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By Q. Quadir. Medical College of Wisconsin. 2018.

There is Guidelines for administration of central and peripheral strong evidence that weight loss reduces risk factors for parenteral nutrition include the following: cardiovascular disease discount maxalt 10mg on-line, including blood pressure cheap 10mg maxalt mastercard, serum • Administer with an infusion pump to control the flow triglycerides discount maxalt 10mg overnight delivery, and total and LDL cholesterol. In addition, in overweight and tent rate so nutrients can be used and complications pre- obese people without diabetes, weight loss reduces vented. The initial flow rate is usually 50 mL/hour; flow blood glucose levels and the risk for development of rate is then increased as tolerated to meet nutritional re- type 2 diabetes. For people who already have type 2 di- quirements (approximately 1500 to 3000 mL/day). In general, modest weight losses of only 5 to 10 lbs lower blood pressure and blood lipids and im- prove insulin resistance and glucose tolerance. The Ensure is supplied in 2 • There is increasing consensus that obesity is a chronic 240-cc cans. How will you dilute this formula, and at what rate disease and that obese people should take weight loss will you set the infusion pump? Usually, however, the 446 SECTION 5 NUTRIENTS, FLUIDS, AND ELECTROLYTES medications are recommended only in clients whose Emphasis is being placed on prevention of obesity, espe- health is significantly endangered by obesity. The main • When drug therapy is indicated, a single drug in the elements are a more active lifestyle, a low-fat diet, regular lowest effective dose is recommended. As with most meals, avoidance of snacking, drinking water instead of other drugs, low doses decrease risks of adverse drug calorie-containing beverages, and decreasing the time spent effects. Nutritional Support and • Maximum weight loss usually occurs during the first Obesity in Older Adults 6 months of drug therapy. With most available drugs, use for this long is an unlabeled use of the drug. Older adults are at risk for development of deficits and ex- • After a weight loss regimen of a few months, some ex- cesses in fluid volume. Inadequate intake is common and may perts recommend letting the body adjust to the lower result from numerous causes (eg, impaired thirst mechanism, weight before attempting additional losses. Thus, a impaired ability to obtain and drink fluids, inadequate water weight maintenance program, possibly with continued with tube feedings). Fluid • The National Institutes of Health do not recommend volume excess is most likely to occur with large amounts or combining weight loss medications except in the con- rapid administration of IV fluids, especially in older adults text of clinical trials. Inadequate intake may result from the inability to obtain and prepare food, as well as disease processes that interfere with the ability to digest and Nutritional Support and Obesity in Children use nutrients. When alternative feeding methods (tube feed- ings, IV fluids) are used, careful assessment of nutritional sta- Children in general need increased amounts of water, protein, tus is required to avoid deficits or excesses. Overweight and carbohydrate, and fat in proportion to their size to support obesity are also common among older adults. However, reports of needs are usually decreased, primarily because of slowed me- childhood obesity and inadequate exercise abound and are tabolism and decreased physical activity, most people continue steadily increasing. With the high incidence of atherosclero- is to meet needs without promoting obesity. Anorexiant drugs should the recommended rate of administration is no more than be used very cautiously, if at all, because older adults often 5 mL every 5 to 10 minutes for premature and small infants have cardiovascular, renal, or hepatic impairments that in- and 10 mL/minute for older infants and children. The use of orlistat in tion of formulas, positioning of children, and administration older adults has not been studied. Parenteral nutrition may be indicated in infants and children Use in Renal Impairment who cannot eat or be fed enterally. With newborns, especially preterm and low-birth-weight infants, parenteral nutrition is Because the kidneys excrete water and waste products of needed within approximately 3 days of birth because they have food metabolism, clients with renal impairment often have little nutritional reserve. However, lipid emulsions should be accumulation of water and urea nitrogen. As a result, these given cautiously in preterm infants because deaths have been clients have special needs in relation to nutritional support.

Adult dosage is 2 mg children younger than 5 years of age cheap maxalt 10 mg line, and the safety and effi- (no more than 1 mg/minute); child dosage is 0 discount 10 mg maxalt overnight delivery. Rapid administration may The drugs cause the same adverse effects in children as in cause bradycardia maxalt 10mg otc, hypersalivation (with subsequent respira- adults. However, they may be more severe because children tory distress), and seizures. Facial flushing is com- life-threatening dysrhythmias, convulsions, or coma occur. Diazepam (Valium) or a similar drug may be given for ex- Ophthalmic anticholinergic drugs are used for cycloplegia cessive CNS stimulation (delirium, excitement). Ice bags, and mydriasis before eye examinations and surgical proce- cooling blankets, and tepid sponge baths may help reduce dures (see Chap. Artificial ventilation and cardiopulmonary resuscita- medical supervision. Cyclopentolate (Cyclogyl) and tropi- tive measures are used if excessive depression of the CNS camide (Mydriacyl) have been associated with behavioral dis- causes coma and respiratory failure. Infants, children, and the turbances and psychotic reactions in children. Tropicamide elderly are especially susceptible to the toxic effects of anti- also has been associated with cardiopulmonary collapse. Use in Older Adults Use in Children Anticholinergic drugs are given for the same purposes as in Systemic anticholinergics, including atropine, glycopyrrolate younger adults. In addition to the primary anticholinergic (Robinul), and scopolamine, are given to children of all ages drugs, many others that are commonly prescribed for older for essentially the same effects as for adults. These include many secretory, antispasmodic agents for gastrointestinal disorders antihistamines (histamine-1 receptor antagonists), tricyclic are not recommended for children. In the presence of liver impairment, verse reactions because of slowed drug metabolism and the dosages should be reduced and given less frequently. Some com- mon adverse effects and suggestions for reducing their im- pact are: Use in Critical Illness • Blurred vision. The client may need help with ambula- tion, especially with stairs or other potentially haz- Atropine is an important drug in the emergency drug box. Remove obstacles and hazards cording to ACLS guidelines, atropine is the first drug to be ad- when possible. For clients with asystole, 1 mg of atropine is ad- strenuous activity and high environmental temperatures. Administration of atropine in doses take of high-fiber foods and fluids and adequate exercise less than 0. Encourage adequate fluid intake endotracheal tube in clients without an intravenous access. Men should be ex- The recommended dose is 2 to 3 mg diluted in 10 mL normal amined for prostatic hypertrophy. Dosage of these drugs should be carefully Anticholinergic drugs have potential intoxicating effects. Abuse of these drugs may produce euphoria, disorientation, hallucinations, and paranoia in addition to the classic anti- cholinergic adverse reactions. Use in Renal Impairment Anticholinergic agents that have a tertiary amine structure, Home Care such as atropine, are eliminated by a combination of hepatic metabolism and renal excretion. In the presence of renal im- Anticholinergic medications are commonly used in home pairment, they may accumulate and cause increased adverse care with children and adults. Quaternary amines are eliminated largely in the feces probably most likely to experience adverse effects of these and are less affected by renal impairment. With elderly clients, the home care nurse needs to assess medication regimens for combinations of drugs with anticholinergic effects, espe- Use in Hepatic Impairment cially if mental confusion develops or worsens. The home care nurse may also need to teach elderly clients or care- Because some anticholinergic drugs are metabolized by the givers that the drugs prevent sweating and heat loss and in- liver, they may accumulate and cause adverse effects in the crease risks of heat stroke if precautions to avoid overheating presence of hepatic impairment. CHAPTER 21 ANTICHOLINERGIC DRUGS 317 NURSING Anticholinergic Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. For gastrointestinal disorders, give most oral anticholiner- To allow the drugs to reach peak antisecretory effects by the time gic drugs approximately 30 min before meals and at bedtime.

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A diet adequate in protein and calo- providers should consider the following factors: ries usually provides adequate minerals and electrolytes buy discount maxalt 10mg. An exception is iron buy maxalt 10mg lowest price, which is often needed as a dietary • In general discount maxalt 10mg, recommended daily doses should not be ex- supplement in women and children. For age and gender groups contain different amounts of clients able to eat, foods high in iron may delay onset of some minerals (eg, postmenopausal women need less iron deficiency anemia, foods high in potassium may iron than younger women). This should be considered prevent hypokalemia with diuretic therapy, and salty in choosing a product. For people rary use in the presence of deficiency or a period of unable to eat, IV fluids and electrolytes are usually increased need (eg, pregnancy). In general, oral food intake or tube feeding is taken otherwise because of the risk of accumulation and preferable to IV therapy. CHAPTER 32 MINERALS AND ELECTROLYTES 483 CLIENT TEACHING GUIDELINES Mineral Supplements General Considerations Self- or Caregiver Administration ✔ The best source of minerals and electrolytes is a well- ✔ Take iron preparations with or after meals, with ap- balanced diet with a variety of foods. A well-balanced diet proximately 8 oz of fluid, to prevent stomach upset. Do contains all the minerals needed for health in most peo- not take iron with coffee or other caffeine-containing ple. An exception is iron, which is often needed as a di- beverages, because caffeine decreases absorption. Note that herbal (Take iron and caffeine preparations at least 2 hours preparations of chamomile, feverfew, and St. Do not crush or chew slow-release tablets or may inhibit iron absorption. Acute iron intox- improve the taste, dilute the drug, and decrease gastric ication is a common problem among small children and irritation. Take after meals initially to decrease gastric irrita- supplements (eg, remind them to spit out oral rinses and tion. If no anorexia, nausea, vomiting, or other problems gels rather than swallow them). Do not stop odic blood tests and other follow-up procedures when taking the medication without notifying the physician mineral–electrolyte supplements are prescribed (eg, potas- who prescribed it, especially if also taking digoxin or di- sium chloride). These amounts differ in various preparations lems may develop from either high or low levels of and should be included in estimations of daily intake. Larger doses are needed to treat deficiency states than consumed in dairy products and other foods should be are needed to prevent deficiencies from developing. In addi- considered and the UL of 2500 mg daily should not be tion to producing potential toxicity, large doses of one mineral exceeded. With colds, zinc likely to produce toxicity, more convenient to administer, and reportedly helps some people and does not help others. With wounds, zinc is reportedly beneficial only if the client has a zinc deficiency. More studies are needed before supplemental zinc can be recommended for general use. Management of Sodium Disorders Hyponatremia PRINCIPLES OF THERAPY Treatment of hyponatremia is aimed at restoring normal lev- Prevention of an Excess State els of serum sodium. This can be done with isotonic NaCl so- lution when hyponatremia is caused by sodium depletion and When a mineral is given to correct a deficiency state, there is with restriction of water when hyponatremia is caused by a risk of producing an excess state. In severe deficits, a higher concentration and a higher Treatment of hypernatremia requires administration of flow rate may be necessary. In these situations, an sodium-free fluids, either orally or IV, until serum sodium infusion pump to control flow rate accurately and levels return to normal. Milder states usually respond to continuous cardiac monitoring for detection of hyper- increased water intake through the GI tract; more severe kalemia are necessary. Also, serum potassium levels hypernatremia requires IV administration of 5% dextrose in must be checked frequently and dosage adjusted if in- water.

The bladder pressure rises and sphincter pressure falls after a series Nerve Cuffs of pulses generic maxalt 10 mg free shipping, emptying the bladder in spurts purchase 10mg maxalt fast delivery. Telemetric stimulation of S-2 using an im- Direct stimulation and recording from nerve planted stimulator has shown promise in roots and peripheral nerves may improve the restoring continence and voiding on command functionality of systems for hand use discount 10 mg maxalt with mastercard, walking, after SCI. Patients with this lesion may benefit from a closed loop system that reads sensory feed- electrodes placed within the bladder wall, but back from heel contact to toe-off during the 198 Neuroscientific Foundations for Rehabilitation gait cycle to aid FNS stepping25 and to detect can interrupt a pathway and cause transient hyperreflexive bladder contractions and inhibit speech arrest or hemineglect (see Chapter 3), them by sacral root stimulation have put the DBS may interfere with a network and with nerve cuff field on a solid technical platform. This inhibitory or disinhibitory po- These sleeves, placed around a portion of a tential may be put to use, for example, in the nerve, provide a permanent electrochemical patient with persisting hemineglect after a interface to selectively initiate or record elec- stroke. A for attention with the affected right hemi- cuff may also be designed to orient and assist sphere may lessen left hemineglect. Perhaps the regeneration of axonal sprouts between a stimulation of the basal ganglia or thalamus in proximal and a distal stump by electrical or a patient with a subcortical stroke, such as the pharmacologic stimulation. Multichannel cuffs patient whose PET scan appears in Figure 3–3, have been designed to monitor separate prop- can reactivate the hypometabolic cortical con- agating extracellular signals and to stimulate nections of the transsynaptically disconnected different subpopulations of axons within a frontal lobe to improve, in this instance, work- nerve. Deep brain electrical stimulators chemical signals or molecules and ions, a cuff may release neurotransmitters and neu- could also be designed to monitor the neural rotrophins as well. In rodents, electrical stim- environment and the degree of successful re- ulation of the left and right somatosensory cor- generation of axons. Epidural, subdural, deep brain, and vagal nerve Vagal nerve stimulation reduces seizures in stimulation have come into use for managing some forms of epilepsy. Stimulation also may pain, movement disorders, and epilepsy, and improve aspects of memory. Could certain parameters of crease excitation or inhibition in other net- stimulation produce long-term potentiation to works for other symptoms and signs. Epidural stimulation repetitive transcranial magnetic stimulation with four electrodes over the motor cortex is Neurostimulators and Neuroprostheses 199 already employed to manage central pain proaches also require more fundamental in- caused by stroke. Lemay and Grill point out that investigators have to think differently about cord stimulation Spinal Cord Stimulators compared to peripheral nerve and muscle FNS. State-de- preformed to reduce some types of central pendent changes may also evolve in the senso- pain, may also lessen hypertonicity after SCI. Walking speed and en- cacy during and beyond the time of electrical durance increased beyond what had been ac- stimulation. In addition, although re- extensor leg movements appears to include searchers can localize the best regions to stim- rhythmic drive of dorsal horn afferents, in- ulate animals based on retrograde and cluding Ia fibers (see Chapter 1 under Central antegrade labeling of the cord and multiple mi- Pattern Generation). Thus, epidural stimula- croarray placements, such approaches are not tion may be an adjunct to locomotor training feasible in patients. With some imagination, in highly disabled patients, along with FNS, however, clinicians may forsee the application should reliable and safe techniques evolve. The combination of biologic re- terns of movement such as hip and knee ex- pair strategies with short-term microstimula- tension or, in another nearby spinal gray re- tion to modulate the function or connectivity gion, hip flexion and knee flexion toward a of regenerating axons is also conceivable. A reproducible point in the workspace of the cerebral neuroprosthesis that commands a limb. These primitives produce movements de- spinal or muscle-nerve FNS system offers a scribed experimentally as force fields during more exotic, but potentially feasible neural ma- spinal microstimulation studies. Many of the technical challenges have be managed by computer programs, and the been addressed or clever solutions are in the responsiveness of a neuroprosthesis system for making to take command signals derived from use in paraplegic humans over time have to brain electrical activity to control a neuropros- be resolved. A variety of brain sig- gets such as letters, a brain-computer interface nals have been employed. If rithms to extract specific features, such as the no eye movement or EMG activity is available amplitude of an evoked potential or a specific to a subject, slow cortical potentials, P300 rhythm from sensorimotor cortex or the firing evoked potentials, and mu and beta rhythms rate of cortical spikes. A trans- when an unexpected or significant auditory, vi- lation algorithm takes the particular electro- sual, or sensory stimulus occurs. The basis for physiologic features chosen to give simple use of an evoked response potential is that the commands to a device, such as a word proces- component measured such as the peak after sor, virtual keyboard, Web site, an upper ex- 300 ms represents a specific activity of the tremity neuroprosthesis, or to a thought trans- brain invoked to serve a specific processing lation device. The amplitude of the P300 does have An ideal brain–computer interface would a proportional relationship to the probability have an open architecture for self-learning of that an item seen is the oddball for each type multisensory inputs and outputs, employ non- of task. With little or no training, the user invasive recordings, be portable and cosmeti- watches a six by six matrix of rows and columns cally acceptable, quickly allow a trainer to de- that contain the letter or word of interest flash termine if the patient can achieve a good every 125 ms. The user counts the times the enough performance to benefit, readily allow symbol to be communicated is flashed.

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