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The major mode of transmission is contamination of skin or environmental surfaces cheap beconase aq 200MDI overnight delivery allergy symptoms upon waking. The infected person, with viruses on the hands from contact with nasal secretions (eg, sneezing, THE COMMON COLD coughing), touches various objects (eg, doorknobs, faucet handles, telephones). The uninfected person touches these The common cold, a viral infection of the upper respiratory contaminated surfaces with the fingers and then transfers tract, is the most common respiratory tract infection. A cold often begins with dry, stuffy Cold viruses can survive for several hours on the skin and feelings in the nose and throat, an increased amount of clear hard surfaces, such as wood and plastic. As the mucous airborne spread from sneezing and coughing, but this source 728 CHAPTER 49 NASAL DECONGESTANTS, ANTITUSSIVES, AND COLD REMEDIES 729 is considered secondary. Once the viruses gain entry, the in- pharyngitis) and chronic obstructive pulmonary dis- cubation period is about 5 days, the most contagious period eases (eg, emphysema, chronic bronchitis). Because of the way cold viruses are duction or decreased ability to cough or otherwise re- spread, frequent and thorough handwashing (by both infected move secretions from the respiratory tract. Secretions and uninfected people) is the most important protective and may seriously impair respiration by obstructing airways preventive measure. Secretions also may cause atelectasis (a condition in which part of the lung is airless and col- SINUSITIS lapses) by blocking air flow, and they may cause or ag- gravate infections by supporting bacterial growth. Sinusitis is inflammation of the paranasal sinuses, air cells Respiratory disorders characterized by retention of se- that connect with the nasal cavity and are lined by similar mu- cretions include influenza, pneumonia, upper respiratory cosa. As in other parts of the respiratory tract, ciliated mucous infections, acute and chronic bronchitis, emphysema, and membranes help move fluid and microorganisms out of the acute attacks of asthma. This movement becomes predispose to secretion retention include immobility, impaired when sinus openings are blocked by nasal swelling, debilitation, cigarette smoking, and postoperative status. Symptoms may include moderate to severe headache, ten- DRUGS FOR RESPIRATORY derness or pain in the affected sinus area, and fever. DISORDERS Numerous drugs are available and widely used to treat the COMMON SIGNS AND SYMPTOMS symptoms of respiratory disorders. Many are nonprescription OF RESPIRATORY DISORDERS drugs and can be obtained alone or in combination products. Available products include nasal decongestants, antitussives, • Nasal congestion is manifested by obstructed nasal and expectorants. It is a prominent symptom of the common cold and rhinitis (including allergic rhinitis; see Chap. Nasal Decongestants Nasal congestion results from dilation of the blood ves- sels in the nasal mucosa and engorgement of the mu- Nasal decongestants are used to relieve nasal obstruction and cous membranes with blood. Adrenergic (sympathomimetic) drugs are most membranes are stimulated to increase mucus secretion. These agents re- Related symptomatic terms are rhinorrhea (secretions lieve nasal congestion and swelling by constricting arterioles discharged from the nose) and rhinitis (inflammation of and reducing blood flow to nasal mucosa. Oxymetazoline nasal mucosa, usually accompanied by nasal conges- (Afrin) is a commonly used nasal spray; pseudoephedrine tion, rhinorrhea, and sneezing). Rebound nasal swelling can occur • Cough is a forceful expulsion of air from the lungs. It is with excessive or extended use of nasal sprays (eg, >7 days, normally a protective reflex for removing foreign bodies, perhaps sooner). The cough reflex involves central tis associated with respiratory infections or allergies. Centrally, the cough center also may be used to reduce local blood flow before nasal in the medulla oblongata receives stimuli and initiates the surgery and to aid visualization of the nasal mucosa during reflex response (deep inspiration, closed glottis, buildup diagnostic examinations. Pe- These drugs are contraindicated in clients with severe hy- ripherally, cough receptors in the pharynx, larynx, tra- pertension or coronary artery disease because of their cardiac chea, or lungs may be stimulated by air, dryness of stimulating and vasoconstricting effects. A cough is traindicated for clients with narrow-angle glaucoma and productive when secretions are expectorated; it is non- those taking tricyclic or monoamine oxidase inhibitor anti- productive when it is dry and no sputum is expectorated. They must be used with caution in the presence Cough is a prominent symptom of respiratory tract of cardiac dysrhythmias, hyperthyroidism, diabetes mellitus, infections (eg, the common cold, influenza, bronchitis, glaucoma, and prostatic hypertrophy. Fell, an elderly man with a history of hypertension and dia- Many cold remedies are over-the-counter (OTC) formula- betes, has a cold.

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If he believes he has a disease order beconase aq 200MDI online allergy testing while on xolair, he will behave as if he has that disease. And as in this patient, if a person thinks he is a man, he will act as if he is a man. How else can we explain some people with severe disease who function so well, while others with little disease do so poorly? I became determined to learn how to change perceptions from unhealthy ones to healthy ones. My odyssey had washed me onto the shore of a strange land of parents, faculty, state legis- lators, fiscal officers, lawyers, and federal regulators; most of them were angry about something or wanted something. By the time I learned the language and mores of these strange people, I resigned. I had been dean for nearly five years when the average tenure was closer to two. Te sirens who had called me to medical administra- tion stopped singing their seductive songs. Te calmer and more familiar waters of clinical medicine called me again. As a state medical school, we had an obligation to consider the health of the people of the state. I began to wonder about the real causes of disease from a population basis. At the end of my deanship, I decided to redirect my clinical interests from pure endocrinology to a broader look at illness, par- ticularly at patients with symptoms but no medical disease. I had begun to ask myself, If these people do not have a medical disease, then what is their problem? He came from Pittsburgh, at the time a center and hub for faculty who were interested in the psychological as- pects of illness. Sapira led me patient by patient and week by week through an understanding of the fallacy of the mind-body dichot- omy. Before working with him, I had slowly begun to reject the dichotomy, but Sapira was able to reject it in a manner that also appealed to my need for scientific rigor. He was quick to point out that a stimulus or agent for disease was not limited to what could be visualized under a microscope or put in a test tube. Sounds, voices, sights, smells, colors, touches, and all the varied sensory stimuli that impinge on humans were legitimate material for scien- tific inquiry. Combine all of those into human communication and language and those complexes were equally legitimate material for scientific study—difficult, but amenable to direct observation and study. I came to fully understand that the mind and the body were one—not separated, not disconnected. Sitting above all the molecules, tissues, organs, and mind of the human body was an integrated person. Tis person was connected to a family and perhaps to a spouse, and the family was connected to some social structure and society at large. All this social structure impinged on the person, and the person impinged on the social structure. Tere was a continuum all the way from so- ciety to the person to the organs and even down to the molecules. George Engel (1977) posited such a continuum and hierarchy of interlocking subsystems in his classic paper Te Need for a New Medical Model: A Challenge for Biomedicine. It may seem strange that I am describing my transition from a belief that the mind and body were separated to one that saw no separation. Even today, some physicians still func- tion as if the body and mind are separate and disconnected entities. Tis erroneous view is part of the explanation for our excessive use of procedures and technology. In addition to having an integrated model of humans and dis- ease, Sapira was also a superb teacher of interviewing techniques.

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Also best beconase aq 200MDI allergy fever, do not work, stress management, and relaxation techniques keep the drug container at the bedside, because a person sedated by a previous dose may take additional doses. These mind- ✔ Try to identify and avoid factors that cause nervousness or altering, brain-depressant drugs should be taken only by insomnia, such as caffeine-containing beverages and stim- those people for whom they are prescribed. This may prevent or decrease the severity of ✔ Do not stop taking a Valium-related drug abruptly. With- nervousness or insomnia so that sedative-type drugs are drawal symptoms can occur. These drugs lose ✔ Most nerve pills and sleeping pills belong to the their effectiveness in 2–4 weeks if taken nightly, and same chemical group and have similar effects, including cause sleep disturbances when stopped. Thus, there is no logical reason (Zantac), a drug for heartburn and peptic ulcers. Ati- Self-Administration van, Xanax, Valium, and Restoril are commonly used ex- ✔ Follow instructions carefully about how much, how often, amples of this group, but there are several others as well. These drugs produce ✔ Inform all health care providers when taking a sedative- more beneficial effects and fewer adverse reactions type medication, preferably by the generic and trade when used in the smallest effective doses and for the names. This helps avoid multiple prescriptions of drugs shortest duration feasible in particular circumstances. Avoid smoking, ambulating without help, dri- ✔ Omit one or more doses if excessive drowsiness occurs ving a car, operating machinery, and other potentially haz- to avoid difficulty breathing, falls, and other adverse drug ardous tasks. It is not fully effective analgesics, sedating herbs such as kava and valerian, and until after 3–4 weeks of regular use; it is ineffective for the dietary supplement melatonin) while taking any anti- occasional use. An ✔ Take zolpidem on an empty stomach, at bedtime, because antihistamine that causes drowsiness is the active ingre- the drug acts quickly to cause drowsiness. CLIENT TEACHING GUIDELINES Antipsychotic Drugs Antipsychotic drugs are given to clients with schizophrenia, a ✔ These drugs should be tapered in dosage and discontin- chronic mental illness. Because of the nature of the disease, ued gradually; they should not be stopped abruptly. Assist or prompt the client to: General Considerations ✔ Take medications in the correct doses and at the correct times, to maintain blood levels and beneficial effects. If an antacid the desired results, when results can be expected, and is needed (eg, for heartburn), it should be taken 1 hour be- the tentative length of drug therapy. Antacids de- ✔ Maintain an adequate supply of medication to ensure crease absorption of these drugs from the intestine. Consistent blood levels are nec- ✔ Lie down for approximately an hour after receiving med- essary to control symptoms and prevent recurring episodes ication, if dizziness and faintness occur. Drowsiness, slowed thinking, and impaired muscle coordination are especially likely during the first thorough and frequent toothbrushing, drinking fluids, 2 weeks of drug therapy but tend to decrease with time. Mouth dryness is a com- ✔ Report unusual side effects and all physical illnesses, be- mon side effect of the drugs. Although it is usually not cause changes in drug therapy may be indicated. Alcohol and sleeping pills should with some of the drugs and may produce a sunburn-type be avoided because they may cause excessive drowsi- of skin reaction. In hot weather or climates, being taken by the client, to decrease risks of undesir- keep the client indoors and use air conditioning or fans able drug interactions. Describe the nursing role in preventing, recog- use, adverse effects, principles of therapy, and nizing, and treating overdoses of antidepres- nursing process implications. Analyze important factors in using anti- uptake inhibitors with tricyclic antidepressants. Critical Thinking Scenario Betty McGrath, 73 years of age, was recently widowed. She depended on her husband to handle their finances, maintain their home, and make major decisions. McGrath seems to be losing weight, stays home most of the time, complains she feels very tired, and sleeps much more than usual.

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In addition to drug therapy buy beconase aq 200MDI low price allergy medicine symptoms, prevention of sleep deprivation, Many drugs stimulate the CNS, but only a few are used regular sleeping and waking times, avoiding shift work, and therapeutically, and their indications for use are limited. Attention Deficit-Hyperactivity Disorder Narcolepsy ADHD is reportedly the most common psychiatric or neu- robehavioral disorder in children. It occurs before 7 years of Narcolepsy is a sleep disorder characterized by daytime sleep age and is characterized by persistent hyperactivity, a short at- attacks in which the victim goes to sleep at any place or any tention span, difficulty completing assigned tasks or school- time. Signs and symptoms also include excessive daytime work, restlessness, and impulsiveness. Such behaviors make drowsiness, fatigue, muscle weakness and hallucinations at it difficult for the child to get along with others (eg, family onset of sleep, and disturbances of nighttime sleep patterns. The members, peer groups, teachers) and to function in situations hazards of drowsiness during normal waking hours and sud- requiring more controlled behavior (eg, classrooms). Its cause is un- impulsiveness and inattention continue but hyperactivity is 251 252 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM not a prominent feature. A major criterion for diagnosing later sodium benzoate is occasionally used as a respiratory stimulant ADHD is a previous diagnosis of childhood ADHD. Central nervous system stimulants cause cardiac stimulation and thus are contraindicated in clients with cardiovascular dis- TYPES OF STIMULANTS orders (eg, angina, dysrhythmias, hypertension) that are likely to be aggravated by the drugs. They also are contraindicated Most CNS stimulants act by facilitating initiation and trans- in clients with anxiety or agitation, glaucoma, or hyper- mission of nerve impulses that excite other cells. They are usually contraindicated in clients with a somewhat selective in their actions at lower doses but tend to history of drug abuse. The major groups are amphetamines and related drugs, analeptics, and xanthines. Amphetamines increase the amounts of norepinephrine, INDIVIDUAL CENTRAL NERVOUS dopamine, and possibly serotonin in the brain, thereby pro- SYSTEM STIMULANTS ducing mood elevation or euphoria, increasing mental alert- ness and capacity for work, decreasing fatigue and drowsiness, Individual drugs are described below; dosages are listed in and prolonging wakefulness. Larger doses, however, produce Drugs at a Glance: Central Nervous System Stimulants. Overdoses can produce convulsions Amphetamines and Related Drugs and psychotic behavior. Amphetamines also stimulate the sympathetic nervous system, resulting in increased heart Amphetamine, dextroamphetamine (Dexedrine), and meth- rate and blood pressure, pupil dilation (mydriasis), slowed amphetamine (Desoxyn) are closely related drugs that share gastrointestinal motility, and other symptoms. They are more drugs reduce behavioral symptoms and may improve cognitive important as drugs of abuse than as therapeutic agents. Methylphenidate (Ritalin) is chemically related to am- Amphetamines are Schedule II drugs under the Controlled phetamines and produces similar actions and adverse effects. Substances Act and have a high potential for drug abuse and It is well absorbed with oral administration. These plasma levels occur in about 2 hours with immediate-release drugs are widely sold on the street and commonly abused (see tablets and about 5 hours with extended-release tablets. Amphetamine-related drugs (methylphenidate and dexme- Most of a dose is metabolized in the liver and excreted in urine. It is well absorbed with Analeptics are infrequently used (see doxapram and oral administration and reaches peak plasma levels in 1 to modafinil, below). Xanthines stimulate the cerebral cortex, increasing mental alertness and decreasing drowsiness and fatigue. Other effects include myocardial stimulation with increased cardiac output Analeptics and heart rate, diuresis, and increased secretion of pepsin and hydrochloric acid. Large doses can impair mental and physi- Doxapram (Dopram) is occasionally used by anesthesiolo- cal functions by producing restlessness, nervousness, anxiety, gists and pulmonary specialists as a respiratory stimulant. Although it increases tidal volume and respiratory rate, it also increases oxygen consumption and carbon dioxide production. Limitations include a short duration of action (5 to 10 minutes Indications for Use after a single intravenous [IV] dose) and therapeutic dosages near or overlapping those that produce convulsions. Endotra- Amphetamines and methylphenidate are used in the treatment cheal intubation and mechanical ventilation are safer and more of narcolepsy and ADHD. Dexmethylphenidate is indicated effective in relieving respiratory depression from depressant only for ADHD. Its ability to promote wakefulness is similar to that in nonprescription analgesics and stimulants that promote of amphetamines and methylphenidate, but its mechanism of wakefulness (eg, No-Doz). Like other CNS stimulants, it also has CHAPTER 16 CENTRAL NERVOUS SYSTEM STIMULANTS 253 Drugs at a Glance: Central Nervous System Stimulants Routes and Dosage Ranges Generic/Trade Name Indications for Use Adults Children Amphetamines Amphetamine Narcolepsy Narcolepsy: PO 5–60 mg/d in divided Narcolepsy: >6 y: PO 5 mg/d initially, ADHD doses increase by 5 mg/wk to effective dose ADHD: 3–5 y: PO 2. Usual dose, 15–25 mg daily, in 2 divided doses Amphetamine mixture (Adderall) ADHD Narcolepsy: PO 10 mg daily initially, >6y: ADHD, PO 5 mg 1–2 times daily, Narcolepsy increase if necessary increased if necessary Amphetamine-Related Drugs Dexmethylphenidate (Focalin) ADHD PO 2.

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