten d. Iatrogenic: complication of medical or surgical procedures, ary spontaneous pneumothorax, occurring in intervals of such as therapeutic thoracentesis, tracheos to my, pleural 1. Mortality: Rate is 15% for those with secondary pneumo mechanical ventilation, inadvertent intubation of right thorax associated with underlying lung disease. The device consists of a water seal Pleural space: Area between the parietal pleura (membrane lin and collection chambers and a suction-control chamber, or a ing the chest cavity) and the visceral pleura, which surrounds one-way mechanical valve, depending on the amount of the lungs. Empyema: Pus from an infection, such as pneumonia, in the Tension pneumothorax: Unrelieved accumulation of air in the pleural space. Thoracentesis: Use of a needle to rapidly remove fluid from the Hemothorax: Collection of blood in the pleural space, which can pleural space. Care Setting Related Concerns Client is treated in inpatient medical or surgical unit. Moni to r for asynchronous respira to ry pattern when using Difficulty breathing with ventila to r or increasing airway pres mechanical ventila to r. Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed areas have decreased sounds. Regularly scheduled evaluation also helps determine areas of good air exchange and pro vides a baseline to evaluate resolution of pneumothorax. Voice and tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue. Maintain position of comfort, usually with head of bed Promotes maximal inspiration; enhances lung expansion and elevated. This care plan concerns the hospitalized client whose treatment plan includes use of a traditional chest drainage system. Mobile drains are indicated for those clients who are ambu la to ry and do not require a suction for reinflation of lungs. Once chest tube is inserted: Determine if dry-seal chest drain or water-seal system is Some chest drains use a mechanical one-way valve in place of used. The one-way valve allows air to escape from the chest and prevents air from entering the chest. Dry suction-control systems regulate suction pres sure mechanically rather than with a column of water. Some dry suction systems use a screw-type valve that varies the size of the opening to the vacuum source, thereby limiting the amount of negative pressure that can be transmitted to the chest. These valves narrow the opening of the chest drain in order to adjust the level of negative pressure; there fore, the to tal amount of air that can flow out of the chest drain is also limited. Thus, this type of dry suction-control mechanism is impractical for clients with significant pleural air leaks (Atrium Product Support, no date given). If water-seal system is used: Check suction-control chamber for correct amount of suction, Maintains prescribed intrapleural negativity, which promotes as determined by water level, wall or table regula to r, at optimum lung expansion and fluid drainage. Check fluid level in water-seal chamber; maintain at Water in a sealed chamber serves as a barrier that prevents at prescribed level. Note: Underfilling the water-seal chamber leaves it ex posed to air, putting client at risk for pneumothorax or tension pneumothorax. Overfilling, a more common mis take, prevents air from easily exiting the pleural space, thus preventing resolution of pneumothorax and possibly creat ing a tension pneumothorax. Bubbling usually decreases as the lung ex pands or may occur only during expiration or coughing as the pleural space diminishes. Absence of bubbling may in dicate complete lung reexpansion (normal) or represent complications, such as obstruction, in the tube. Evaluate for abnormal or continuous water-seal chamber With suction applied, this indicates a persistent air leak bubbling. Determine location of air leak (client or system centered) by If bubbling s to ps when catheter is clamped at insertion site, clamping thoracic catheter just distal to exit from chest. Place petrolatum gauze or other appropriate material around Usually corrects insertion site air leak. Clamp tubing in stepwise fashion downward to ward Isolates location of a system-centered air leak. Seal drainage tubing connection sites securely with length Prevents or corrects air leaks at connec to r sites. Tidaling of 2 to 6 cm during inspiration is normal and may increase briefly during coughing episodes. Continuation of excessive tidal fluctuations may indicate existence of airway obstruction or presence of a large pneumothorax. Position drainage system tubing for optimal function; for ex Improper position, kinking, or accumulation of clots and fluid in ample, shorten tubing or coil extra tubing on bed, making the tubing changes the desired negative pressure and im sure tubing is not kinked or hanging below entrance to pedes air or fluid evacuation. Note character and amount of chest tube drainage, whether Useful in evaluating resolution of pneumothorax or develop tube is warm and full of blood and whether bloody fluid ment of hemorrhage requiring prompt intervention. Some drainage systems are equipped with an au to transfu sion device, which allows for salvage of shed blood. May be indicated to maintain drainage in the presence of fresh bleeding, large blood clots, or purulent exudates (empyema). Caution is necessary to prevent undue discom fort or injury, such as invagination of tissue in to catheter eyelets and rupture of small blood vessels. Note: Although some physicians have expressed concern about this proce dure for clot dislodgement, there does not appear to be con sensus or guidelines (Hogg et al, 2011). If thoracic catheter is disconnected or dislodged: Observe for signs of respira to ry distress. If possible, recon Pneumothorax may recur, requiring prompt intervention to nect thoracic catheter to tubing and suction, using clean prevent fatal pulmonary and circula to ry impairment. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. After thoracic catheter is removed: Cover insertion site with sterile occlusive dressing. Observe Early detection of a developing complication, such as recur for signs or symp to ms that may indicate recurrence of rence of pneumothorax or presence of infection, is essential. Collaborative Assist with and prepare for reinflation procedures; for example, Treatment goals include air evacuation, lung reinflation, and simple aspiration, Heimlich valve, and chest tube placement prevention of recurrence. Heimlich one-way valve procedures may be useful for small uncomplicated pneumothorax with little or no drainage, chest tube placement is the treatment of choice for trau matic hemopneumothoraces. Note: Tension pneumothorax requires immediate needle depression, followed by chest tube placement. Placement of tube(s) is determined by the cause of the prob lem; for example, anterior chest near apex of lung, or one tube at the apex and one at posterior fifth to sixth inter costal space. Review Assesses status of gas exchange and ventilation and need for vital capacity and tidal volume measurements, where continuation or alterations in therapy. Administer supplemental oxygen via cannula, mask, or Aids in reducing work of breathing; promotes relief of respira mechanical ventilation, as indicated. Given to manage pleuritic pain and reduce anxiety and tachy cardia associated with impaired respira to ry function, espe cially when client is on a ventila to r. Identify changes and situations that should be reported to care Timely intervention may prevent serious complications. Provide safe transportation if client is sent off unit for diagnostic Promotes continuation of optimal evacuation of fluid or air dur purposes. If client is draining large amounts of chest correct fluid level; presence or absence of bubbling; and pres fluid or air, tube should not be clamped or suction inter ence, degree, and timing of tidaling. Ascertain whether chest rupted because of risk of accumulating fluid or air, compro tube can be clamped or disconnected from suction source. Moni to r thoracic insertion site, noting condition of skin and Provides for early recognition and treatment of developing skin presence and characteristics of drainage from around the or tissue erosion or infection. Observe for signs of respira to ry distress if thoracic catheter is Pneumothorax may recur or worsen, compromising respira to ry disconnected or dislodged. Provides knowledge base for understanding underlying dynamics of condition and significance of therapeutic interventions. In oth erwise healthy clients who suffered a spontaneous pneu mothorax, incidence of recurrence is 10% to 50%. Those who have a second spontaneous episode are at high risk for a third incident (60%) (Roman, 2000). Review signs and symp to ms requiring immediate medical Recurrence of pneumothorax and hemothorax requires medical evaluation, for example, sudden chest pain, dyspnea, air intervention to prevent and reduce potential complications. Review significance of good health practices, such as adequate Maintenance of general well-being promotes healing and may nutrition, rest, and exercise. Prevents respira to ry complications, such as fibrotic changes in lung tissue, and may prevent recurrence of collapsed lung. Inability to maintain adequate oxygenation (hypoxemia) instability from positive-pressure ventilation, barotrau b. Acute respira to ry acidosis: acute exacerbation of chronic to the expira to ry phase with signal to terminate the inspira emphysema or asthma to ry activity of the machine: c. Preset volume (volume-cycled ventila to r) aphragm due to Guillain-Barre syndrome, myasthenia ii. Preset pressure limit (pressure-cycled ventila to r) gravis, spinal cord injury, or the effects of anesthetic and iii. Mode of ventilation ditions, such as stroke, brain tumor, infections, sleep apnea; i. If the client fails to Hyperventilation: Fast rate of respiration, which results in loss initiate a breath, the ventila to r delivers the preset ventila to r of carbon dioxide from the blood. Assisted breath: Initiated by the client, but controlled and ended Hypoxemia: Low oxygen levels in the blood. Cycling: Ventila to r switches from inspiration to expiration; the Positive-pressure ventilation: Increases pressure in airway, thus flow has been delivered to the volume or pressure target. This mechanism requires less work by the client Volume cycle ventila to r: Volume of gas (tidal volume) is prede than pressure triggering. Care Setting Spinal cord injury (acute rehabilitative phase), page 248 Total nutritional support: parenteral/enteral feeding, the focus of this plan of care is the client with invasive me page 437 chanical ventilation who remains on a ventila to r, whether in an acute or postacute care setting. Client Assessment Database However, some clients are either unsuccessful at weaning or are not candidates for weaning. For these clients, portions Gathered data depend on the underlying pathophysiology and of this plan of care would need to be modified for the dis reason for ventila to ry support. Refer to the appropriate plan charge care setting, whether it be an extended care facility of care. Pneumothorax/hemothorax, page 150 Refer to section at end of plan for postdischarge Psychosocial aspects of care, page 729 considerations. Disease process, prognosis, and therapeutic regimen un ders to od, including home ventila to ry support if indicated.

Br J mance of the Bipolar Spectrum Diagnostic Scale in psychiatric outpa Psychiatry symptoms carbon monoxide poisoning buy requip 0.5 mg overnight delivery. Cochrane Data bipolar medicine 751 buy 0.5mg requip otc, anxiety treatment lyme disease requip 1 mg without a prescription, and post-traumatic stress disorders in primary care medicine xl3 order requip canada. Does stage of illness impact treat International consensus study of antipsychotic dosing medications grapefruit interacts with requip 1mg lowest price. Accessed September 16 medications you cant take while breastfeeding order 0.5mg requip amex, the management of patients with bipolar disorder: update 2009. Does lithium protect against associated with carbamazepine and oxcarbazepine therapy: a review. Adjunctive psychotherapy for bipolar disorder: state of with suicidality in bipolar disorder. The book covers most areas of disease where physical activity has a documented effect. Content: Thirty-three chapters address the effects of and recommendations of physical activity in diseases and conditions within cardiovascular and metabolic medicine, psychiatry, orthopaedics, neurology, gastro-intestinal medicine, nephrology, rheuma to logy, pulmonary medicine and more. The book is also useful for physical activity organisers Physical Activity in working with physical activity on prescription and for educational institutions, such as colleges and universities that focus on health sciences and public health. Stroke 611 Preface Ostersund, November 2010 Physical activity has both health promoting and disease prevention properties. An increase in physical activity is one of the measures that would have the greatest positive impact on the health of the population. If everyone followed the recommendation of being physi cally active on a daily basis, the health of the population would improve considerably and healthcare costs would drop dramatically. Regular exercise has well-documented preventative and/or curative effects on a number of different diseases, such as diabetes, cardiovascular disease, colon cancer and depression. The burden of illness and disease related to physical inactivity costs society a great deal in terms of increased healthcare costs and production losses. According to the World Health Report 2000, physical inactivity was estimated to cause 1. The healthcare system is in a strong position to work on increasing physical activity in the population. On one hand, people often come in to contact with the healthcare system on a regular basis. On the other, people often trust their health and medical care providers in matters regarding their health. Healthcare providers also reach the groups in society that are the most sedentary, such as the elderly and the ill. One advantage of physical activity as a treatment compared to medication is that physical activity makes patients feel actively involved in their own treatment and encourages them to take personal responsibility for their own health. Physical activity on prescription (FaR ) is a method used in Swedish health care to increase physical activity in the population. With this method, the patient receives an individualized prescription for physical activity in a group or individual setting. Use of this method has grown in recent years and was applied by all county councils in Sweden in 2008. The English version of this text has been partly updated with additional beneficial correlations between physical activity and metabolic syndrome, stress, dementia, schizo phrenia and other conditions. In some cases, physical activity can also replace pharma ceuticals and, in others, can reduce the need for medication. Prescribing physical activity should be just as natural as other proven treatments and methods. We would like to express our gratitude to all of the authors for their excellent work. The first edition felt mostly like an inciter of interest in the area, but those of us who worked with the second Swedish and now the first English edition still feel that the area is just as current and exciting as then, while at the same time noting that the handbook is now perceived as an established concept in Swedish healthcare. A great deal has happened in the field over the past eight years, and new facts from several well-done studies have now completed the knowledge base. The objective of the book is to increase the knowledge of the value of promoting physical activity in the population. The book is intended to be a knowledge base, easily available and prac tical, for all who work with promoting physical activity, but also to function as a textbook for various educational programmes. We would hereby like to express a huge debt of gratitude to the Swedish National Institute of Public Health and especially former Direc to r General Gunnar Agren and current Direc to r General Sarah Wamala and their co-workers for their whole-hearted cooperation and support. To further deepen the knowledge in this book, we have chosen to cooperate with the Norwegian Direc to rate of Health and the National Council for Physical Activity in Norway. Accordingly, both Swedish and Norwegian authors have contributed to a broader knowledge base and more in-depth analysis of the evidence. We would like to direct a major thanks to all of the Norwegian co-authors and edi to rs, especially Anita Andaas Aadland, Department of Physical Activity, Norwegian Direc to rate of Health, and Professor Roald Bahr, Norwegian School of Sports Sciences and National Council for Physical Activity, for a smooth and well-functioning cooperation. Most organs and tissues are affected by physical activity and adapt to regular exercise. This chapter focuses on the immediate effects of physical exertion and the long-term effects of regular physical activity/fitness training (aerobic training). Physical activity refers to all bodily movement that results from the contraction of the skeletal muscles and results in increased energy expenditure (1). Oxygen consumption, which is directly linked to energy expenditure, increases from 0. Ventilation multiplies, blood pressure increases, body temperature rises, perfusion in the heart and muscles increases, more lactic acid is formed and the secretion of hormones such as adren aline, growth hormone and cortisol increases. Maximum oxygen uptake capacity depends on body size, gender, age, fitness level, genetics and more. The fac to rs that limit performance capacity in full-body exertion differ depending on the length of the session. The longer the exertion continues, the more performance capacity is limited by properties of the engaged skeletal muscles (mi to chondria, capillaries, some transport molecules, buffer capacity, etc. Several fac to rs determine how much a person improves if the degree of physical activity increases. One important fac to r is the fitness/performance level when the period of exer cise training begins. A person who is inactive and in poor shape improves more in rela tive terms than a person who is well trained. Although some effects from exercise can be seen after a surprisingly short time of one to a few weeks, the effects are considerably greater if training continues for several months to years. Three other important fac to rs are frequency (how often the person exercises), duration (how long a session is) and intensity (how hard/intense the session is). It should be pointed out that low doses also have an effect, although to a more limited extent. Frequency For physical activity to have the maximum performance and health effects, it must be pursued often and regularly. The effect that an exercise session has can affect the body for several days, and then subside. Duration As a rule, the longer the activity continues, the greater the effect it has. One common recommendation with regard to time is 30 minutes of physical activity per day. Intensity the harder an exercise session is, the greater its performance and health effects usually are, although excessively intense exercise can lead to deteriorations. Forexample,exercisecanbeconductedwithrelativelyconstan to rwithvaryinginten sity(intervaltraining)andwithvaryingsizeoftheengagedmusclemass(arm,abdomenandleg muscles compared with just leg muscles, for example). Genetics also seem to play a rela tively large role in how large the response to exercise training is, perhaps accounting for around a third to one half of the variation between people. There is some evidence in the literature that individuals who increase their performance capacity at a certain exercise dose more than others appear to activate key genes in a stronger way (7, 8). It has not been estab lished whether differences in exercise response are only due to genetic mechanisms (9). Age can be of significance, although older persons do not generally appear to have a worse ability to increase their relative performance. The composition of the diet may also play a role; a deficient diet lessens the response to exercise training. Effects of acute exertion and regular exercise When discussing the effects of physical activity on the bodily organs and organ systems, it is necessary to differentiate 1) what happens in the body during (and after) a session of physical activity compared with the situation at rest, and 2) what differences are achieved (at rest or under exertion) after a certain period of exercise training compared with an untrained condition. The effects of acute exertion are due to a number of fac to rs and differ between different tissues. The time for achieving different effects from exercise training varies from function to function, some processes start imme diately in connection with the first exercise session, others take weeks to months before they are noticeable. From a physiological perspective, a physical activity is called either aerobic or anaer obic, depending on which form of metabolism is dominant. One rule of thumb is that phys ical activity is aerobic (dependent on oxygen) if the maximum time one can perform the activity exceeds two minutes (3). Then the muscles mainly obtain their energy from the oxygen-dependent degradation of carbohydrates or fat. If one has the energy to carry out the activity for two minutes, but no longer, the metabolism is probably approximately 50 per cent aerobic and 50 per cent anaerobic (not oxygen-dependent). In short-term, intense physical activity, the muscles work without a sufficient oxygen supply (anaerobic metabolism) and the dominant energy-providing process is the splitting of glycogen and glucose in to the degradation product lactic acid. Consequently, it is natural that aerobic exercise and anaerobic exercise provide different effects of exercise training. Aerobic exercise performed for a sufficient period of time stimulates the adaptation of the heart and the aerobic systems of the skeletal muscles, which is why regular exercise leads to the heart increasing its capacity accompanied by an increased mi to chondrial volume in the 14 physical activity in the prevention and treatment of disease engaged skeletal muscle cells. The exercise time in pure anaerobic exercise (such as sprint training) is to o short to provide these exercise responses in the heart and muscles. Such anaerobic training instead leads to improved conditions for greater lactic acid production and lactic acid to lerance. Daily physical activity often has elements of both aerobic and anaerobic activities, such as walking in hilly terrain. Strength training, especially with heavy weights, is an extreme form of anaerobic exercise. Pedometers, or step counters, that measure vertical movements, are good aids for measuring the to tal number of steps when walking and running, but are relatively insensitive to many other movements. Training effects in aerobic exercise are often measured as the change in the maximum oxygen uptake capacity. This is the highest oxygen consumption a person can achieve and is measured when the individual works with a maximum pulse during. Since direct measurement of the maximum oxygen uptake capacity is relatively difficult, and requires both special equipment and nearly maximum exertion by the indi vidual, an indirect approach is often used where the maximum oxygen uptake capacity is calculated based on heart rate measurements at lower levels of exertion (3). Determination of the anaerobic threshold (lactic acid threshold test) can be achieved in a reliable manner from blood lactic acid samples taken during non-maximum exertion (13). In terms of percentages, it increases more than the maximum oxygen uptake capacity after a period of endurance training. Accordingly, less energy is consumed for the same amount of work performed (meas ured as lower oxygen consumption), efficiency is improved.

May differentiate current pain from preexisting patterns as well Discuss family his to ry if pertinent treatment zinc toxicity buy generic requip on line. Delays in reporting pain hinders pain relief and may necessi tate increased dosage of medication to achieve relief treatment junctional rhythm buy requip no prescription. In ad dition medications 1 gram purchase requip visa, severe pain may induce shock by stimulating the sympathetic nervous system medicine 54 543 purchase requip in india, thereby creating further dam age and interfering with diagnostics and relief of pain symptoms ulcer purchase 0.5 mg requip fast delivery. Assist or instruct in relaxation techniques symptoms synonym trusted 0.5mg requip, such as deep, slow Helpful in decreasing perception of or response to pain. Check vital signs before and after administration of opioid Hypotension and respira to ry depression can occur as a result medication. These problems may increase myocardial damage in presence of ventricular insufficiency. Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia. Administer medications, as indicated; for example: Anti-anginals, such as nitroglycerin (Nitro-Bid, Nitrostat, Nitrates are useful for pain control by coronary vasodilating ef Nitro-Dur), isosorbide dinitrate (Isordil), and mononitrate fects, which increase coronary blood flow and myocardial (Imdur) perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand. Investigate sudden changes or contin Cerebral perfusion is directly related to cardiac output and is ued alterations in mentation, such as anxiety, confusion, influenced by electrolyte and acid-base variations, hypoxia, lethargy, and stupor. Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses. Irregularities suggest dysrhythmias, which may require further evaluation and moni to ring. S3 is usually associated with heart failure, but it may also be noted with the mitral insufficiency (regurgitation) and left ventricular overload that can accompany severe infarction. A fourth heart sound can occur with or without signs of heart failure (Williams, 1990). Presence of rub with an infarction is also associated with in flammation, such as pericardial effusion and pericarditis. Moni to r hemodynamic pressures Hypotension may occur related to ventricular dysfunction, when invasive lines/devices are available. However, hypertension is also a common phenomenon, possibly related to pain, anxiety, catecholamine release, and preexisting vascular problems. Document dysrhythmias via Heart rate and rhythm can be affected by presence of coronary telemetry. Dysrhythmias, espe cially premature ventricular contractions or progressive heart blocks, can compromise cardiac and become lethal. Acute or chronic atrial flutter or fibrillation may be seen with coronary artery or valvular involvement and may or may not be pathological. Record urine Decreased output may reflect systemic perfusion problems and specific gravity, as indicated. Inotropic drugs may be needed for support of circulation or additional fluids to enhance circu lating volume and kidney function. Supplemental oxygen should be given to maintain oxygen sat uration >90% to prevent hypoxemia and resultant depres sion of myocardial function and dysrhythmias (Zafari, 2013). Measure cardiac output and other functional parameters as Cardiac index, preload and afterload, contractility, and cardiac appropriate. Useful in evaluating re sponse to therapeutic interventions and identifying need for more aggressive or emergency care. Provides information regarding progression or resolution of in farction, status of ventricular function, electrolyte balance, and effect of drug therapies. Electrolyte imbalances, such as hypo or hyperkalemia, adversely affect cardiac rhythm and contractility. Beta blockers Beta-adrenergic blockers are of benefit when given intravenously within 4 hours of the onset of pain and continued on a long term basis. Correlate with myocardial oxygen deprivation that may require short-term reports of chest pain or shortness of breath. Thereafter, limit activity Reduces myocardial workload and oxygen consumption, re on basis of pain or adverse cardiac response. Instruct client to avoid actions that raise abdominal pressure, Activities that require holding the breath and bearing down, such as straining during defecation. Explain pattern of graded increase of activity level, such as get Progressive activity provides a controlled demand on the heart, ting up to commode or sitting in chair, progressive ambula increasing strength and preventing overexertion. Review signs and symp to ms reflecting in to lerance of present Palpitations, pulse irregularities, development of chest pain, or activity level or requiring notification of nurse or physician. Provides continued support and additional supervision and promotes participation in recovery and wellness process. Encourage expressions of, and avoid denying feelings Client may fear death or be anxious about immediate envi of, anger grief, sadness, and fear. Ongoing anxiety related to concerns about impact of heart attack on future lifestyle, matters left unattended or unresolved, and effects of illness on family may be present in varying degrees for some time and may be manifested by symp to ms of depression. Observe for verbal and nonverbal signs of anxiety, and stay Client may not express concern directly, but words or actions with client. Denial can be beneficial in decreasing anxiety but can post pone dealing with the reality of the current situation. Con frontation can promote anger and increase use of denial, reducing cooperation and possibly impeding recovery. Provide consistent information; Accurate information about the situation reduces fear, repeat as indicated. Allows needed time for personal expression of feelings; may en hance mutual support and promote more adaptive behaviors. Provide rest periods and uninterrupted sleep time and quiet Conserves energy and enhances coping abilities. Support normality of grieving process, including time Can provide reassurance that feelings are normal response to necessary for resolution. Encourage independence, self-care, and decision making Increased independence from staff promotes self-confidence within accepted treatment plan. Collaborative Administer anti-anxiety or hypnotics, as indicated, such as Promotes relaxation and rest and reduces feelings of anxiety. Sudden or continued dyspnea when pain is relieved may indi cate thromboembolic pulmonary complications. Assess gastrointestinal function, noting anorexia, decreased or Reduced blood flow to mesentery can produce gastrointestinal absent bowel sounds, nausea and vomiting, abdominal dis dysfunction, such as loss of peristalsis. Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis. Instruct client in application and periodic removal of anti Limits venous stasis, improves venous return, and reduces risk embolic hose, when used. Cimetidine (Tagamet), ranitidine (Zantac), and antacids May occasionally be used to reduce or neutralize gastric acid, preventing discomfort and gastric irritation, especially in presence of reduced mucosal circulation. Present information in varied learning formats, such as Using multiple learning methods enhances retention of programmed books, audiovisual tapes, question-and material. Review activity limitations, such as refraining from strenuous During healing phase, restrictions may be needed to limit activities until first checking with provider. S to p any activity if chest pain, unusual shortness of breath, dizziness, light-headedness, or nausea occurs. Explain rationale of dietary regimen, diet low in sodium, Excess saturated fats, cholesterol, calories, and sodium in saturated fats, and cholesterol. Discuss use of herbals, such as ginseng, garlic, ginkgo, Use of supplements or herbal remedies can result in alterations hawthorn, and bromelain, as indicated. Encourage identification and reduction of individual risk fac these behaviors and chemicals have direct adverse effects on to rs, such as smoking and alcohol consumption and obesity. Educate Gradual increase in activity increases strength and prevents client regarding resumption of activities, such as walking, overexertion, may enhance collateral circulation, and pro work, and recreational and sexual activity. Note: Sexual activity can lines for gradually increasing activity and instruction regard be safely resumed once client can accomplish activity ing target heart rate and pulse taking, as appropriate. Review signs and symp to ms requiring reduction in activity and Pulse elevations beyond established limits, development of notification of healthcare provider. Differentiate between chest pain, or dyspnea may require changes in exercise and increased heart rate that normally occurs during various medication regimen. Recommend client receive annual influenza and periodic pneu Helps protect against viral and bacterial cardiorespira to ry ill monia vaccination unless otherwise contraindicated. Emphasize importance of contacting physician if chest pain, Timely evaluation and intervention may prevent complications. Depressed clients have a greater risk of dying 6 to 18 months Discuss signs of pathological depression versus transient following a heart attack (Glassman, 2007). Tachyarrhythmias: caused by reentry, often due to enhanced surgery or abnormal au to maticity b. Causes abnormalities of the heart rate, rhythm, or both fever and dehydration; sepsis; shock states (hypovolemic, ii. Change in conduction may alter pumping action of heart, cardiogenic); anemia; pulmonary diseases; brain injury; affecting blood pressure and perfusion of body organs. Classification: Types of Dysrhythmias (Wedro, 2007) stress or vigorous exercise; anxiety disorders and panic a. Named according to the site of origination and the attacks mechanism of conduction involved: c. Associated with physiological or psychological stress; med 200 if untreated ications, such as catecholamines, aminophylline, atropine, b. Rapid heartbeat initiated within the ventricles, characterized electrolyte disturbances, drug overdose, and poisoning. Electrical signal is sent from the ventricles at a very fast and with elevated and regular heart rate (such as 160 to 240 erratic rate, impairing the ability of ventricles to fill with blood beats per minute). Heart rate sustained at a high rate causes symp to ms such as sulting in very low blood pressure and loss of consciousness. Usually asymp to matic, although some clients can feel kalemia, hyperglycemia, hypothermia, to xins, tamponade, irregularities (palpitations) of the heartbeat, or syncope tension pneumothorax, thrombosis (cardiac or pulmonary), may occur, which usually is observed in more advanced and trauma. Symp to matic with fatigue, dizziness, and syncope and between to o fast and to o slow (bradycardia-tachycardia syn possible loss of consciousness drome). Can be life-threatening, especially if associated with beats, especially after an episode of tachycardia. In types 1 and 2, the flow of potassium through ion mal impulse of the sinus node. Electrical signal originates in the ventricles, causing them to slower than normal, such as during sleep. Medications may include (or are not limited to ) antihis weakness, fatigue, dizziness, fainting, or palpitations. Irritability of the heart demonstrated by frequent and or antidepressants, cholesterol-lowering drugs. Palpitations asso mechanism (au to maticity, reentry, fibrillation); and by site of ciated with dizziness, near-syncope, or syncope suggest origin (atrial, ventricular, junctional). Pulsus alternans: Regular strong beat, alternating with Bigeminal pulse: Irregular strong beat alternating with weak beat. Pacemaker: A system that sends electrical impulses to the heart Sudden cardiac death (also known as sudden cardiac arrest in order to set the heart rhythm. The only treatment Palpitations: An increased awareness of the heartbeat and palpi is defibrillation with an electrical shock. Care Settings Related Concerns Generally, minor dysrhythmias are moni to red and treated in Acute coronary syndrome, page 58 the community setting; however, potential life-threatening sit Angina, page 67 uations (including heart rates above 150 beats per minute) Heart failure: chronic, page 43 may require a short inpatient stay. May also be used to evaluate pacemaker function, antidys rhythmic drug effect, or effectiveness of cardiac rehabilitation. A treadmill test may be used for stable client whose sus pected dysrhythmias are clearly exercise-related. Drug-induced testing helps identify dysrhythmias that may be from ischemia in client who cannot physically perform treadmill. Sodium, potassium, calcium, adversely affects cardiac rhythm and contractility calcium, and magnesium are common electrolytes. Auscultate heart sounds, noting rate, rhythm, presence of extra Specific dysrhythmias are more clearly detected audibly than heartbeats, and dropped beats. Hearing extra heartbeats or dropped beats helps identify dysrhythmias in the unmoni to red client. Determine type of dysrhythmia and document with rhythm Useful in determining need and type of intervention required. Although it gen erally does not require treatment, persistent tachycardia may worsen underlying pathology in clients with ischemic heart disease because of shortened dias to lic filling time and increased oxygen demands.

Investigate sudden reduction or cessa Sudden decrease in urine flow may indicate obstruction or tion of urine flow treatment pink eye purchase requip 1 mg visa. Note: Reduced urinary output not related to hy povolemia medicine and health order online requip, associated with abdominal distention medications used for anxiety order discount requip line, fever treatment 1st degree av block generic 2mg requip with mastercard, and clear symptoms 8 days after iui purchase 1mg requip with mastercard, watery discharge from the incision; suggests urinary fistula medications multiple sclerosis order requip on line amex, also requiring prompt intervention. Note hematuria or bleeding Urine may be slightly pink, which should clear up in 2 to 3 days. Rubbing or washing s to ma may cause temporary oozing because of vascular nature of mucosal tissues. Continued bleeding, frank blood in the pouch, or oozing around the base of s to ma requires medical evaluation and intervention. Position tubing and drainage pouch so that it allows unimpeded Blocked drainage allows pressure to build within urinary flow of urine. Note: Stents inserted to maintain patency of ureters during period of pos to perative edema may be in advertently dislodged, compromising urine flow. Demonstrate self-catheterization techniques and reservoir After a healing time of several weeks, catheters will be re irrigations, as appropriate. Rarely, men will be unable to urinate by pelvic floor relaxation and Val salva maneuver. Periodic irrigations with sterile water or saline are needed in the continent reservoir to remove accu mulated mucus. Assists in maintaining hydration and adequate circulating volume and urinary flow. Impaired renal function in client with intestinal conduit increases risk of severe electrolyte or acid-base problems, such as hy perchloremic acidosis. Retrograde ileogram may be done to evaluate patency of conduit; nephros to my tube or stents may be inserted to maintain urine flow until edema or obstruction is resolved. When coupled with the fear of rejection by a partner, the desired level of intimacy can be greatly impaired. Sexual needs are very basic, and client will be rehabilitated more successfully when a satisfy ing sexual relationship is continued or developed. Note: Even with nerve-sparing procedures, 15% to 50% of men will experience erectile dysfunction, and 30% to 40% of women will experience painful intercourse (Costa, 2012). Suggest wearing Disguising uros to my appliance may aid in reducing feelings pouch cover, T-shirt, or short nightgown. Laughter can help individuals deal more effectively with difficult situation and promote a positive sexual experience. Discuss and role-play possible interactions or approaches Rehearsal helps deal with actual situations when they arise, pre when dealing with new sexual partners. Provide birth control information, as appropriate, and stress Confusion about impotency and sterility can lead to an unwanted that impotence does not mean client is necessarily sterile. Collaborative Arrange meeting with an os to my visi to r or support group, if Sharing of how these problems have been resolved by others appropriate. If problems persist longer than several months after surgery, a trained therapist may be required to facilitate communication between client and partner. Review ana to my, physiology, and implications of surgical inter Provides knowledge base from which client can make informed vention. Provides references after discharge to support client efforts for independence in self-care. Allow time Promotes positive management and reduces risk of improper for return demonstrations and provide positive feedback os to my care. When client feels confident about uros to my, energy and atten tion can be focused on other tasks. Demonstrate padding to absorb urethral drainage; ask client to Small amount of leakage may continue for several weeks after report changes in amount, odor, and character. Recommend routine trimming of hair around s to ma to edges Hair can be pulled out when the pouch is changed, causing irri of pouch adhesive. Encourage clients with Kock pouch to lengthen voiding interval Increases capacity of reservoir to achieve a more normal void each week unless discomfort noted. Review signs of reservoir overdistention and need for immediate Client and caregiver will need to recognize signs, such as medical intervention. Severe overdistention can result in neobladder rup ture, a life-threatening complication (Costa, 2012). Promotes wound healing and increases utilization of energy to facilitate tissue repair. Anorexia may be present for several months pos to peratively, requiring conscious effort to meet nutritional needs. Discuss use of acid-ash diet: cranberries, prunes, plums, cere May be useful in acidifying urine to decrease risk of infection als, rice, peanuts, noodles, cheese, poultry, and fish; avoid and crystal or s to ne formation. Products containing bicar ance of salt substitutes, sodium bicarbonate, and antacids; bonate or calcium potentiate risk of crystal and s to ne forma and cautious use of products containing calcium. Note: Use of sulfa drugs requires alkaline urine for optimal absorp tion, necessitating acid-ash diet and vitamin C supplements withheld. Note: Weight loss of 10 to 20 lb is not uncommon because of intestinal involvement and anorexia. Stress necessity of increased fluid intake of at least 2 to 3 L/day Maintains urinary output and promotes acidic urine to reduce and cranberry juice or ascorbic acid and vitamin C tablets. Note: Oranges Explain to client that urine should be pale yellow to almost and citrus fruits make urine alkaline and are therefore colorless. Large doses of vitamin C can inhibit vitamin B12 absorption, requiring periodic moni to ring of vitamin B12 levels. Discuss resumption of presurgery level of activity and possibil Client should be able to manage same degree of activity as ity of sleep disturbance, anorexia, and loss of interest in previously enjoyed and in some cases increase activity usual activities. Immobility or inactivity increases urinary stasis and calcium shift out of bones, potentiating risk of s to ne formation and resultant urinary obstruction or infection. Refer Smoking cessation is critical to the health of the new bladder, for medication and smoking cessation assistance, if client ureters, and kidneys because of the vasoconstrictive, acidic, is cooperative. Moni to rs healing and disease process and provides opportu nity for discussion of appliance problems, general health, and adaptation to condition. Note: Bowel resection of the distal ileum creating ileal conduit can lead to vitamin B12 malabsorption. Therefore, long-term moni to ring may be necessary as deficiency can lead to anemia, neurological problems, and anorexia (Clark, 2005; Pieper et al, 2006). En therapist, visiting nurse, and pharmacy or medical supply teros to mal nurse can be very helpful in solving appliance house. Cause is unknown, although tes to sterone and other hor gressive enlargement of the prostate gland, resulting in mones may affect growth. Microscopically characterized as a hyperplastic process and frequency (Deters et al, 2013; Shiller, 2007) with the number of cells in the gland increasing with age b. Questions, and subsequent scoring, focus on degree of States have symp to ms related to benign enlargement incomplete emptying, frequency, intermittency, urgency, (Deters et al, 2013). Care Settings Related Concerns Client is treated at the community level, with more acute care Acute kidney injury, page 505 provided during outpatient procedures. An elevated reading indicates of glandular epithelium, which in turn reflects prostate size. Demonstrate postvoid residuals of less than 50 mL, with absence of dribbling or overflow. Ask client about stress incontinence when moving, sneezing, High urethral pressure inhibits bladder emptying or can inhibit coughing, laughing, or lifting objects. Note Urinary retention increases pressure within the ureters and diminished urinary output. Increased circulating fluid maintains renal perfusion and flushes kidneys, bladder, and ureters of sediment and bacteria. Note: Fluids may be restricted to prevent bladder distention if se vere obstruction is present or until adequate urinary flow is reestablished. Observe for hypertension, periph Loss of kidney function results in decreased fluid elimination eral or dependent edema, and changes in mentation. Collaborative Administer medications, as indicated, for example: Medications have long been used as a first-line therapy for clients with mild to moderate symp to ms. Alpha-adrenergic antagonists, such as alfuzosin (UroXatral), these agents block effects of postganglionic synapses that terazosin (Hytrin), doxazosin (Cardura), and tamsulosin affect smooth muscle and exocrine glands. This action can (Flomax) decrease adverse urinary tract symp to ms and increase urinary flow. Catheterize for residual urine and leave indwelling catheter, as Relieves and prevents urinary retention and rules out presence indicated. Coude catheter may be required be cause the curved tip eases passage of the tube around the enlarged prostate. Note: Bladder decompression should be done with caution to observe for signs of adverse reaction, such as hematuria due to rupture of blood vessels in the mucosa of the overdistended bladder and syncope due to excessive au to nomic stimulation. Prepare for and assist with urinary drainage, such as emer May be indicated to drain bladder during acute episode with gency cys to s to my. Prepare for minimally invasive therapies, such as: these therapies rely on heat to cause destruction of prostatic Heat therapies, such as laser, transurethral microwave tissue. Tape drainage tube to thigh and catheter to the abdomen, if Prevents accidental dislodging of catheter with attendant urethral traction not required. Provide comfort measures, such as back rub, helping client Promotes relaxation, refocuses attention, and may enhance assume position of comfort. Administer medications, as indicated, for example: Opioids, such as meperidine (Demerol) Given to relieve severe pain; provide physical and mental relaxation. Antibacterials, such as methenamine hippurate (Hiprex) Reduces bacteria present in urinary tract and those introduced by drainage system. Antispasmodics and bladder sedatives, such as flavoxate Relieves bladder irritability. Client may have restricted oral intake in an attempt to control urinary symp to ms, reducing homeostatic reserves and in creasing risk of dehydration and hypovolemia. Evaluate capillary refill and oral mucous Enables early detection of and intervention for systemic membranes. As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia. Replaces fluid and sodium losses to prevent or correct hypo volemia following outpatient procedures. Establish trusting relationship with client Demonstrates concern and willingness to help. Provide information about specific procedures and tests and Helps client understand purpose of what is being done and re what to expect afterward, such as catheter, bloody urine, duces concerns associated with the unknown, including fear and bladder irritation. Defines the problem, providing opportunity to answer ques tions, clarify misconceptions, and problem-solve solutions. Allows client to deal with reality and strengthens trust in care givers and information presented. Client should understand that this includes ongo ing periodic evaluation for change (Neal, 2009). Review drug therapy, use of herbal products, and diet, such as Some clients may prefer to treat with complementary therapy increasing intake of fruits and soybeans. Note: Nutrients known to inhibit prostate enlargement include zinc, soy protein, es sential fatty acids, flaxseed, and lycopene. Herbal supple ments that client may use include saw palmet to , pygeum, stinging nettle, and pumpkin seed oil. However, a recent study found no difference in efficacy or side effects be tween saw palmet to and a placebo, indicating a need for further research as to benefit versus variability of potency or purity of botanical products (Bent, 2006). Recommend avoiding spicy foods, coffee, alcohol, long au to May cause prostatic irritation with resulting congestion. Note: Medications, such as finasteride (Proscar), are known to interfere with libido and erections. Alternatives include terazosin (Hytrin), doxazosin mesylate (Cardura), and tamsu losin (Flomax), which do not affect tes to sterone levels. Provide information about sexual ana to my and function as it Having information about ana to my involved helps client under relates to prostatic enlargement. Encourage questions and stand the implications of proposed treatments because they promote a dialogue about concerns. Discuss necessity of notifying other healthcare providers of Reduces risk of inappropriate therapy, such as the use of de diagnosis. Reinforce importance of medical follow-up for at least 6 months Recurrence of hyperplasia and infection caused by same or dif to 1 year, including rectal examination and urinalysis. Discuss personal safety issues and potential environmental Recent research reports increased risk of falls in presence of changes.

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