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Ask someone to help you to the bathroom if dietary intake of potassium-containing foods (eg safe 100 mg suprax, bananas best suprax 100 mg, you are elderly buy suprax 200mg line, weak purchase suprax 100mg line, dizzy, or unsteady in walking (or orange juice). Too much potassium (hyperkalemia) can result from ✔ Take or give most diuretics with or after food to decrease the use of potassium-saving diuretics, the overuse of stomach upset. Torsemide (Demadex) may be taken with- potassium supplements, or from the use of salt substi- out regard to meals. Potassium-saving diuretics are not a major cause ✔ If you are taking digoxin, a potassium-losing diuretic, and of hyperkalemia because they are usually given along a potassium supplement, it is very important that you with a potassium-losing diuretic. This is a common com- ments are prescribed, they should be taken as directed. Stopping or changing the dose of potassium chloride instead of sodium chloride. Hyper- one of these medications while continuing the others can kalemia is most likely to occur in people with decreased lead to serious illness. Digoxin toxicity is related to diuretic- treated for hypertension and heart failure. Potassium is a myocardial depressant enalapril (Vasotec) 10 mg qd and Lasix 40 mg bid. What as- and antidysrhythmic; it has essentially opposite cardiac effects sessment data are important to collect before administering these to those of digoxin. The higher the serum potassium, the less effective a given dose of digoxin will be. Conversely, de- creased serum potassium increases the likelihood of digoxin- 1. Some of the fixed-dose combinations of hydro- diuretic, and other measures to prevent hypokalemia are chlorothiazide and a potassium-sparing diuretic con- often used to maintain normal serum potassium levels (3. Clients who do not achieve an adequate diuretic re- Prevention and Management sponse with usual doses of an oral drug may need larger of Potassium Imbalances doses or an IV drug. With torsemide, which is highly bioavailable after oral Potassium imbalances (see Chap. Hypokalemia and hyperkalemia are cardiotoxic and clients may be switched from one route to the other should be prevented when possible. In liver disease, small doses of all diuretics are usually may occur with potassium-losing diuretics (eg, hydro- indicated because diuretic-induced electrolyte imbal- chlorothiazide, furosemide). Bumetanide may be a daily of hydrochlorothiazide) useful alternative, because it can be given in smaller b. Sustained-release tablets are usually better mide, the initial dose is usually metolazone 2. Giving a potassium-sparing diuretic along with the sired response is achieved. If an adequate diuretic effect potassium-losing drug occurs with the first dose of metolazone, the dose of d. Hydrochlorothiazide vocate this approach as preferable to supplemental 50 mg may also be used with furosemide and may be potassium or combination diuretic therapy, but its safer than metolazone because of its shorter duration effectiveness is not clearly established. Use in Edema You are working on a cardiac unit, caring for clients after bypass When diuretics are used to manage clients with edema, the surgery. Vellara has Lasix 80 mg ordered bid to pull off extra fluid underlying cause of the edema should be addressed, not just that is retained from the surgery. When managing such clients, it is prefer- you look through the chart as you document the medication you gave. You note that the nursing assistant has charted the following: able to aim for a weight loss of approximately 2 lb (1 kg) per Vital signs: 142/88 (lying) 108/60 (sitting), AP 96 and regular, day. CHAPTER 56 DIURETICS 827 minimal daily requirement of potassium is unknown, kidneys and may increase the incidence of patent ductus arte- usual recommendations are 40 to 50 mEq daily for riosus and neonatal respiratory distress syndrome. Potassium loss with diuretics may furosemide may be given with indomethacin to prevent non- be several times this amount. In both tations for having high potassium content; actually, preterm and full-term infants, furosemide half-life is prolonged large amounts must be ingested. To provide 50 mEq but becomes shorter as renal and hepatic functions develop. Some of these closely monitored in children because of frequent changes in foods are high in calories and may be contraindi- kidney function and fluid distribution associated with growth cated, at least in large amounts, for obese clients.
Physicians and nurses also disliked the presence of an additional step in the order process suprax 200 mg. Consequently buy discount suprax 100 mg on line, immunization rates improved somewhat but then dropped because of physician and nurse resistance to use of the order set order suprax 100mg mastercard. Additional physician-related interventions included multiple chart-based reminders and computer-generated forms that ordered vaccination prior to discharge discount 200mg suprax otc. Despite these efforts, vaccination rates improved little, as the vaccination order was often overlooked or the patient was unwilling to delay hospital departure to await the vaccine. Although there has been some fluctuation, this action led to the sustained improvement of vac- cination rates at Irving. The screening and vaccination rate at Irving rose from 4 percent in January 2000 to 91 percent in June 2003. Although gaps in the data during 1999, 2000, and 2001 exist, a large jump in screening and vac- cination percentages occurred, from single digits to figures ranging from 70 percent to 100 percent. Applying a run chart for the period from June 2001 to June 2003 shows fewer than seven data points on one side of the 54 The Healthcare Quality Book weighted average, so Figure 3. This assignable variation tells us that the screening and vaccination protocols Irving implemented resulted in real improvements at one hos- pital. The difference in the rates at Irving and at other BHCS hospitals suggests that Irving is doing something different from the remaining BHCS hospitals, although this conclusion is largely intuitive and does not necessarily exclude random variation in accounting for this difference. Over time, these improvements can be measured to determine their broader success. Conclusion Contemporary industrial and commercial methods to improve quality, such as Six Sigma and ISO 9000, emphasize the need to minimize variation, if not eliminate it altogether. While certainly appropriate in a setting that requires the repetitive manufacturing of mass quantities of identical prod- ucts, these tools may unnecessarily mask variation in the healthcare envi- ronment and consequently obscure opportunities to change or improve essential processes of care. The keys to successful management—rather than elimination—of variation in pursuit of quality healthcare are to be able to 100 L L L L L NL NL L L L L L L L L L L L L L L L L L L L L L L FIGURE 3. V ariation in Medical Practice and Implications for Quality 57 FIGURE 3. Ultimately, variation tells us what is working and what is not and how far from optimal our healthcare processes really are. Rather than avoiding variation in pursuit of quality healthcare, we are better off embracing it as an essential method of assess- ing our progress toward success. While exploring opportunities to improve processes of care for a group practice, you find no variability across physicians over time for colorectal cancer screening based on the recommendation of the U. Discuss the role of financial compensation strategies as part of the process to reduce variation in medical practice. How effective are these financial incentives, especially in terms of timing or use with other strategies? Identify different ways to distinguish between random and assigna- ble variation. In many cases, improvements in healthcare quality are small incre- mental, or evolutionary, changes and not necessarily break- through, or revolutionary, changes. Discuss the value of multiple small variations to effect long-term, sustained improvement. The Shoulder: Rupture of the Supraspinatus Tendon and Other Lesions in or About the Subacromial Bursa. A Study in Hospital Efficiency as Demonstrated by the Case Report of the First Five Years of a Private Hospital. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. V ariation in Medical Practice and Implications for Quality 59 Dartmouth Atlas of Health Care. Striving for Quality in Health Care: An Inquiry into Practice and Policy.
In mally harmless substances (eg suprax 200 mg lowest price, foods buy generic suprax 200 mg, pollens) as anti- desensitization procedures buy suprax 100mg with visa, weak extracts of antigenic sub- gens and mounts an immune response generic 100 mg suprax mastercard. More specifically, stances (eg, foods, plant pollens, penicillin) are prepared as IgE binds to antigen on the surface of mast cells and drugs and administered in small, increasing amounts so the pa- causes the release of chemical mediators (eg, histamine) tient develops a tolerance for the substances and avoids serious that produce the allergic manifestations. Most of these disorders occur more often in women than men, possibly because of 1. What is the difference between innate and acquired hormonal differences. Where are T lymphocytes formed, and what are their SELECTED REFERENCES functions? What is complement, and how does it function in the physiology: Concepts of altered health states, 6th ed. Discuss ways to promote immunization of all promoting health and preventing disease. Critical Thinking Scenario A young couple brings their 6-week-old infant to the clinic for a well-baby check and her required shots. They have lots of questions and ask whether all those shots are really necessary. Basic information regarding immunizations that every new parent should have. Teaching regarding what the parents may expect for 2 to 3 days after the injection and appropriate symptom management. OVERVIEW used for many years contained live virus and caused viral shedding and a few cases of polio. The main dis- Immune responses and types of immunity are described in advantages of IPV are that it must be injected and it is Chapter 42. Early sci- • Hepatitis B virus (HBV) infection can cause serious entists observed that people who contracted certain diseases liver diseases such as acute and chronic hepatitis, cir- were thereafter protected despite repeated exposure to the rhosis, and hepatocellular carcinoma. As knowledge evolved, it was discovered that pro- of HBV may be asymptomatic reservoirs for viral trans- tection stemmed from body substances called antibodies, and mission. Children who become infected are at high risk that antibodies could also be induced by deliberate, controlled of becoming chronically infected. Subsequently, immunization tech- cumstances, hepatitis B vaccine is now recommended niques were developed. Overall, been used, the development of immunizing agents and rec- the goal is to achieve universal immunization, decrease ommendations for their use continue. The oral vaccine One strategy is to combine vaccines so that only one in- 640 CHAPTER 43 IMMUNIZING AGENTS 641 jection is required when the need and time for multiple For maximum effectiveness, vaccines and toxoids must be vaccines coincide. In addition to the long-used, measles- given before exposure to the pathogenic microorganism. They mumps-rubella (MMR) and diphtheria-tetanus-pertussis should also be given by the recommended route to ensure the (DTaP) combinations, available combinations include desired immunologic response. Haemophilus b (Hib) with hepatitis B (Comvax), DTaP with Haemophilus b (DTaP-HIB; TriHIBit), and he- patitis A and hepatitis B (Twinrix). Another strategy is Indications for Use to give multiple vaccines (in separate syringes, at differ- ent sites) at one visit to a health care provider when fea- Clinical indications for use of vaccines and toxoids include sible. For example, several vaccines are recommended the following: to be given at the same time for routine immunization of 1. Routine immunization of all children against diphthe- infants and young children. In addition, influenza and ria, Haemophilus b infection, hepatitis B, mumps, per- pneumococcal vaccines can be administered concur- tussis, pneumococcal infection, poliomyelitis, rubella rently, and at least one study indicates that varicella and (German measles), rubeola (red measles), tetanus, and MMR can be given at the same office visit. Immunization of prepubertal girls or women of apparently withdrawn because of infrequent use.