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By Y. Sigmor. University of Missouri-Saint Louis.

This characteristic 632 SECTION 7 DRUGS AFFECTING HEMATOPOIESIS AND THE IMMUNE SYSTEM allows booster doses of antigen to increase antibody levels Immune Responses to Antigens and maintain active immunity against some diseases buy generic benicar 20 mg line arrhythmia examples. The immune response involves antigens that induce the for- Passive immunity occurs when antibodies are formed by mation of antibodies or activated T lymphocytes safe 10 mg benicar pulse pressure 120. The initial the immune system of another person or animal and trans- response occurs when an antigen is first introduced into the ferred to the host. B lymphocytes recognize the antigen as foreign and de- tected for several months by maternal antibodies received velop antibodies against it. Antibodies are proteins called im- through the placenta during gestation. Also, antibodies pre- munoglobulins that interact with specific antigens. These antibodies act against antigen–antibody complexes, agglutination or clumping of antigens immediately. Passive immunity is short-term, last- cells, neutralization of bacterial toxins, destruction of pathogens ing only a few weeks or months. Activated complement stimulates chemotaxis T lymphocytes in body tissues) and humoral immunity (of monocytes, neutrophils, basophils, and eosinophils) and the (mainly involving B lymphocytes and antibodies in the blood). With a later ex- nected, that virtually all antigens elicit both cellular and hu- posure to the antigen, antibody is rapidly produced. The number moral responses, and that most humoral (B cell) responses of exposures required to produce enough antibodies to bind a require cellular (T cell) stimulation. Thus, an allergic re- Although most humoral immune responses occur when action may occur with the second exposure or after several ex- antibodies or B cells encounter antigens in blood, some occur posures, when sufficient antibodies have been produced. The and function of other T lymphocytes and help to regulate anti- antibodies in body fluids other than blood are produced by a body production by B lymphocytes. T cells are involved in de- part of humoral immunity sometimes called the secretory or layed hypersensitivity reactions, rejection of tissue or organ mucosal immune system. The B cells of the mucosal system transplantats, and responses to neoplasms and some infections. The antibodies (mostly immunoglobulin A [IgA], some IgM and IgG) secreted at these sites act locally rather than systemically. IMMUNE CELLS This local protection combats foreign substances, especially pathogenic microorganisms, that are inhaled, swallowed, or Immune cells (Fig. When exposure to an antigen occurs and an im- mune response is aroused, WBCs move toward the antigen in Antigens a process called chemotaxis. Specific WBCs are granulocytes Antigens are the foreign (nonself) substances (eg, micro- (neutrophils, eosinophils, basophils), and nongranulocytes organisms, other proteins, or polysaccharides) that initiate (monocytes and lymphocytes). Antigens have specific sites that inter- role, neutrophils, monocytes, and lymphocytes are especially act with immune cells to induce the immune response. Granulo- number of antigenic sites on a molecule depends largely on cytes often contain inflammatory mediators or digestive en- its molecular weight. Sub- molecules (eg, animal danders, plant pollens, and most stances (eg, complement) released from infected or inflamed drugs) are incomplete antigens (called haptens) and cannot tissue cause neutrophils to migrate to the affected tissue. However, they have anti- WBCs arrive first, usually within 90 minutes of injury. They genic sites and can combine with carrier substances to be- localize the area of injury and phagocytize organisms or parti- come antigenic. In cles by releasing digestive enzymes and oxidative metabolites discussions of allergic conditions, antigens are often called that kill engulfed pathogens or destroy other types of foreign allergens. The number of neutrophils increases greatly during CHAPTER 42 PHYSIOLOGY OF THE HEMATOPOIETIC AND IMMUNE SYSTEMS 633 Pluripotential stem cells Pluripotential stem cells Committed stem cells CFU* blast cells CFU megakaryocytes CFU Lymphoid stem cells granulocytes/monocytes Erythrocytes Platelets Granulocytes Monocytes Neutrophils Macrophages Eosinophils Basophils T lymphocytes B lymphocytes (Thymus) T cell + antigen Memory cells Activated T cells (Bone marrow) Helper T cells Cytotoxic T cells Suppressor T cells B cell + antigen Plasma cells Memory cells Antibodies (immunoglobulins G, M, A, E, D) * CFU = colony-forming unit Figure 42–1 Hematopoiesis and formation of immune cells. These cells circulate in the blood- Each T or B lymphocyte reacts only with a specific type of stream for approximately 10 hours, then move into tissues antigen and is capable of forming only one type of antibody where they live for 1 to 3 days. When a specific antigen attaches to cell Eosinophils increase during allergic reactions and para- membrane receptors to form an antigen–antibody complex, sitic infections. In parasitic infections, they bind to and kill the complex activates the lymphocyte to form tremendous the parasites. In hypersensitivity reactions, they produce en- numbers of duplicate lymphocytes (clones) that are exactly zymes that inactivate histamine and leukotrienes and may like the parent cell. Clones of a B lymphocyte eventually se- produce other enzymes that destroy antigen–antibody com- crete antibodies that circulate throughout the body. Despite these generally beneficial effects, eosinophils a T lymphocyte are sensitized or activated T cells that are re- also may aggravate tissue damage by releasing cytotoxic leased into lymphatic ducts, carried to the blood, circulated substances. Basophils release histamine, a major chemical through all tissue fluids, then returned to lymphatic ducts and mediator in inflammatory and immediate hypersensitivity recirculated. Monocytes are the largest WBCs, and their life span is much longer than that of the neutrophils. Monocytes can phagocytize larger sizes T Lymphocytes and amounts of foreign material than neutrophils. In addi- tion to their activity in the bloodstream, monocytes can leave T lymphocytes are the primary regulators of immune re- blood vessels and enter tissue spaces (and then are called sponses because they direct the activities of B cells and fixed tissue macrophages), although they can again become macrophages.

Fluid re- symptoms of menopause) should discuss their individual tention and edema may occur and produce weight gain purchase benicar 20mg without prescription hypertension jokes. CLIENT TEACHING GUIDELINES Oral Contraceptives General Considerations ✔ Avoid pregnancy for approximately 3 to 6 months after ✔ Seek information about the use of oral contraceptives order 20mg benicar mastercard hypertension signs and symptoms. These inserts provide ✔ See a health care provider every 6 to 12 months for blood information about safe and effective use of the drugs. Cigarette smoking increases ✔ Take about the same time every day to maintain effective risks of blood clots in the legs, lungs, heart, or brain. If you forget to take one pill, take it as soon as ✔ Several medications may reduce the effectiveness of you remember. If you do not remember until the next oral contraceptives (ie, increase the likelihood of preg- scheduled pill, you can take two pills at once. These include several antibiotics (eg, ampicillin, miss two pills in a row, you may take two pills for the clarithromycin and similar drugs, rifampin, penicillin V, next 2 days. If you miss more than two pills, notify your sulfonamides [eg, Bactrim], tetracyclines, and antiseizure health care provider. Inform all health care providers who The drugs may cause photosensitivity, with increased like- prescribe medications for you that you are taking a birth lihood of sunburn after short periods of exposure. The drugs ✔ Be prepared to use an additional or alternative method of may cause fluid retention; decreasing salt intake may be birth control if a dose is missed, if you are unable to take helpful. For exam- redness, or swelling; chest pain; weakness or numb- ple, use a different method of birth control while taking an ness in an arm or leg; or sudden difficulty with seeing or antibiotic and for the remainder of that cycle. Compliance involves the willingness to on the therapeutic effects of the birth control pills? How should take the drugs as prescribed and to have examinations you advise her? What teaching can you provide that will help her of breasts and pelvis and blood pressure measurements remember to take her birth control pills regularly? Assessment also includes identi- fying clients in whom hormonal contraceptives are con- traindicated or who are at increased risk for adverse drug effects. These include alcohol, some benzodiazepines estrogen–progestin combinations (see Table 28–1). If one of these drugs is progestogenic, estrogenic, antiestrogenic, and andro- taken concurrently with an oral contraceptive, the drug may genic activity. Use in Specific Situations Emergency (Postcoital) Contraception Emergency contraception (ie, high doses of estrogen and Contraception progestin) may be used to avoid pregnancy after unprotected Estrogen and progestin contraceptive preparations are nearly sexual intercourse, especially for victims of rape or incest or 100% effective in preventing pregnancy. Some guidelines for women whose physical or mental health is threatened by their use include the following: pregnancy. It is most effective if started within 24 hours and • Numerous preparations are available, with different no later than 72 hours after exposure. The drugs are believed components and different doses of components, so that to act mainly by inhibiting ovulation. Smaller and Drug Administration (FDA) for postcoital contracep- amounts (eg, 20 mcg) may be adequate for small or tion, multiple tablets of several birth control pills are also ef- underweight women; larger amounts (eg, 50 mcg) may fective. When estro- Amounts include 4 tablets of Levlen, Lo-Ovral, Nordette, gen is contraindicated, a progestin-only contraceptive Triphasil, or Tri-Levlen, 2 tablets of Ovral, and 5 tablets of may be used. These are high doses and common adverse effects • Current products contain small amounts of estrogen and are nausea and vomiting. Antiemetic medication or repeat- cause fewer adverse effects than previous products. Women who take a hor- spite the decreased estrogen dosage, oral contraceptives monal contraceptive should probably ask the prescriber about may still be safest when administered to nonsmoking possible postcoital use. A woman who has not menstruated for a full year is considered menopausal, although symptoms of estrogen de- How Can You Avoid This Medication Error? Physiologic menopause results from Tami Smithford, a 19-year-old college student, comes into the col- the gradual cessation of ovarian function and the resultant lege health clinic to renew her prescription for oral contraceptives. Surgical menopause results When she is there, she complains of a sore throat and having a fever for the last 2 days. A culture for streptococcus is performed, from excision of both ovaries and the sudden loss of ovar- she is placed on ampicillin, and her oral contraceptives are re- ian estrogen. The nurse provides the following patient teaching: Take and other sites are still produced, the amount is insufficient ampicillin 500 mg (1 capsule) 4 times a day for 10 days. ERT prevents vasomotor instability (hot flashes) and Drink lots of fluids and get plenty of rest. A commonly prescribed regimen CHAPTER 28 ESTROGENS, PROGESTINS, AND HORMONAL CONTRACEPTIVES 421 is a conjugated estrogen (eg, Premarin) 0. The main function of the progestin is to progestins in postmenopausal women may be indicated for decrease the risk of endometrial cancer; thus, women who have management of menopausal symptoms.

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TOC uses five tools (current reality tree benicar 10mg discount blood pressure chart chart, con- flict resolution diagram benicar 10 mg cheap heart attack 22 years old, future reality tree, prerequisite tree, and transi- tion tree) in its ongoing improvement process (Heim 1999). Total Quality Management Total quality management (TQM) has been defined as a holistic approach to running an organization such that every facet earns the description qual- ity (Grandzol 1997). TQM systems range from the all inclusive (Pegels 1995) to the common sense and concise (Cohen and Brand 1993). Some are based on various dimensions of quality (Garvin 1987), whereas others stress management commitment, structure/strategy, training, problem identification, measurement, and culture (Talley 1991). Some emphasize TQM as a philosophy (Drummond 1992), whereas others proclaim that it represents a social revolution in the workplace (Hutchins 1992). Quality Im provem ent System s, Theories, and Tools 75 Tools, Methods, and Procedures: Tip of the Iceberg Model As with icebergs, where only a small portion is actually visible above the surface, what we see in an organization (behaviors, methods, practices) is only the tip of the iceberg. The visible part of the iceberg is supported by a large, unseen structure. Tools, methods, and procedures are analogous to the tip of the ice- berg. We can see them making a flowchart, plotting a control chart, or using a checklist. These tools and procedures are the logical results of systems and models that people put in place (knowingly and unknowingly). People may use several tools and procedures to make improvements, and these tools might form one part of an improvement system. Although we can observe people using the tools of the system, the system itself is invisible and can- not be observed. These systems come from theories that might be shared among many people who work together to improve quality, or they may come from ideas held by individuals. Several probing questions may be necessary to bring to the surface the underlying assumptions behind the systems in place. One of the difficult things about quality is explaining how a tool is different from a process or system. For example, the previous section described ISO 9000 and the Baldrige criteria. Neither are tools, but rather models that describe how tools can be used. Another example is the current emphasis on lean production and Six Sigma in U. Neither is actually a tool; both are systems that provide an effec- tive integration of many different tools. But had Six Sigma been introduced earlier in the quality revolution, it likely would not have been successful. Because many organizations have devel- oped greater levels of quality maturity over the past two decades they can now better understand Six Sigma. This section is not intended to be an all-inclusive reference for quality tools, but rather a summary of more than two dozen of the most widely used tools that have been organized into six categories: (1) basic; (2) management; (3) creativity; (4) statistical; (5) design; and (6) measurement. The first four are used primarily to help under- stand the process, identify potential causes for process performance prob- lems, and collect and display data indicating which causes are most prevalent. The last five tools are used for more precise data analysis; they can help identify trends, distribution, and relationships. Flowchart The flowchart is a map of each step of a process, in the correct sequence, showing the logical sequence for completing an operation. The flowchart is a good staring point for a team seeking to improve an existing process or attempting to plan a new process or system. Cause-and-Effect Diagram Cause-and-effect analysis is sometimes referred to as the Ishikawa, or fish- bone, diagram. In a cause-and-effect diagram, the problem (effect) is stated in a box on the right side of the chart, and likely causes are listed around major headings (bones) that lead to the effect. Cause-and-effect diagrams can assist in organizing the contributing causes to a complex problem (American Society for Quality 2000). Pareto Chart Vilfredo Pareto, an Italian economist in the 1880s, observed that 80 per- cent of the wealth in Italy was held by 20 percent of the population. Juran later applied this Pareto principle to other applications and found that 80 percent of the variation of any characteristic is caused by only 20 per- cent of the possible variables. A Pareto chart is a display of the frequency of occurrences that helps to show the vital few contributors to a prob- lem so that management can concentrate resources on correcting these major contributors (American Society for Quality 2000). Check Sheet Check (or tally) sheets are simple tools used to measure the frequency of events or defects over short intervals. This tool initiates the process of infor- mation gathering, is easy to use, can be applied almost anywhere, is easily taught to most people, and immediately provides data to help to under- stand and improve a process. Run Chart Run charts are plots of data, arranged chronologically, that can be used to determine the presence of some types of signals of special cause variation Quality Im provem ent System s, Theories, and Tools 77 in processes.

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Cardiovascular effects—cardiac dysrhythmias discount benicar 40 mg otc arrhythmia drugs, hypertension Tachycardia and hypertension are common; if severe or pro- longed generic benicar 20 mg fast delivery heart attack high 3000 miles from the south, myocardial ischemia or heart failure may occur. Prema- ture ventricular contractions and other serious dysrhythmias may occur. Propranolol (Inderal) or another beta blocker may be given to decrease heart rate and hypertension resulting from overdosage of adrenergic drugs. Excessive central nervous system (CNS) stimulation— These effects are more likely to occur with ephedrine or high doses nervousness, anxiety, tremor, insomnia of other adrenergic drugs. Sometimes, a sedative-type drug is given concomitantly to offset these effects. Rebound nasal congestion, rhinitis, possible ulceration of These effects occur with excessive use of nasal decongestant drugs. Drugs that increase effects of adrenergic drugs: Most of these drugs increase incidence or severity of adverse reactions. Also increased mydriasis and there- fore contraindicated with narrow-angle glaucoma. When these azid [Marplan]) drugs are given concurrently with adrenergic drugs, there is danger of cardiac dysrhythmias, respiratory depression, and acute hyper- tensive crisis with possible intracranial hemorrhage, convulsions, coma, and death. Effects of MAO inhibitors may not occur for sev- eral weeks after treatment is started and may last up to 3 weeks after the drug is stopped. Every client taking MAO inhibitors should be warned against taking any other medication without the advice of a physician or pharmacist. Sympathomimetics with CNS- coffee, tea, cola drinks; theophylline) stimulating properties (eg, ephedrine, isoproterenol) may produce excessive CNS stimulation with cardiac dysrhythmias, emotional disturbances, and insomnia. Drugs that decrease effects of adrenergics: (1) Anticholinesterases (eg, neostigmine [Prostigmin], Decrease mydriatic effects of adrenergics; thus, the two groups pyridostigmine [Mestinon]) and other cholinergic drugs should not be given concurrently in ophthalmic conditions. Therefore, epineph- rine should not be used to treat hypotension induced by these drugs. Why is it important to have epinephrine and other adren- Nursing Notes: Apply Your Knowledge ergic drugs readily available in all health care settings? Which adrenergic drug is the drug of choice to treat acute Answer: As an adrenergic agent, ephedrine stimulates both anaphylactic reactions? Why is inhaled epinephrine not a drug of choice for vasoconstriction of vessels in the nasal passage, thus decreasing long-term treatment of asthma and other bronchocon- nasal congestion. For a client who reports frequent use of OTC asthma How Can You Avoid This Medication Error? Mentally rehearse nursing interventions for various emer- must be diluted to a concentration of 1:10,000 (0. In an gency situations (anaphylaxis, acute respiratory distress, emergency situation, it is easy to pick up the concentration of ep- inephrine that is intended for intramuscular or subcutaneous cardiac arrest) in terms of medications and equipment use. Labeling on these preparations should include Not for IV needed and how to obtain them promptly. What signs and symptoms occur with overdose of non- solution in an emergency. Neurotransmission: The autonomic and basis for disease in adults and children, 3rd ed. Compare and contrast beta-adrenergic blocking in terms of effects on body tissues, indica- agents in terms of cardioselectivity, indications tions for use, nursing process implications, for use, adverse effects, and selected other principles of therapy, and observation of characteristics. Discuss principles of therapy and nursing tions for use, adverse effects, and selected process for using antiadrenergic drugs in other characteristics. Critical Thinking Scenario Joe Moore, 56 years of age, comes to the clinic with complaints of chest pain with exertion. His vital signs are blood pressure (BP) 194/88, pulse 92, respiration 18. His primary provider prescribes a selective beta blocker, atenolol (Tenormin), and schedules a follow-up visit in 2 weeks. What are the advantages of using a selective rather that a nonselective beta blocker? DESCRIPTION of antiadrenergic drug therapy is to suppress pathologic stim- ulation, not the normal, physiologic response to activity, stress, Antiadrenergic or sympatholytic drugs decrease or block the and other stimuli. Included here are receptors are blocked by adrenergic antagonists or when pre- clonidine and related centrally active antiadrenergic drugs, synaptic alpha2 receptors are stimulated by agonist drugs (see which are used primarily in the treatment of hypertension, and Chap. Most antiadrenergic drugs have antagonist (block- peripherally active agents (alpha- and beta-adrenergic block- ing) effects in which they combine with alpha1, beta1, beta2, or ing agents), which are used to treat various cardiovascular and a combination of receptors in peripheral tissues and prevent other disorders. A few uncommonly used antiadrenergic drugs adrenergic (sympathomimetic) effects. This results in a negative feedback type of mecha- normal body functioning, including regulation of blood pres- nism that decreases the release of additional norepinephrine. Therefore, the goal Thus, the overall effect is decreased sympathetic outflow 283 284 SECTION 3 DRUGS AFFECTING THE AUTONOMIC NERVOUS SYSTEM from the brain and antiadrenergic effects on peripheral tissues (ie, decreased activation of alpha and beta receptors by nor- epinephrine throughout the body). Receptor site Nerve ending on cell surface Alpha-Adrenergic Agonists and Blocking Agents Epinephrine Alpha2-adrenergic agonists inhibit the release of norepineph- and norepinephrine rine in the brain, thereby decreasing the effects of sympathetic nervous system stimulation throughout the body. Although clinical Beta adrenergic effects are attributed mainly to drug action at presynaptic blocking drug alpha2 receptors in the brain, postsynaptic alpha2 receptors in the brain and peripheral tissues (eg, vascular smooth muscle) may also be involved.

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