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By Q. Vatras. Simpson College, Redding California. 2018.
As mentioned pletal 100 mg amex spasms above ear, lack of scheduled piperacillin blood draws limited the ability to counterbalance the bias introduced by scavenged samples in the piperacillin analysis. This is likely 9 due to the excellent temperature stability of metronidazole (unlike that of piperacillin). Moreover, it facilitated the development of a new, simplified scheme based on postmenstrual age that compared very favorably with current dosing guidelines. For this drug, the scavenged sampling approach was a more powerful tool to advance drug development in preterm infants. The piperacillin and metronidazole experiences using scavenged samples uncovered some advantages and disadvantages of this minimal-risk approach. Some of the limitations of scavenged sampling included uncertainty around dosing and sampling collection dates and times; no documentation of time when samples were frozen; no documentation of concomitant medication; and limited collection of scheduled blood draws. If these limitations are addressed in future trials, scavenged sampling could provide more robust data and widen its application across drugs in preterm infants and older children. The minimal-risk methods evaluated in this proposal proved successful in many aspects related to drug development in preterm infants. In the future, prospective trials will need to be conducted to validate these findings. In this study, 32 preterm infants were enrolled and given piperacillin-tazobactam per routine medical care. In addition to the clinical data of special interest specifically designed for each drug, data regarding time of scavenged sample freezing will also be obtained in these trials. With this information, it will be possible to establish a time cut-off for utilization of scavenged samples for unstable drugs such as piperacillin based on the time needed to freeze the scavenged samples. Another initiative to validate the use of alternative biological sample collection techniques is in process. In summary, minimal-risk methods can revolutionize the way drug development is conducted in preterm infants and can be extrapolated to older pediatric populations. Clearly defined objectives for minimal-risk methods are important to achieve the appropriate balance between study feasibility and data quality. In the future, validation of minimal-risk methods will provide additional evidence of the utility of these approaches. Minimal-risk methods can be applied to other commonly used therapeutics in children to decrease the profound knowledge gap regarding this population. Metronidazole population pharmacokinetics in preterm neonates using dried blood-spot sampling. Pharmacokinetic study of piperacillin in newborns relating to gestational and postnatal age. Single-dose pharmacokinetics of piperacillin and tazobactam in infants and children. Simultaneous quantification of amoxycillin and metronidazole in plasma using high-performance liquid chromatography with photodiode array detection. Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education. Important Guidelines for Printing and Photocopying Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors. This material is intended for educational use only by practicing health care workers or students and faculty in a health care field. Since it comprises most of the contents of course outline on medical bacteriology to nursing, pharmacy and environmental science students, it can be used as a main learning material to these category of students. This lecture note gives emphasis on the knowledge and procedures of medical bacteriology to common pathogens in our country. At last but not least, the quality of this lecture note is kept updated by continous comments made by users of this lecture note. Dennis Carlson for his invaluable technical and moral support for the completion of this work. We also extend our appreciation to those individuals who reviewed this lecture note in different teaching institutions for the materialization of this lecture note.
Tumors of the urinary collecting system discount pletal 100 mg without a prescription spasms body, ureter, and bladder are most commonly transitional cell carcinomas. These tumors can cause flank pain when they obstruct the urinary tract, and they commonly present with gross hematuria. About 30% of patients with a renal pelvic cancer complain of flank pain, whereas only 15% of patients with a ureteral tumor experience flank pain. Bladder tumors usually present with hematuria; however, when the tumor is located at the ureteral orifice, it can cause flank pain due to ureteral obstruction. Bladder tumors that obstruct the ureter tend to be advanced at the time of discovery, and prognosis is guarded. Urologic tumors rarely are palpable on physical examination unless they are large; however, most renal tumors are seen during 680 J. For this reason, all patients with flank pain who also have gross hematuria require urologic consultation. Traumatic Flank Pain Flank pain due to trauma usually is obvious, given the clinical pre- sentation. In the trauma setting, imaging of the urinary system is nec- essary to exclude serious injury to the urinary tract, such as renal laceration, renal contusion, or ureteral avulsion (Table 38. In the pediatric population, a hydronephrotic kidney, due to a congenital ureteropelvic junction obstruction, can rupture from a rel- atively minor traumatic event. Also, the pediatric kidney is more prone to injury since it is not well protected. In the adult, a signifi- cant amount of fat, muscle, and bone protect the kidney from injury, but this protective barrier is not well developed in children. Therefore, all children who present with flank pain following a traumatic event require upper tract imaging. Injuries to the collecting system of the kidney usually are due to significant trauma, except in the pediatric population for the reasons mentioned above. Administration of intravenous contrast often is nec- essary to document these injuries, since they usually are not seen on a plain abdominal x-ray or ultrasound examination and urinalysis may be normal (Table 38. Thus, a normal urinalysis in the trauma setting does not exclude serious urologic injury. Renal Artery Emboli Renal artery emboli can result secondary to mitral valve disease, atrial fibrillation, acute myocardial infarction, endocarditis, and cardiac tumors. In addition, atherosclerotic aortic disease and thrombi originating in renal artery aneurysms have been known to cause renal artery emboli (Table 38. Ureteral and renal pelvic injuries from external trauma: diagnosis and man- agement. The use of indwelling ureteral stents in managing ureteral injuries due to external violence. Ureteral and renal pelvic injuries from external trauma: diagnosis and management. The use of indwelling ureteral stents in managing ureteral injuries due to external violence. Patients who present with renal artery emboli usually are med- ically unstable or recently have suffered a cardiac event. Surgical Number of Operative outcome (%) mortality Institution patients Cured Improved Failed (%) Bowman Gray 152 15 75 10 1. Renal artery angiogram demonstrating normal right renal vascu- lature and abrupt cutoff of left renal artery due to emboli. For bilateral renal artery emboli or emboli to a solitary kidney, streptokinase catheter embolectomy or surgical treatment may be necessary. Nonurologic Causes Other problems that cause flank pain that should be considered by the clinician include intraabdominal pathology that secondarily results in flank pain. Since the kidneys are related anatomically to the colon, pancreas, spleen, ovaries, and psoas muscle, pathology involving these organs can produce flank pain.
In the same doses purchase pletal 100 mg overnight delivery muscle relaxant histamine release, less frequently repeated, it will prove an excellent tonic, strengthening the functions of both stomach and intestines, giving improved digestion. In indigestion, with some diarrhœa of a papescent character, it will be found a good remedy. In some cases it will prove our best remedy in the treatment of obstinate constipation. The cases are those in which there is an unnatural sensation of constriction in stomach and bowels, and contraction of the abdominal muscles. I prescribe it in these cases in doses of ten drops to a large glass of water, on rising in the morning. In the severer cases it is associated with thorough fatty inunction over the abdomen, and friction. I employ it as a restorative, where there is special need of increased nutrition of nerve tissue. It is thus associated with the preparations of phosphorus, and with cod liver oil. The influence of the Rhododendron on the circulation is very marked, It undoubtedly acts like veratrum and aconite, stimulating the circulatory apparatus through the sympathetic, and diminishing the frequency of the pulse by increasing the power of the heart, and removing capillary obstruction. Acting in this way, it has been employed with advantage in rheumatism, gout, syphilis, and some acute diseases. It is claimed to exert an influence upon the reproductive apparatus, being used in orchitis, in suppression of gonorrhœa, and in hydrocele. It has been but little employed in this country, but our native specimens deserve a thorough examination. It has not been much used, and we can not tell whether it will prove better than others of this class; still it deserves a thorough trial. It is claimed to be antidotal to the action of mercury, especially in chronic mercurial disease, and has been employed in the treatment of secondary syphilis, after mercurialization, with advantage. The indications for Rhus may be briefly summed up as follows: Sharp pain in frontal region, especially in left orbit, sharp stroke of pulse; tip of tongue showing small red points on upper surface; local pain sharp and burning; burning pain of surface; bright redness of surface. With such indications it may be administered in any form of disease with a certainty of benefit. The Rhus has proven one of our most valuable medicines, and will be highly prized by every practitioner when its use is learned. It is antidotal to such animal poisons (zymotic) as determine to the skin, in erysipelas or erysipeloid disease, or in low grades of inflammation of cellular tissue, or in low grades of inflammation of mucous membranes. A frequent, small pulse, redness of mucous membranes, brown sordes, bright superficial redness of skin, tympanitis, acrid discharges from bowels or bladder, are indications for its use. So also is inflammatory action, presenting tumid, bright reddened tissues, deep seated or superficial burning pain, inflammation giving an ichorous discharge, in which the tissues seem to melt away without sloughing. Old ulcers, that present reddened, glistening edges, scrofulous or syphilitic disease, with tumid-red, glistening swellings. I have preferred to thus point out distinctly the indications for the use of the Rhus, without reference to the disease, according to our present nomenclature. It will be seen to point to erysipelas, typhoid fever and typhoid disease in general, and the entire list of zymotic diseases. Our Homœopathic friends give the following indications for its use: “Affections of the ligaments, tendons and synovial membranes; tensions, drawing and tearing in the limbs, worse during rest, and in the cold season, or at night, in bed, frequently attended with numbness of the affected part after moving it; creeping pains; sensation in inner organs as if something would be torn loose; lameness and paralysis, also hemiplegia; vesicular erysipelas; rhagades; pustules which break and discharge a fluid; hang-nails; red, shining swelling; violent and spasmodic yawning; evening fever, with diarrhœa; sweat during the pains, frequently with violent trembling; illusions of the fancy, and delirium; pain as if the brain would be torn; painful creeping in the head; swelling of the head; phagedenic scald-head; small, soft tumors on the hairy scalp; swelling and inflammation of the parotid glands; acne rosacea around the mouth and chin; nightly discharge of yellowish, or bloody saliva; ulcerative pain in the pit of the stomach as if something would be torn off, especially when stooping or making a false step; the small of the back feels as if bruised, especially when lying still on it. This remedy has been but little used, yet its activity is such that we may reasonably expect that experiment will develop some valuable medicinal use. It acts on the stomach and bowels in large doses, and exerts an influence upon the nervous system. It is employed locally in the treatment of cancer, the following formula being employed: “Cancer Balsam. It is then ready for use, and should be put up in sealed boxes or closely stopped bottles, in order to prevent evaporation. It makes no difference whether it is called syphilis, scrofula or cancer, the indication for use is the replacement of tissue with lower organizations. To what extent it opposes the processes of degeneration we are unable to say, the use has been so limited, but it deserves a thorough investigation.
Jerome Jaffe generic pletal 100 mg otc muscle relaxant general anesthesia, who headed the hours, patients could take it once a day Special Action Office for Drug Abuse without using a syringe. Prevention in the Executive Office of the W hite ï Methadone relieved the opioid craving or House in the early 1970s. Jaffeís office hunger that patients with addiction described oversaw the creation of a nationwide, publicly as a major factor in relapse and continued funded system of treatment programs for illegal use. Methadone Association for the Treatment of Opioid maintenance became a major public health Dependence n. Naltrexone also may benefit with the cost averaging $7 returned for every some patients in the beginning stages of opioid dollar invested (Gerstein et al. Other patient groups day of treatment paid for itself (the benefits frequently have demonstrated poor compliance to taxpaying citizens equaled or exceeded the with long-term naltrexone therapy, mainly costs) on the day it was received, primarily because naltrexone neither eases craving for through an avoidance of crimeî (Gerstein et the effects of illicit opioids when used as direct- al. History of M edication-Assisted Treatm ent for Opioid Addiction 19 ï Methadone treatment was among the most ï Encourage programs to provide comprehen- cost-effective treatments, yielding savings of sive services, such as individual and group $3 to $4 for every dollar spent. It identified the greatest reductions in criminal activity such barriers as the publicís misperception of and drug selling, down 84 percent and 86 persons who are opioid addicted not as individ- percent, respectively, of any type of opioid uals with a disease but as ìotherî or ìdifferent,î addiction treatment studied. B]) amended that Services and must comply with regulations portion of the Controlled Substances Act man- established by the U. Attorney General dating separate registration for practitioners regarding security of opioid stocks and mainte- who dispense opioids in addiction treatment. Interest in accreditation grew because Substance Abuse and Mental Health Services of its emphasis on self-assessment and Administration 2003a; see also chapter 3). In addition, trends in national health care Regulation fueled movement toward accreditation. Several States eligibility, evaluation procedures, dosages, grant exemptions from State licensing take-home medications, frequency of patient requirements (called ìdeemed statusî) to visits, medical and psychiatric services, coun- accredited health care facilities. The new regulations acknowledged that addiction is a medical disorder not medical disorder As experience with amenable to one-size-fits-all treatment. They the effectiveness of recognized that different patients, at different not amenable to methadone grew, times, could need vastly different services. Coverage of naltrexone is short because its use Dosage Formseiusmod in the United States generally has been limited to easing withdrawal symptoms for a small portion of patients undergoing medically super- EfficacyUt enim vised withdrawal after maintenance treatment. Exhibit 3-1 provides ad minim information about these and other medications for opioid addiction Side Effects veniam quis treatment, including the year of their U. Qualified physicians may dispense care settings should help move medical mainte- or prescribe buprenorphine products for up to nance treatment of opioid addiction into main- 30 patients at a time under the provisions of stream medical practice. Any criteria of the Secretary under this subclause shall be established by regulation. Any such criteria are effective only for 3 years after the date on which the criteria are promulgated, but may be extended for such additional discrete 3-year periods as the Secretary considers appropriate for purposes of this subclause. Such an extension of criteria may only be effectuated through a statement published in the Federal Register by the Secretary during the 30-day period preceding the end of the 3-year period involved. Pharm acology of M edications Used To Treat Opioid Addiction 27 are opioid addicted. Patients with special needs Pharm acology and may require split methadone doses given more Pharm acotherapy than once daily. Therapeutically appropriate entering the body equals the amount being doses of these agonist medications produce excreted) of methadone usually is achieved in 5 cross-tolerance for short-acting opioids such as to 7. Unlike of methadone also attenuate or block the methadone, it cannot be administered daily euphoric effects of heroin and other opioids. Methadoneís body clearance rate varies patients who cannot take oral methadone, considerably between individuals. Pharm acology of M edications Used To Treat Opioid Addiction 29 Buprenorphine course of buprenorphine-naloxone therapy for detoxification from opioids. As a result, there is a greater mar- function more like an antagonist under these gin of safety from death by respiratory depres- conditions (see ìInductionî in chapter 5). Buprenorphine overdose is Naltrexone uncommon, although it has been reported in Naltrexone is a highly effective opioid antago- France, and it is associated almost always with nist that tightly binds to mu opiate receptors.
If you find that your agitating assumptions rule your life and cause you intense anxiety and misery cheap 100 mg pletal with mastercard xanax muscle relaxant qualities, you may want to consult a professional psychologist or mental-health counselor. Sometimes anxiety does have a physical base, and your primary care doctor can give you a referral after physical causes have been looked into. Should you consult a professional, you’ll still find this book useful because most anxiety experts are familiar with the tools that we provide, and they’ll help you implement them. Tempering perfectionist tendencies Perfectionists believe they have to be the best in everything they do. They feel horrible when they make mistakes, and if they’re not outstanding at something, they generally refrain from trying. Fortunately, a good cost/benefit analysis can often help them see that perfectionism exacts a terrible toll. Thus, if they weren’t perfect, these folks assume that they would become sloths with no standards at all. If you’re worried about giving up on your perfectionism schema, we have good news for you. You may find it helpful to copy the following statements, or what we call “balanced views” on an index card. Carry your card around with you as a reminder for those times when you start to get hung up on perfectionism. Not only that, perfectionists of perfectionism probably can improve the qual- more often develop various types of anxiety ity of your work, sports, and other endeavors disorders, depression, physical ailments, and as long as you don’t let it get out of hand. A more balanced schema is that you like doing things well, but that all humans make mistakes and so do you. For example, think about all the people you admire, yet who make numerous mistakes over time. Balancing an approval addict Approval addicts desperately want to be liked all the time. Chapter 7: Busting Up Your Agitating Assumptions 119 ✓ What other people think matters, but it’s not usually crucial. In addition, consider collecting evidence that refutes your anxious approval schema. For example, think about people whom you like and admire who manage to speak their minds and look out for their own needs. If you feel addicted to approval and assume you must have the approval of others at all times and at virtually any cost, consider a more balanced per- spective. Sure, everyone likes to be liked, but realize that no matter what you do, some people won’t like you some of the time. Try thinking that your needs matter and that what other people think of you does not define your worth. Balancing vulnerability People who hold the vulnerability schema feel unsafe and worry constantly about every conceivable mishap. They might worry about safety, health, natural disasters, or the future; they often feel like victims of life’s circum- stances. The modern world with constant news about pandemics, natural catastrophes, financial ruin, and terror probably increases everyone’s sense of vulnerability. People with this assumption fail to understand that worry has never stopped a single catastrophe. Nor does excessive worry help you prepare for the inevitable bad luck and misfortune that occur in everyone’s life. A better, alternative assumption can keep you reasonably safe without all that worry. If you want to give up your vulnerable assumption, try carrying these ideas with you and use them like mantras, repeating them to yourself frequently: ✓ I need to take reasonable precautions but stop obsessing over safety. Try thinking that no one can prevent the trials and tribulations of life, but that you can usually cope when they do occur. Collect evidence about the many unpleasant incidents that you were able to cope with in the past. For example, when you had high blood pressure, perhaps you exercised or took medication to control it, or when you lost someone whom you cared for, you grieved, but you survived. They always want to know everything that’s going on around them in their families and at work.
A patient had surgery for colorectal cancer pletal 100mg for sale muscle relaxant creams over the counter, after Answers to Questions 1–3 which he received chemotherapy for 6 months. No useful clinical information in this case that is elevated in 70%–80% of patients with ovarian Immunology/Apply principles of basic laboratory cancer and about 20% of patients with pancreatic procedures/Tumors/Testing/1 cancer. Which of the following substances, sometimes cancer; and the fast-migrating liver isoenzyme, which used as a tumor marker, is increased two- or is a marker for metastatic liver cancer. Neuron-specific enolase is an Immunology/Tumor markers/Testing/1 enzyme that is used as a tumor marker primarily for 6. High levels may be digital-rectal examination caused by prostate malignancy, benign prostatic B. The sensitivity is sufficiently high to with malignant disease warrant its use as a screening test, but sensitivity for Immunology/Correlate laboratory data with stage A cancer is below 60%. For genetic linkage studies diseases and for genetic counseling because certain C. Is not useful in this situation typing is not specifically used to diagnose a disease or assess its severity. Analysis of family pedigrees for the linkage antigens marker and disease can be used to determine the B. Impossible to determine complement are detected with a supravital dye Immunology/Evaluate laboratory data to make such as eosin. B Inactive rabbit complement may not become fixed antigens in a complement-dependent cytotoxicity to antibodies that have bound test leukocytes; assay. Too much supravital dye was added supravital dye is added, all cells will appear negative B. Which of the following serial dilutions contains an Answers to Questions 1–3 incorrect factor? Which routine laboratory test is most cardiolipin or phospholipids have a biological false- likely to be abnormal for this patient? C3 assay by immunonephelometry the majority of patients with these antibodies do not have lupus and would have a normal C3 level. C The correct list, in which all mediators are involved in an inflammatory response within 72 hours after initial 3. Inflammation involves a variety of biochemical infection, is neutrophils, macrophages, complement, and cellular mediators. Phagocytic cells, may be increased within 72 hours after an initial acute phase reactants, and fibrinolytic factors enter infection? Macrophages, T cells, B cells, ceruloplasmin, complement Immunology/Apply principles of basic immunologic responses/Inflammation/2 113 114 Chapter 3 | Immunology 4. An 18-month-old boy has recurrent sinopulmonary Answers to Questions 4–7 infections and septicemia. A A patient with Bruton’s X-linked agammaglobulinemia test result would be markedly decreased? What serum IgA and normal IgG substantiate the diagnosis immunologic test would help to determine the of selective IgA deficiency. D Low plasma concentrations of IgG and IgA and an Immunology/Determine laboratory tests/ abundance of IgM is consistent with hyper-IgM Immunodeficiency/Testing/3 syndrome. What Patients with common variable immunodeficiency is the most likely explanation of these findings and have low serum IgG, IgA, and IgM. Test specimen was not added properly; repeat treponemal tests remain positive in over 95% of both procedures cases. Patient has common variable immunodeficiency; for diagnosis of neurosyphilis because treponemal perform B-cell count tests remain positive after treatment. Patient has immunodeficiency with hyper-M; used as the confirmatory test when the serum perform immunoglobulin levels treponemal test is positive. No laboratory test is positive for late (tertiary) syphilis Immunology/Correlate laboratory data with physiological processes/Syphilis/Testing/3 3. A hospital employee received the final dose of the rash, severe headaches, stiff neck, and sleep hepatitis B vaccine 3 weeks ago. Te clinical symptoms and laboratory results are donate not characteristic of Lyme disease Immunology/Correlate laboratory data with C.
Promoting Home and Community-Based Care Teaching Patients Self-Care The nurse instructs the patient about the medications that are prescribed (vitamins 100 mg pletal sale spasms with fever, anticholinergics, and antispasmodics) and their actions. It also is important to inform the patient and family about symptoms that should be reported to the physician, including jaundice, dark urine, pale-colored stools, pruritus, and signs of inflammation and infection, such as pain or fever. This is the result of a continual trickle of bile through the choledochoduodenal junction after cholecystectomy. Usually, such frequency diminishes over a period of a few weeks to several months. If a patient is discharged from the hospital with a drainage tube still in place, the patient and family need instructions about its management. The nurse instructs them in proper care of the drainage tube and the importance of reporting to the surgeon 95 promptly any changes in the amount or characteristics of drainage. Managing Pain You may experience pain or discomfort in your right shoulder from the gas used to inflate your abdominal area during surgery. Sitting upright in bed or a chair, walking, or use of a heating pad may ease the discomfort. Managing Follow-Up Care Make an appointment with your surgeon for 7 to 10 days after discharge. This is an abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. In addition, fat breakdown occurs, resulting in an increased production of ketone bodies, which are the byproducts of fat breakdown. Type 2 Diabetes Mellitus • Accounts for 90% of patients with diabetes • Usually occurs in people over 40 years of age • 80-90% of patients are overweight Etiology and Pathophysiology • Pancreas continues to produce some endogenous insulin • Insulin produced is either insufficient or poorly utilized by the tissues • Insulin resistance –Body tissues do not respond to insulin –Results in hyperglycemia • Inappropriate glucose production by the liver –Not considered a primary factor in the development of type 2 diabetes Normally, insulin binds to special receptors on cell surfaces and initiates a series of reactions involved in glucose metabolism. In type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. However, if the beta cells cannot keep up with the increased demand for insulin, the glucose level rises, and type 2 diabetes develops. One consequence of undetected diabetes is that long-term diabetes complications (eg, eye disease, peripheral neuropathy, peripheral vascular disease) may have developed before the actual diagnosis of diabetes is made Etiology (not well know) –Genetic factors –Increased weight. Secondary Diabetes • Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels –Cushing syndrome –Hyperthyroidism –Parenteral nutrition Clinical Manifestations Diabetes Mellitus • Polyuria • Polydipsia (excessive thirst) • Polyphagia • In Type I –Weight loss –Ketoacidosis Polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal, and recurrent infections. Plasma glucose values are 10% to 15% higher than whole blood glucose 103 values, and it is crucial for patients with diabetes to know whether their monitor and strips provide whole blood or plasma results Assessing the Patient with Diabetes • History: Symptoms related to the diagnosis of diabetes: Symptoms of hyperglycemia Symptoms of hypoglycemia Frequency, timing, severity, and resolution Results of blood glucose monitoring Status, symptoms, and management of chronic complications of diabetes: Eye; kidney; nerve; genitourinary and sexual, bladder, and gastrointestinal Cardiac; peripheral vascular; foot complications associated with diabetes Adherence to/ability to follow prescribed dietary management plan Adherence to prescribed exercise regimen Adherence to/ability to follow prescribed pharmacologic treatment (insulin or oral antidiabetic agents) Use of tobacco, alcohol, and prescribed and over-the-counter medications/drugs Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment Effects of diabetes or its complications on functional status (eg, mobility, vision) Physical examination Blood pressure (sitting and standing to detect orthostatic changes) Body mass index (height and weight) Fundoscopic examination and visual acuity Foot examination (lesions, signs of infection, pulses) Skin examination (lesions and insulin-injection sites) Neurologic examination Vibratory and sensory examination using monofilament Deep tendon reflexes Oral examination • Laboratory Examination • Need for Referrals 104 105 Diabetes Mellitus Collaborative Care • Goals of diabetes management: –Reduce symptoms –Promote well-being –Prevent acute complications –Delay onset and progression of long-term complications Nutritional Therapy –Overall objectives • Assist people in making changes in nutrition and exercise habits that will lead to improved metabolic control • Control of total caloric intake to attain or maintain a reasonable body weight, control of blood glucose levels, and normalization of lipids and blood pressure to prevent heart disease. Nutrition, meal planning, and weight control are the foundation of diabetes management. Alcohol may decrease the normal physiologic reactions in the body that produce glucose (gluconeogenesis). These effects are useful in diabetes in relation to losing weight, easing stress, and maintaining a feeling of well-being. Exercise also alters blood lipid concentrations, increasing levels of high-density lipoproteins and decreasing total cholesterol and triglyceride levels. Exercise/ Precautions • Don‘t exercise if blood glucose > 250 mg/dL or if there is ketone bodies in the urine. The liver then releases more glucose, and the result is an increase in the blood glucose level –Several small carbohydrate snacks can be taken to prevent hypoglycemia • Before exercising • At the end of the exercise with strenuous exercise • At the time with strenuous exercise • Deduce them from total daily calories –May need to reduce inlsulin dose The physiologic decrease in circulating insulin that normally occurs with exercise cannot occur in patients treated with insulin. Initially, patients who require insulin should be taught to eat a 15-g carbohydrate snack (a fruit exchange) or a snack of complex carbohydrates with a protein before engaging in moderate exercise, to prevent unexpected hypoglycemia. Drug Therapy: Insulin • Exogenous insulin: –Required for type 1 diabetes –Prescribed for the patient with type 2 diabetes who cannot control blood glucose by other means • Types of insulin –Human insulin • Most widely used type of insulin • Cost-effective ¯ Likelihood of allergic reaction Human insulin preparations have a shorter duration of action than insulin from animal sources because the presence of animal proteins triggers an immune response that results in the binding of animal insulin, which slows its availability. Names include Humulin N, Novolin N, Humulin L, Novolin L –Long-acting: Ultralente, Lantus Onset 6-8h, peak 12-16 h and lasts 20-30h. When they do occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives). The treatment is desensitization, with small doses of insulin administered in gradually increasing amounts.
