By B. Bandaro. Emmanuel College. 2018.
Consumers are interested in care-related information for selection purposes discount 80mg super levitra mastercard. That is purchase super levitra 80 mg mastercard, Numerous opportunities for improvement exist in every healthcare organ- ization. Improvements that are powerful and worthy of organization resources include those that will positively affect a large number of patients, elimi- nate or reduce instability in critical clinical or business processes, decrease risk, and ameliorate serious problems. In short, it may be most appropri- ate to focus on high-risk, high-volume, problem-prone areas to maximize your performance-improvement investment. Because performance measurement lies at the heart of any per- formance-improvement process, it is imperative that performance meas- ures be selected in a thoughtful and deliberate manner. Performance measures may be internally developed or adopted from a multitude of external resources. However, regardless of the source of performance measures, each measure should be considered against certain character- istics to help ensure a credible and beneficial measurement effort. Reliable measures accurately and consistently identify the events they were designed to identify across multiple healthcare settings. Valid meas- ures raise good questions about current processes and therefore underlie the identification of opportunities for improvement. Some measurement activities are simply not worth the investment necessary to collect and analyze the data. Continuous Process Improvement Cycle make any change in the fall-prevention protocols until the cause of the spe- cial cause is identified and eliminated. On the other hand, if the observed variation were only common cause variation (as in the first case), then it would be appropriate to try to improve the process by introducing a new fall-prevention program. If after introducing a fall-prevention program the number of falls in the second year decreased to, say, an average of 17 per month with a range of 14 to 19, this change would be a special cause that was positive. In summary, the control chart will tell an HCO whether the observed variation is due to common or special causes and will help them determine how to approach improving a process. If there is a special cause, one should investigate it and eliminate it, not change the process. If there is common cause variation, it is appropriate to change the process to improve it. A con- trol chart will subsequently reveal whether or not the change was effective. A control chart is a line graph with the addition of a centerline represent- ing the overall process average (or mean). It shows the flow of a process over time, as distinguished from a distribution, which is a collection of data S tatistical Tools for Quality Im provem ent S tatistical Tools for Quality Im provem ent Mean –2. In healthcare, professional societies and expert panels routinely develop scientifically based guidelines of patient care practices for given treatments or procedures. The goal of these guideline-setting efforts is to provide healthcare organizations with tools that, if appropriately applied, can help raise their performance to the level of industry leaders. Performance measure data can be used to track how often, and how well, organizations comply with the guidelines. What are common data quality problems in healthcare performance measurement? What are the threats associated with poor quality data in the use of data? When sample data are used in performance measurement, how can appropriate sample sizes be determined, and how can it be ensured that the sample data represent the entire population? How should small sample sizes be handled in the analysis and use of control and comparison charts? How does the rigorous use of control and comparison charts for performance management and improvement contradict, if at all, the art of medicine philosophy that each patient is unique? Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations. Collecting the Data Interpreting the Results Communicating the Results 178 Case Study Studies comparing self-reports with proxy reports do not consistently sup- port the hypothesis that self-reports are more accurate than proxy reports (U. However, the conclusions drawn from studies in which responses were verified using hos- pital and physician records show that, on average, (1) self-reports tend to be more accurate than proxy reports, and (2) health events are generally underreported in both populations. In terms of reporting problems with care, most studies comparing proxy responses to patients responses show that proxies tend to report more problems with care compared to patients (vom Eigen et al. Therefore, the percentage response by proxy needs to be taken into consideration in the interpretation of survey results. Typically, patients receive questionnaires from two weeks to four months after discharge from the hospital. Studies of memory have shown that the greater the effect of the hospitalization and the nature of the condition, the greater the ability to recall health events. Studies also suggest that most people find it difficult to recall precise details, such as minor symptoms or the number of times a specific event occurred. For ambulatory surveys, patients should be surveyed as close to the visit or event as possible. Adjustments should be considered when hospital survey results are being released to the public. The characteristics com- monly associated with patient reports on quality of care are (1) patient age (i. The ability of healthcare organizations to deliver high-quality, patient-cen- tered care to their members and patients depends in part on their under- standing of basic customer service principles and their ability to integrate these principles into clinical settings. Do everything you can to create a budget that supports the type of data collection necessary to achieve your goals. If you are reporting patient experience-of-care data to the public, you need to maximize the rigor of the data collection to ensure excellent response rates and sampling, and you may need to spend more money to accomplish that goal.
These people may be at risk for reactivation of TB generic super levitra 80 mg otc, fection or other conditions that suppress the immune system but the exact risk is unknown discount super levitra 80mg with amex. Lower doses and intermittent and inhibit the ability to react to the tuberculin antigen. Traditionally, local health departments have been responsible for testing, interpreting, and providing follow-up care; some institu- CHAPTER 38 DRUGS FOR TUBERCULOSIS AND MYCOBACTERIUM AVIUM COMPLEX (MAC) DISEASE 563 BOX 38–2 TREATMENT OF LATENT TUBERCULOSIS INFECTION (LTBI) Recommended Regimens for Adults stopped and not resumed if enzyme levels are higher than Isoniazid (INH) daily or twice weekly for 9 months is the pre- ﬁve times the upper limit of normal in an asymptomatic per- ferred regimen, including persons with HIV infection or radio- son, are higher than normal range if symptoms of hepatitis graphic evidence of prior TB. This regimen is used mainly for vantage of this regimen over the 9-month schedule is greater ad- clients who cannot tolerate INH or pyrazinamide. This Special Populations regimen may be used for HIV-negative adults with normal chest 1. The preferred regimen for treatment of LTBI radiographs; it is not recommended for HIV-positive persons, is INH, administered daily or twice weekly for 9 or 6 months. For HIV-positive women with higher risks of pro- Rifampin and pyrazinamide (RIF-PZA) daily or twice gression to active TB, treatment should not be delayed; for those weekly for 2 months. This regimen may be used for contacts of with lower risks, some experts recommend waiting until after de- patients with INH-resistant TB and for those who are unlikely to livery to start treatment. In general, INH, rifampin, and etham- complete a longer course of treatment. Rifampin is contraindicated butol have good safety records in pregnancy. Pyrazinamide and in HIV-positive patients who are receiving protease inhibitors or streptomycin are contraindicated during pregnancy. INH daily or twice weekly for greatly stimulates metabolism and decreases the effectiveness of 9 months is recommended. Rifabutin, which causes less enzyme induction of age with LTBI are at high risk for progression to disease. Pyrazinamide is They are also more likely than older children and adults to de- contraindicated during pregnancy. To reduce the risks of liver injury, the tive for children than adults, and the risk for INH-related he- American Thoracic Society and the CDC, with the endorsement of patitis is minimal in infants, children, and adolescents, who the Infectious Diseases Society of America, issued new recom- generally tolerate the drug better than adults. Routine adminis- mendations for choosing patients and for more intensive clinical tration of pyridoxine is not recommended for children taking and laboratory monitoring, as follows: INH, but should be given to breast-feeding infants, children 1. The RIF-PZA regimen is not recommended for persons and adolescents with pyridoxine-deﬁcient diets, and children who have underlying liver disease or who have had INH- who experience paresthesias when taking INH. It should be used with caution in pa- Although few studies have been done in infants, children, tients who take other hepatotoxic medications or use alcohol, and adolescents, rifampin alone, rifampin with INH, and ri- even if alcohol use is stopped during treatment. Persons being fampin with pyrazinamide have been used to treat LTBI with considered for treatment with this regimen should be in- effectiveness. Although the optimal length of rifampin therapy formed about potential hepatotoxicity and asked whether in children with LTBI is unknown, the American Academy of they have had liver disease or adverse effects from INH. The RIF-PZA regimen is recommended mainly for clients There have been no reported studies of any regimen for treat- who are unlikely to complete longer courses of treatment ment for LTBI in HIV-infected children. The RIF-PZA regimen does increase risks of hepatotoxicity skin-test reactions (>5 mm) should be treated with one of the in clients with HIV infection. Still, INH daily for 9 months recommended regimens described above, regardless of age. Contacts of patients with INH-resistant, rifampin-susceptible LTBI when completion of treatment can be assured. For patients with intolerance to pyrazinamide, <20 mg/kg/d and a maximum of 2 g/d; giving no more than rifampin alone for 4 months is recommended. If rifampin can- a 2-week supply of rifampin and pyrazinamide at a time; not be used, rifabutin can be substituted. Contacts of patients with multidrug-resistant (MDR)-TB who adherence, tolerance, and adverse effects, and at 8 weeks to are at high risk for developing active TB are generally given document treatment completion. Immunocompetent contacts may be observed with- and seek medical care if abdominal pain, emesis, jaundice, out treatment or treated for 6 months; immunocompromised con- or other symptoms of hepatitis develop. Provider continu- tacts (eg, HIV-infected persons) should be treated for 12 months. Perform liver function tests (eg, serum aspartate and alanine butol are recommended for 9 to 12 months if the isolate is sus- aminotransferases [AST and ALT] and bilirubin) at base- ceptible to both drugs. RIF-PZA treatment should be (continued) 564 SECTION 6 DRUGS USED TO TREAT INFECTIONS BOX 38–2 TREATMENT OF LATENT TUBERCULOSIS INFECTION (LTBI) (Continued) drugs to which the infecting organism is likely susceptible should (eg, the length and complexity, possible adverse effects, and be given. With rifampin, the drug is contraindicated or with intermittent regimens (eg, twice weekly) and when possi- should be used with caution in persons who are taking protease ble with 2-month regimens and in certain settings (eg, institu- inhibitors or nonnucleoside reverse transcriptase inhibitors tional settings, community outreach programs, and for persons (NNRTIs). Rifabutin can be substituted for rifampin in some living in households with patients who are receiving home- circumstances, but it should not be used with hard-gel based DOT for active TB). This is determined by the soft-gel saquinavir and nevirapine because data are limited. For daily INH, the 9-month regimen should include at daily dose (ie, from 300 mg/d to 150 mg/d) with indinavir, least 270 doses in 12 months and the 6-month regimen should in- nelﬁnavir, or amprenavir and to one fourth the usual dose clude at least 180 doses in 9 months. For twice-weekly INH, the (ie, 150 mg every other day or 3 times a week) with ritonavir. For the 2-month regimen of daily rifampin (or ri- fabutin) and pyrazinamide, at least 60 doses should be given in not recommended as a substitute for rifampin because its 3 months. For the 4-month regimen of daily rifampin alone, at safety, effectiveness, and interactions with anti-HIV medication least 120 doses should be given in 6 months.
Action onset and peak occur rapidly 3 minutes and peaks in 60 to 90 minutes effective super levitra 80 mg. Adverse effects in- with IV administration; onset is rapid and peak occurs in 1 to clude sedation super levitra 80 mg low price, restlessness, and extrapyramidal reactions 2 hours with oral drug. Metoclopramide may increase the effects of alcohol and cyclosporine (by increasing their absorption) and decrease Miscellaneous Antiemetics the effects of cimetidine and digoxin (by accelerating passage through the GI tract and decreasing time for absorption). Dronabinol is a cannabinoid (derivative of marijuana) used Phosphorated carbohydrate solution (Emetrol) is a in the management of nausea and vomiting associated with hyperosmolar solution with phosphoric acid. Dronabi- reduce smooth muscle contraction in the GI tract and is avail- nol causes the same adverse effects as marijuana, includ- able over the counter. Withdrawal symptoms (eg, insomnia, irritability, restless- ness, others) may occur if dronabinol is abruptly stopped. Onset occurs within 12 hours, with peak intensity within Indications for Use 24 hours and dissipation within 96 hours. These symptoms are most likely to occur with high doses or prolonged use. Antiemetic drugs are indicated to prevent and treat nausea Sleep disturbances may persist for several weeks. As a result, it can de- antiemetic drugs are ineffective or only a few doses are crease nausea and vomiting associated with gastroparesis and needed. Metoclopramide also has central antiemetic effects; it antagonizes the action of dopamine, a Contraindications to Use catecholamine neurotransmitter. Metoclopramide is given orally in diabetic gastroparesis and esophageal reflux. Large Antiemetic drugs are usually contraindicated when their use doses of the drug are given intravenously during chemother- may prevent or delay diagnosis, when signs and symptoms of apy with cisplatin (Platinol) and other emetogenic antineo- drug toxicity may be masked, and for routine use to prevent plastic drugs. A Interventions few studies have investigated its antiemetic activity in hu- Use measures to prevent or minimize nausea and vomiting: mans. Results indicated that ginger was comparable sights and odors; excessive ingestion of food, alcohol, or to metoclopramide and that both treatments were more effec- nonsteroidal anti-inﬂammatory drugs). Similar results were obtained in another study with tration of analgesics before painful diagnostic tests and 120 patients having gynecologic surgery; in this study, meto- dressing changes or other therapeutic measures may be clopramide was given orally. The general consensus • Administer antiemetic drugs 30 to 60 minutes before a seems to be that it is premature to recommend ginger for any nausea-producing event (eg, radiation therapy, cancer therapeutic use until long-term, controlled studies are done. For any drug likely to cause nausea and vomiting, check reference Nursing Process sources to determine whether it can be given with food without altering beneﬁcial effects. In some instances, a drug • Identify risk factors (eg, digestive or other disorders in (eg, digoxin, an antibiotic) may need to be discontinued which nausea and vomiting are symptoms; drugs associ- or reduced in dosage. In other instances (eg, paralytic ileus, ated with nausea and vomiting). GI obstruction), preferred treatment is restriction of oral • Interview regarding frequency, duration, and precipitating intake and nasogastric intubation. Also, question the client • Eating dry crackers before rising in the morning may about accompanying signs and symptoms, characteristics help prevent nausea and vomiting associated with preg- of vomitus (amount, color, odor, presence of abnormal nancy. Nursing Diagnoses • Minimize activity during acute episodes of nausea and • Deﬁcient Fluid Volume related to uncontrolled vomiting vomiting. Lying down and resting quietly are often • Imbalanced Nutrition: Less Than Body Requirements helpful. Offer small • Risk for Injury related to adverse drug effects amounts of food and ﬂuids orally when tolerated and ac- • Deﬁcient Knowledge related to nondrug measures to re- cording to client preference. Planning/Goals • Decrease environmental stimuli when possible (eg, noise, The client will: odors). Allow the client to lie quietly in bed when nause- • Receive antiemetic drugs at appropriate times, by indicated ated. Decreasing motion may decrease stimulation of the routes vomiting center in the brain. CHAPTER 63 ANTIEMETICS 907 such as meclizine and dimenhydrinate are also useful • Help the client rinse his or her mouth after vomiting. This for vomiting caused by labyrinthitis, uremia, or post- decreases the bad taste and corrosion of tooth enamel by operative status. For ambulatory clients, drugs causing minimal seda- • Provide requested home remedies when possible (eg, a tion are preferred. However, most antiemetic drugs cool, wet washcloth to the face and neck). Promethazine (Phenergan), a phenothiazine, is often • Observe and interview for decreased nausea and vomiting. Although phenothiazines are effective antiemetic agents, • Compare current weight with baseline weight. Consequently, phenothiazines other than promethazine usually should not be used, especially for PRINCIPLES OF THERAPY pregnant, young, elderly, and postoperative clients, un- less vomiting is severe and cannot be controlled by Drug Selection other measures. The 5-HT3 receptor antagonists (ondansetron, grani- setron, and dolasetron) are usually the drugs of ﬁrst choice for clients with chemotherapy-induced or post- Dosage and Administration Factors operative nausea and vomiting. In chemotherapy, stud- ies indicate greater effectiveness when combined with Dosage and route of administration depend primarily on the a corticosteroid (eg, dexamethasone). Doses of phenothiazines are much smaller for antiemetic ties are preferred for motion sickness. CLIENT TEACHING GUIDELINES Antiemetic Drugs General Considerations mood changes, and other mind-altering effects.
When blood glucose values are above 250 mg/dL buy super levitra 80 mg line, diet Juvenile Diabetes Foundation International soda super levitra 80 mg generic, unsweetened tea, and other ﬂuids without sugar 120 Wall Street should be given. New York, NY 10005-4001 • For infants and toddlers who weigh less than 10 kg or 1-800-JDF-CURE require less than 5 units of insulin per day, a diluted in- 1-800-223-1138 sulin can be used because such small doses are hard to measure in a U-100 syringe. The most common dilution Type 2 Diabetes is U-10, and a diluent is available from insulin manu- facturers. Vials of diluted insulin should be clearly la- Type 2 diabetes is being increasingly identiﬁed in children. This trend is attributed mainly to obesity and inadequate ex- • Rotation of injection sites is important in infants and ercise because most children with type 2 are seriously over- young children because of the relatively small areas weight and have poor eating habits. In addition, most are 402 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM members of high-risk ethnic groups (eg, African American, Oral drugs. Sulfonylureas and their metabolites are ex- Native American, or Hispanic) and have relatives with dia- creted mainly by the kidneys; renal impairment may lead betes. These children are at high risk for development of seri- to accumulation and hypoglycemia. They should be used ous complications during early adulthood, such as myocardial cautiously, with close monitoring of renal function, in infarction during their fourth decade. Management involves clients with mild to moderate renal impairment, and are exercise, weight loss, and a more healthful diet. Alpha- glucosidase inhibitors are excreted by the kidneys and accumulate in clients with renal impairment. However, Use in Older Adults dosage reduction is not helpful because the drugs act locally, within the GI tract. Metformin requires assess- General precautions for safe and effective use of antidiabetic ment of renal function before starting and at least annu- drugs apply to older adults, including close monitoring of ally during long-term therapy. In addition, older adults may have im- initially if renal impairment is present; it should be paired vision or other problems that decrease their ability to stopped if renal impairment occurs during treatment. They but increments should be made cautiously in clients with also may have other disorders and may take other drugs that renal impairment or renal failure requiring hemodialysis. For example, renal insuf- ﬁciency may increase risks of adverse effects with antidiabetic drugs; treatment with thiazide diuretics, corticosteroids, estro- Use in Hepatic Impairment gens, and other drugs may cause hyperglycemia, thereby in- creasing dosage requirements for antidiabetic drugs. There may be higher blood levels of insulin in With oral sulfonylureas, drugs with a short duration of ac- clients with hepatic impairment because less insulin tion and inactive metabolites are considered safer, especially may be degraded. Careful monitoring of blood glucose with impaired liver or kidney function. Therapy usually should levels and insulin dosage reductions may be needed to start with a low dose, which is then increased or decreased prevent hypoglycemia. Sulfonylureas should be used cautiously and Few guidelines have been developed for the use of newer liver function should be monitored. Insulin analogs appear to lized in the liver and hepatic impairment may result in have some advantages over conventional insulin. Acarbose, higher serum drug levels and inadequate release of he- miglitol, and metformin may not be as useful in older adults patic glucose in response to hypoglycemia. With glip- as in younger ones because of the high prevalence of impaired izide, initial dosage should be reduced in clients with renal function. Glyburide may cause hypoglycemia in clients with renal insufﬁciency because they have a longer clients with liver disease. With metformin, dosage should require no precautions with hepatic impairment because be based on periodic tests of renal function and the drug acarbose is metabolized in the GI tract and miglitol is not should be stopped if renal impairment occurs or if serum lac- metabolized. In addition, dosage should not be titrated to the clients with clinical or laboratory evidence of hepatic maximum amount recommended for younger adults. With the impairment because risks of lactic acidosis may be in- glitazones, older adults are more likely to have cardiovascu- creased. Meglitinides should be used cautiously and lar disorders that increase risks of ﬂuid retention and conges- dosage increments should be made very slowly, because tive heart failure. With meglitinides, effects were similar in serum drug levels are higher, for a longer period of time, younger and older adults during clinical trials. Glitazones have been associated with hepatoxicity and require monitoring of liver enzymes. The drugs should Use in Renal Impairment not be given to clients with active liver disease or a serum alanine aminotransferase (ALT) >2. It is difﬁcult to pre- ated, liver enzymes should be measured every 2 months dict dosage needs because, on the one hand, less insulin for 1 year, then periodically. On the other hand, muscles and possibly Use in Critical Illness other tissues are less sensitive to insulin, and this insulin resistance may result in an increased blood glucose level Insulin is more likely to be used in critical illness than any of if dosage is not increased. Reasons include greater ability to titrate to prevent dangerous hypoglycemia, especially in clients dosage needs in clients who are often debilitated and unsta- whose renal function is unstable or worsening. One important consideration with IV insulin tively participate in diabetes management. Some aspects of therapy is that 30% or more of a dose may adsorb into con- the nursing role include mobilizing and coordinating health tainers of IV ﬂuid or infusion sets. In addition, many critically care providers and community resources, teaching and sup- ill clients are unable to take oral drugs. Vigilant monitoring The person with diabetes has a tremendous amount of infor- is essential for any client who has diabetes and a critical illness.
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