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At the other extreme arthritis in dogs symptoms uk order 60mg etoricoxib with amex, the hemolysis can be so severe that the resul- Chapter 33 Assessment and Management of Patients With Hematologic Disorders 893 should be emphasized rheumatoid arthritis deadly purchase etoricoxib 60mg free shipping. Corticosteroid therapy is not without significant risk arthritis worse at night discount etoricoxib 120mg mastercard, and patients need to be monitored closely for complications arthritis diet for humans order etoricoxib overnight. The short- and long-term complications of corticosteroid therapy are presented in Chart 33-4 and in Chap. The excessive iron is deposited in various organs, particularly the liver, myocardium, testes, thyroid, and pancreas. The actual incidence of hemochromatosis is unknown; however, hereditary hemochromatosis is diagnosed in 0. Recent data suggest that this defect may be a common cause of diabetes (Schechter, et al. Because of to their natural loss of iron through menses, women are less affected than men. Because the accumulation of iron in body organs occurs gradually, there often is no evidence of tissue injury until middle age. Symptoms of weakness, lethargy, arthralgia, weight loss, and loss of libido are common. The skin may be hyperpigmented with melanin deposits (occasionally hemosiderin, an iron-containing pigment) and appears bronze in color. Cardiac dysrhythmias and cardiomyopathy can occur, with resulting dyspnea and edema. Endocrine dysfunction is manifested as hypothyroidism, diabetes mellitus, and hypogonadism (testicular atrophy, diminished libido, and impotence). For example, several chemotherapy protocols include high doses of corticosteroids for a period of several days. In other conditions, such as idiopathic thrombocytopenic purpura or hemolytic anemias, the corticosteroids are very carefully tapered to prevent a flare up of the underlying disease. With the exception of patients with preexisting conditions such as diabetes, hypertension, and osteoporosis, it is difficult to predict which complications will occur in a given patient. Patients who receive high doses of corticosteroids for longer than a few weeks should be screened for symptoms related to the potential complications listed here. If at all possible, patients who require long-term corticosteroid use should be switched to an alternate-day dosing schedule; this method may diminish the severity of complications that arise. The most useful laboratory findings are an elevated serum iron level and high transferrin saturation (more than 60% in men, more than 50% in women). Patients who are homozygous for the gene are at high risk for development of the disorder. The median survival time exceeds 15 years (Gruppo Italiano Studio Policitemia, 1995). Clinical Manifestations Patients typically have a ruddy complexion and splenomegaly (enlarged spleen). The symptoms result from the increased blood volume (headache, dizziness, tinnitus, fatigue, paresthesias, and blurred vision) or from increased blood viscosity (angina, claudication, dyspnea, and thrombophlebitis), particularly if the patient has atherosclerotic blood vessels. Another common and bothersome problem is generalized pruritus, which may be caused by histamine release due to the increased number of basophils. Erythromelalgia, a burning sensation in the fingers and toes, may be reported and is only partially relieved by cooling. Medical Management Therapy involves the removal of excess iron via therapeutic phlebotomy (removal of whole blood from a vein). To achieve this, a frequent phlebotomy schedule is required (1 to 2 units weekly), with a gradual reduction in frequency of phlebotomies over a 1- to 3-year period. After 1 to 3 years, the frequency of phlebotomy can be reduced to 1 unit of blood every several months to prevent reaccumulation of iron deposits. Removal of excess iron appears to diminish the severity of diabetes and skin hyperpigmentation; cardiac function also tends to improve. The erythropoietin level is not as low as would be expected with an elevated hematocrit; it is normal or only slightly low. Nursing Management Patients with hemochromatosis often believe that it is important to limit their dietary intake of iron, although this management method has been shown to be very ineffective and need not be encouraged.

If the disease is detected and treated at an early stage arthritis age purchase line etoricoxib, the 5-year survival rate is 90% arthritis diet natural cure etoricoxib 120mg generic, but only 34% of colorectal cancers are found at an early stage arthritis in the feet and knees discount etoricoxib generic. Most people are asymptomatic for long periods and seek health care only when they notice a change in bowel habits or rectal bleeding arthritis diet pain cheap 60mg etoricoxib. Prevention and early screening are key to detection and reduction of mortality rates. Assessment and Diagnostic Findings Along with an abdominal and rectal examination, the most important diagnostic procedures for cancer of the colon are fecal occult blood testing, barium enema, proctosigmoidoscopy, and colonoscopy (see Chap. As many as 60% of colorectal cancer cases can be identified by sigmoidoscopy with biopsy or cytology smears (Yamada et al. Pathophysiology Cancer of the colon and rectum is predominantly (95%) adenocarcinoma (ie, arising from the epithelial lining of the intestine). It may start as a benign polyp but may become malignant, invade and destroy normal tissues, and extend into surrounding structures. Cancer cells may break away from the primary Complications Tumor growth may cause partial or complete bowel obstruction. Extension of the tumor and ulceration into the surrounding blood vessels results in hemorrhage. Among women, only breast cancer exceeds the incidence of colorectal cancer (Lueckenotte, 2000). Cancer patients usually report fatigue, which is caused primarily by iron-deficiency anemia. In early stages, minor changes in bowel patterns and occasional bleeding may occur. The later symptoms most commonly reported by the elderly are abdominal pain, obstruction, tenesmus, and rectal bleeding. Lack of fiber is a major causative factor because the passage of feces through the intestinal tract is prolonged, which extends exposure to possible carcinogens. Excess fat is believed to alter bacterial flora and convert steroids into compounds that have carcinogenic properties. Treatment for colorectal cancer depends on the stage of the disease (Chart 38-8) and consists of surgery to remove the tumor, supportive therapy, and adjuvant therapy. Data demonstrate delays in tumor recurrence and increases in survival time for patients who receive some form of adjuvant therapy-chemotherapy, radiation therapy, immunotherapy, or multimodality therapy. Radiation therapy is used before, during, and after surgery to shrink the tumor, to achieve better results from surgery, and to reduce the risk of recurrence. For inoperative or unresectable tumors, irradiation is used to provide significant relief from symptoms. Laparoscopic colotomy with polypectomy minimizes the extent of surgery needed in some cases. A laparoscope is used as a guide in making an incision into the colon; the tumor mass is then excised. Bowel resection is indicated for most class A lesions and all class B and C lesions. Surgery is sometimes recommended for class D colon cancer, but the goal of surgery in this instance is palliative; if the tumor has spread and involves surrounding vital structures, it is considered nonresectable. A temporary loop ileostomy is constructed to divert intestinal flow, and the newly constructed J pouch (made from 6 to 10 cm of colon) is reattached to the anal stump. About 3 months after the initial stage, the ileostomy is reversed, and intestinal continuity is restored. It allows the drainage or evacuation of colon contents to the outside of the body. The consistency of the drainage is related to the placement of the colostomy, which is dictated by the location of the tumor and the extent of invasion into surrounding tissues. With improved surgical techniques, colostomies are performed on fewer than one third of patients with colorectal cancer.

Frequent (every 2 to 4 hours initially) electrocardiograms and laboratory measurements of potassium are necessary during the first 8 hours of treatment initial signs of arthritis in fingers cheap etoricoxib 90mg otc. Potassium replacement is withheld only if hyperkalemia is present or if the patient is not urinating rheumatoid arthritis kill you buy etoricoxib 60mg without prescription. In addition arthritis pain relief walgreens buy generic etoricoxib 90 mg on line, fluid replacement enhances the excretion of excessive glucose by the kidneys arthritis in back of neck order generic etoricoxib on-line. After the first few hours, half-normal saline solution is the fluid of choice for continued rehydration, if the blood pressure is stable and the sodium level is not low. Moderate to high rates of infusion (200 to 500 mL per hour) may continue for several more hours. Monitoring fluid volume status involves frequent measurements of vital signs (including monitoring for orthostatic changes in blood pressure and heart rate), lung assessment, and monitoring intake and output. Monitoring for signs of fluid overload is especially important for older patients, those with renal impairment, or those at risk for heart failure. Insulin is usually infused intravenously at a slow, continuous rate (eg, 5 units per hour). Thus, an initial insulin infusion rate of 5 units per hour would equal 25 mL per hour. The insulin is often infused separately from the rehydration solutions to allow frequent changes in the rate and content of rehydration solutions. Insulin must be infused continuously until subcutaneous administration of insulin resumes. Any interruption in adminis- Chapter 41 Assessment and Management of Patients With Diabetes Mellitus 1183 tration may result in the reaccumulation of ketone bodies and worsening acidosis. Even if blood glucose levels are dropping to normal, the insulin drip must not be stopped; rather, the rate or concentration of the dextrose infusion should be increased. The basic biochemical defect is lack of effective insulin (ie, insulin resistance). To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. This condition occurs most often in older people (ages 50 to 70) with no known history of diabetes or with mild type 2 diabetes. Instead, they may tolerate polyuria and polydipsia until neurologic changes or an underlying illness (or family members or others) prompts them to seek treatment. Urine output is monitored to ensure adequate renal function before potassium is administered to prevent hyperkalemia. The electrocardiogram is monitored for dysrhythmias indicating abnormal potassium levels. Vital signs, arterial blood gases, and other clinical findings are recorded on a flow sheet. The mortality rate ranges from 10% to 40%, usually related to an underlying illness. The blood glucose level is usually 600 to 1,200 mg/dL, and the osmolality exceeds 350 mOsm/kg. Mental status changes, focal neurologic deficits, and hallucinations are common secondary to the cerebral dehydration that results from extreme hyperosmolality. The patient is asked to describe symptoms that preceded the diagnosis of diabetes, such as polyuria, polydipsia, polyphagia, skin dryness, blurred vision, weight loss, vaginal itching, and nonhealing ulcers. The blood glucose and, for patients with type 1 diabetes, urine ketone levels are measured. Laboratory values are monitored for metabolic acidosis (ie, decreased pH and decreased bicarbonate level) and for electrolyte imbalance. Once these complications are resolving, nursing care then focuses on long-term management of diabetes, as discussed in this section. Other therapeutic modalities are determined by the underlying illness of the patient and the results of continuing clinical and laboratory evaluation. Treatment is continued until metabolic abnormalities are corrected and neurologic symptoms clear. The patient is asked about major concerns and fears about diabetes; this allows the nurse to assess for any misconceptions or misinformation regarding diabetes. Coping skills are assessed by asking how the patient has dealt with difficult situations in the past. Any misconceptions the patient or family may have regarding diabetes are dispelled (see Table 41-7).

The sedative thalidomide (Thalomid) arthritis treatment knee exercises buy etoricoxib with a mastercard, initially used as an antiemetic arthritis rheumatoid buy etoricoxib online from canada, has significant antimyeloma effects treat arthritis neck purchase etoricoxib 60 mg on line. Thalidomide is effective in refractory myeloma and in "smoldering" disease states arthritis medication while pregnant generic 120mg etoricoxib, and may prevent progression to a more active state. Thalidomide is not a typical chemotherapeutic agent and has a unique side effect profile. Fatigue, dizziness, constipation, rash, and peripheral neuropathy are commonly encountered; myelosuppression is not (Goldman, 2001). Thalidomide is contraindicated in pregnancy because of associated severe birth defects. Patients need to be educated about activity restrictions (eg, lifting no more than 10 pounds, use of proper body mechanics). Patients also need to be instructed about the signs and symptoms of hypercalcemia. Maintaining mobility and hydration is important to diminish exacerbations of this complication; however, the primary cause is the disease itself. Maintaining high urine output (3 L/day) can be very useful in preventing this complication. Because antibody production is impaired, infections, particularly bacterial infections, are common and can be life-threatening. Patients need to be instructed in appropriate infection prevention measures (see Chart 33-8) and should be advised to contact their health care provider immediately if they have a fever or other signs and symptoms of infection. However, for many patients, it is possible to control the illness and maintain their level of functioning quite well for several years or longer. Radiation therapy is very useful in strengthening a specific bone lesion, particularly one at risk for bone fracture or spinal cord compression. It is also useful in relieving bone pain and reducing the size of plasma cell tumors that occur outside the skeletal system. However, because it is a nonsystemic form of treatment, it does not diminish the source of the bone problems (ie, the production of malignant plasma cells). Therefore, radiation therapy is typically used with systemic treatment such as chemotherapy. The biologic agent alpha-interferon has been used successfully to maintain remission in selected types of myeloma, particularly IgA type; however, its role in prolonging survival is controversial. Newer forms of bisphosphonates, such as pamidronate (Aredia) and zoledronic acid (Zometa), have been shown to strengthen bone Bleeding Disorders Normal hemostatic mechanisms can control bleeding from vessels and prevent spontaneous bleeding. The bleeding vessel constricts and platelets aggregate at the site, forming an unstable hemostatic plug. Circulating coagulation factors are activated on the surface of these aggregated platelets, forming fibrin, which anchors the platelet plug to the site of injury. This bleeding is commonly provoked by trauma, but in certain circumstances it can occur spontaneously. When the source is platelet or coagulation factor abnormalities, the site of spontaneous bleeding can be anywhere in the body. When the defect is caused by vascular abnormalities, the site of bleeding may be more localized. In a variety of situations, the bone marrow may be stimulated to increase platelet production (thrombopoiesis). The increased production may be a reactive response, as in a compensatory response to significant bleeding, or a more general response to increase hematopoiesis, as in iron deficiency anemia. Sometimes, the increase in platelets does not result from increased production but from a loss in platelet pooling within the spleen. The spleen typically holds about one third of the circulating platelets at any time. If the spleen is lost (eg, splenectomy), the platelet reservoir is also lost, and an abnormally high amount of platelets enter the circulation.

The amount of oxygen delivered is expressed as a percentage concentration (eg rheumatoid arthritis and depression discount 90mg etoricoxib, 70%) arthritis in neck prevention 120mg etoricoxib sale. These systems do not provide a constant or known concentration of inspired oxygen arthritis in back and legs order etoricoxib 90 mg with mastercard. Examples of low-flow systems include nasal cannula arthritis treatment center buy generic etoricoxib canada, oropharyngeal catheter, simple mask, and partial-rebreather and non-rebreather masks. High-flow systems are indicated for patients who require a constant and precise amount of oxygen. Examples of such systems include transtracheal catheters, Venturi the blood at these levels is 80% to 98% saturated with oxygen; higher inspired oxygen flow (FiO2) values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation (see discussion below). It is important to observe for subtle indicators of inadequate oxygenation when oxygen is administered by any method. Therefore, the nurse assesses the patient frequently for confusion, restlessness progressing to lethargy, diaphoresis, pallor, tachycardia, tachypnea, and hypertension. It is caused by overproduction of oxygen free radicals, which are byproducts of cell metabolism. If oxygen toxicity is untreated, these radicals can severely damage or kill cells. Antioxidants such as vitamin E, vitamin C, and beta-carotene may help defend against oxygen free radicals (Scanlan, Wilkins & Stoller, 1999). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, and alveolar infiltrates evident on chest x-rays. A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. This method is relatively simple and allows the patient to move about in bed, talk, cough, and eat without interrupting oxygen flow. Flow rates in excess of 6 to 8 L/min may lead to swallowing of air; this may cause irritation and drying of the nasal and pharyngeal mucosa. The oropharyngeal catheter is rarely used but may be prescribed for short-term therapy to administer low to moderate concentrations of oxygen. The catheter should be changed every 8 hours, alternating nostrils to prevent infection and nasal irritation. When oxygen is administered via cannula or catheter, the percentage of oxygen reaching the lungs varies with the depth and rate of respirations, particularly if the nasal mucosa is swollen or if the patient is a mouth breather. If oxygen flow ceases, the patient can draw air in through these openings around the mask edges (Scanlan, Wilkins & Stoller, 1999). Although widely used, these masks cannot be used for controlled oxygen concentrations and must be adjusted for proper fit. They should not press too tightly against the skin, because this may cause a sense of claustrophobia and skin breakdown; adjustable elastic bands are provided to ensure comfort and security. Partial-rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse should adjust the liter flow to ensure that the bag does not collapse during inhalation. A higher concentration of oxygen can be delivered because both the mask and bag serve as reservoirs for oxygen. Oxygen enters the mask through small-bore tubing that connects at the junction of the mask and bag. As the patient inhales, gas is drawn from the mask, the bag, and potentially from room air through the exhalation ports. As the patient exhales, the first third of the exhalation fills the reservoir bag. Non-rebreathing masks are similar in design to partialrebreathing masks except that they have two valves.

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