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Therapy with parenteral agents usually is changed to oral antimicrobial agents when there is evidence of a clinical response and the patient is able to tolerate oral medications arrhythmia test questions discount 100 mg lasix visa. The recommended duration of treatment for pneumococcal pneumonia is 72 hours after the patient becomes afebrile blood pressure 140 over 90 buy cheap lasix. Most other forms of pneumonia caused by bacterial pathogens are treated for 1 to 2 weeks after the patient becomes afebrile blood pressure home remedies order lasix with visa. Atypical pneumonia is usually treated for 10 to 21 days (Bartlett arteria jugularis interna lasix 40mg for sale, Dowell, Mandell et al. Antibiotics are ineffective in viral upper respiratory infections and pneumonia and may be associated with adverse effects. Treatment of viral infections with antibiotics is a major reason for the overuse of these medications in the United States. Antibiotics are indicated with a viral respiratory infection only when a secondary bacterial pneumonia, bronchitis, or sinusitis is present. Hydration is a necessary part of therapy because fever and tachypnea may result in insensible fluid losses. Antipyretics may be used to treat headache and fever; antitussive medications may be used for the associated cough. Nasal decongestants may also be used to treat symptoms and improve sleep; however, excessive use may cause rebound nasal congestion. Treatment of viral pneumonia (with the exception of antimicrobial therapy) is the same as that for bacterial pneumonia. If hospitalized, the patient is observed carefully until the clinical condition improves. Pulse oximetry or arterial blood gas analysis is performed to determine the need for oxygen and to evaluate the effectiveness of the therapy. Respiratory support measures include high oxygen concentrations (fraction of inspired oxygen [FiO2]), endotracheal intubation, and mechanical ventilation. Gerontologic Considerations Pneumonia in the elderly patient may occur as a primary problem or as a complication of a chronic disease process. Pulmonary infections in the elderly frequently are difficult to treat and have a higher mortality rate than in younger patients. General deterioration, weakness, abdominal symptoms, anorexia, confusion, tachycardia, and tachypnea may signal the onset of pneumonia. The diagnosis of pneumonia may be missed because the classic symptoms of cough, chest pain, sputum production, and fever may be absent or masked in the elderly patient. Abnormal breath sounds, for example, may be due to microatelectasis that occurs in the aged as a result of decreased mobility, decreased lung volumes, and other respiratory function changes. Because chronic heart failure is often seen in the elderly, chest x-rays may be obtained to assist in differentiating it from pneumonia as the cause of clinical signs and symptoms. Supportive treatment includes hydration (with caution and frequent assessment because of the risk of fluid overload in the elderly), supplemental oxygen therapy, assistance with deep breathing, coughing, frequent position changes, and early ambulation. All of these are particularly important in the care of the elderly patient with pneumonia. To reduce or prevent serious complications of pneumonia in the elderly, vaccination against pneumococcal and influenza infections is recommended. These complications are encountered chiefly in patients who have received no specific treatment or inadequate or delayed treatment. These complications are also encountered when the infecting organism is resistant to therapy and when a comorbid disease complicates the pneumonia. If the patient is seriously ill, aggressive therapy may include hemodynamic and ventilatory support to combat peripheral collapse, maintain arterial blood pressure, and provide adequate oxygenation. Corticosteroids may be administered parenterally to combat shock and toxicity in patients who are extremely ill with pneumonia and in apparent danger of dying of the infection. Congestive heart failure, cardiac dysrhythmias, pericarditis, and myocarditis also are complications of pneumonia that may lead to shock. A parapneumonic effusion is any pleural effusion associated with bacterial pneumonia, lung abscess, or bronchiectasis. After the pleural effusion is detected on a chest x-ray, a thoracentesis may be performed to remove the fluid. There are three stages of parapneumonic pleural effusions based on pathogenesis: uncomplicated, complicated, and thoracic empyema.

Nursing management of the newly diagnosed patient and the patient with diabetes as a secondary diagnosis is presented in subsequent sections of this chapter blood pressure monitor costco purchase lasix 40 mg on-line. Because all diabetic patients must master the concepts and skills necessary for long-term management of diabetes and its potential complications blood pressure medication causes diabetes purchase lasix 100mg amex, a solid educational foundation is necessary for competent self-care and is an ongoing focus of nursing care arrhythmia guidelines 2014 order lasix 100 mg on line. Because diet blood pressure chart stroke discount lasix on line, physical activity, and physical and emotional stress affect diabetic control, patients must learn to balance a multitude of factors. They must learn daily self-care skills to prevent acute fluctuations in blood glucose, and they must also incorporate into their lifestyle many preventive behaviors for avoidance of long-term diabetic complications. In addition, they must learn the skills associated with monitoring and managing diabetes and must incorporate many new activities into their daily routines. A general approach is to organize information and skills into two main types: basic, initial, or "survival" skills and information, and in-depth (advanced) or continuing education. This basic information is literally what the patient must know to survive-that is, to avoid severe hypoglycemic or acute hyperglycemic complications after discharge. When and how to reach the physician For patients with newly diagnosed type 2 diabetes, emphasis is initially placed on diet. Patients with new-onset type 1 diabetes have much shorter hospital stays or may be managed completely on an outpatient basis; patients with new-onset type 2 diabetes are rarely hospitalized for initial care. There has been a proliferation of outpatient diabetes education and training programs, with increasing support of third-party reimbursement. For some patients, however, exposure to diabetes education during hospitalization may be the only opportunity for learning self-management skills and preventing complications. Many hospitals employ nurses who specialize in diabetes education and management and who are certified by the National Certification Board of Diabetes Educators as Certified Diabetes Educators. However, because of the large number of diabetic patients who are admitted to every unit of a hospital for reasons other than diabetes or its complications, the staff nurse plays a vital role in identifying diabetic patients, assessing self-care skills, providing basic education, reinforcing the teaching provided by the specialist, and referring patients for follow-up care after discharge. Organizing Information There are various strategies for organizing and prioritizing the vast amount of information that must be taught to diabetic patients. In addition, many hospitals and outpatient diabetes centers have devised written guidelines, care plans, and documenta- Chapter 41 Assessment and Management of Patients With Diabetes Mellitus 1173 and treating hypoglycemia. If diabetes has gone undetected for many years, the patient may already be experiencing some chronic diabetic complications. Thus, for some patients with newly diagnosed type 2 diabetes, the basic diabetes teaching must include information on preventive skills, such as foot care and eye care-for example, planning yearly or more frequent complete (dilated eye) examinations by the ophthalmologist and understanding that retinopathy is largely asymptomatic until the advanced stages. Patients also need to realize that once they master the basic skills and information, further diabetes education must be pursued. Preventive measures include: of waiting until the patient feels ready to learn; short hospital stays necessitate initiation of survival skill education as early as possible. This gives the patient the opportunity to practice skills with supervision by the nurse before discharge. Follow-up by home health nurses is often necessary for reinforcement of survival skills. A major goal of patient teaching is an educated consumer, a patient who is informed about the wide variations in the prices of medications and supplies and about the importance of comparing prices. Determining Teaching Methods Maintaining flexibility in teaching approaches is important. Teaching skills and information in a logical sequence is not always the most helpful for patients. Before they learn how to draw up, purchase, store, and mix insulins, they should be taught to insert the needle and inject insulin (or practice with saline solution). Once patients have actually performed the injection, most are more prepared to hear and to comprehend other information. Ample opportunity should be provided for the patient and family to practice skills under supervision (including selfinjection, self-testing, meal selection, verbalization of symptoms, and treatment of hypoglycemia). Once skills have been mastered, participation in ongoing support groups may assist patients in incorporating new habits and maintaining adherence to the treatment regimen. Many of the companies that manufacture products for diabetes self-care also provide booklets and videotapes to assist in patient teaching. Patients can continue learning about diabetes care by participating in activities sponsored by local hospitals and diabetes organizations.

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Tobacco use may be one of the strongest risk factors in the development of atherosclerotic lesions blood pressure chart during pregnancy buy cheap lasix on-line. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system arrhythmia quizlet purchase lasix 100 mg otc, causing vasoconstriction blood pressure medication enalapril buy lasix toronto. It also increases the risk for clot formation by increasing the aggregation of platelets arteria carotida interna purchase lasix 40mg amex. Carbon monoxide, a toxin produced by burning tobacco, combines more readily with the hemoglobin than oxygen does, depriving the tissues of oxygen. The amount of tobacco use is directly related to the extent of the disease, and cessation of tobacco use reduces the risks. Inflow surgical procedures are discussed with diseases of the aorta and outflow procedures with peripheral arterial occlusive disease. After the patient receives a local anesthetic, a balloontipped catheter is maneuvered across the area of stenosis. Some theorize that it improves blood flow by overstretching (and thereby dilating) the elastic fibers of the nondiseased arterial segment, but most clinicians believe that the procedure widens the arterial lumen by cracking and flattening the plaque against the vessel wall (see Chap. To decrease the risk of reocclusion, stents (small, mesh tubes made of nitinol, titanium, or stainless steel) may be inserted to support the walls of blood vessels and prevent collapse immediately after balloon inflation. A variety of covered wall stents and stent-grafts may be used for short-segment stenoses. Complications associated with stent or stent-graft use include distal embolization, intimal damage (dissection), and dislodgment. The advantage of angioplasty, stents, and stent-grafts is the decreased length of hospital stay required for the treatment; many of the procedures are performed on an outpatient basis. Prevention Intermittent claudication is a sign of generalized atherosclerosis and may be a marker of occult coronary artery disease. Because a high-fat diet is suspected of contributing to atherosclerosis, it is reasonable to measure serum cholesterol and to begin prevention efforts. The American Heart Association recommends reducing the amount of fat ingested in a healthy diet, substituting unsaturated fats for saturated fats, and decreasing cholesterol intake to no more than 300 mg daily to reduce the risk of cardiovascular disease (Krauss et al. Certain medications combined with dietary modification and exercise are being used to reduce blood lipid levels. There is limited evidence that these medications can alter the course of peripheral arterial disease, but they may reduce the mortality rate from cardiovascular disease. Several classes of medication are used to prevent atherosclerosis: bile acid sequestrants (cholestyramine [Questran, Prevalite] or colestipol [Colestid]), nicotinic acid (niacin, B3, Niacor; Niaspan), statins (atorvastatin [Lipitor], lovastatin [Mevacor], pravastatin [Pravachol], simvastatin [Zocor]), fibric acids (gemfibrozil [Lopid]), and lipophilic substances (probucol). Patients receiving long-term therapy with these medications require close medical supervision. Results of large, randomized studies demonstrated dramatic reductions in myocardial infarction, stroke, and cardiovascular death when blood pressure was decreased to at least 140/90 mm Hg (Moser, 1999; McAlister et al. Although no single risk factor has been identified as the primary contributor to the development of atherosclerotic cardiovascular disease, it is clear that the greater the number of risk factors, the greater the likelihood of developing the disease. Elimination of all controllable risk factors, particularly tobacco use, is strongly recommended. Signs and symptoms detected during the nursing assessment may include claudication pain; rest pain in the forefoot; pallor, rubor, or cyanosis; weak or absent peripheral pulses; and skin breakdown or ulcerations. Clinical Manifestations the clinical signs and symptoms resulting from atherosclerosis depend on the organ or tissue affected. Coronary atherosclerosis (heart disease), angina, and acute myocardial infarction are discussed in Chapter 28. Cerebrovascular diseases, including transient cerebral ischemic attacks and stroke, are discussed in Chapter 62. Atherosclerosis of the aorta, including aneurysm, and atherosclerotic lesions of the extremities are discussed later in this chapter. Renovascular disease (renal artery stenosis and end-stage renal disease), including hypertension, is discussed in Chapter 45.

The major symptoms of hypothyroidism may be depression and apathy blood pressure medication name brands cost of lasix, and may be accompanied by significant weight loss arrhythmia 16 year old purchase 40mg lasix fast delivery. Chapter 42 Medical Management Assessment and Management of Patients With Endocrine Disorders 1217 the primary objective in the management of hypothyroidism is to restore a normal metabolic state by replacing the missing hormone demi lovato heart attack mp3 lasix 40mg without prescription. Desiccated thyroid is used less frequently because it often results in transient elevated serum concentrations of T3 blood pressure 1 buy cheap lasix 100 mg line, with occasional symptoms of hyperthyroidism. If replacement therapy is adequate, the symptoms of myxedema disappear and normal metabolic activity is resumed. Any patient who has had hypothyroidism for a long period is almost certain to have elevated serum cholesterol levels, atherosclerosis, and coronary artery disease. As long as metabolism is subnormal and the tissues, including the myocardium, require relatively little oxygen, a reduction in blood supply is tolerated without overt symptoms of coronary artery disease. When thyroid hormone is administered, however, the oxygen demand increases, but oxygen delivery cannot be increased unless, or until, the atherosclerosis improves. The occurrence of angina is the signal that the oxygen needs of the myocardium exceed its blood supply. Angina or dysrhythmias may occur when thyroid replacement is initiated because thyroid hormones enhance the cardiovascular effects of catecholamines. The nurse must also be alert for signs of angina, especially during the early phase of treatment; if detected, it must be reported and treated at once to avoid a fatal myocardial infarction. If their use is necessary, the dose is one-half or one-third that ordinarily prescribed in patients of similar age and weight with normal thyroid function. If these medications must be used, the patient must be monitored closely for signs of impending narcosis (stupor-like condition) or respiratory failure. Gerontologic Considerations In the elderly patient with mild to moderate hypothyroidism, thyroid hormone replacement must be started with low dosages and increased gradually to prevent serious cardiovascular and neurologic side effects. Angina, for example, may occur with rapid thyroid replacement in the presence of coronary artery disease secondary to the hypothyroid state. Heart failure and tachydysrhythmias may worsen during the transition from the hypothyroid state to the normal metabolic state. Dementia may become more apparent during early thyroid hormone replacement in the elderly patient. Elderly patients with severe hypothyroidism and atherosclerosis may also become confused and agitated if their metabolic rates are raised too quickly. Marked clinical improvement follows the administration of hormone replacement; such medication must be continued for life, even though signs of hypothyroidism disappear within 3 to 12 weeks. Myxedema and myxedema coma generally occur exclusively in patients older than 50 years. The high mortality rate of myxedema coma mandates immediate intravenous administration of high doses of thyroid hormone as well as supportive care. Application of external heat (eg, heating pads) is avoided because it increases oxygen requirements and may lead to vascular collapse. If hypoglycemia is evident, concentrated glucose may be prescribed to provide glucose without precipitating fluid overload. Thyroid hormone (usually Synthroid) is administered intravenously until consciousness is restored if myxedema has progressed to myxedema coma. Because of an associated adrenocortical insufficiency, corticosteroid therapy may be necessary. Obviously, if angina or dysrhythmias occur, thyroid hormone administration must be discontinued immediately. Later, when it can be resumed safely, thyroid hormone replacement should be prescribed cautiously at a lower dosage and under the close observation of the physician and the nurse. Precautions must be taken during the course of therapy because of the interaction of thyroid hormones with other medications. Thyroid hormones may increase blood glucose levels, which may necessitate adjustment in the dosage of insulin or oral antidiabetic agents in patients with diabetes. The effects of thyroid hormone may be increased by phenytoin (Dilantin) and tricyclic antidepressant agents.