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Denial of excessive drinking and of • Risk for Injury: Infection 50mg minocycline overnight delivery infection treatment, hepatitis purchase generic minocycline online antibiotic resistant bacteria in dogs, AIDS related to use problems resulting from alcohol use is a prominent charac- of contaminated needles and syringes for IV drugs teristic of alcoholism; underreporting the extent of drug use is common in other types of drug abuse as well purchase minocycline line antibiotics for stubborn uti. Useful in- Planning/Goals formation includes each specific drug, the amount, the fre- • Safety will be maintained for clients impaired by alcohol quency of administration, and the duration of administration. If answers to general questions reveal problem areas, such • Information will be provided regarding drug effects and as long-term use of alcohol or psychotropic drugs, more treatment resources. For nurses who often encounter substance abusers, efforts to keep up • Administer prescribed drugs correctly during acute intox- with drug names and terminology may be helpful. For example, information may be obtained that rologic functions; mental status; and behavior at regular would indicate the likelihood of a withdrawal reaction, the intervals. These disorders may include infections, liver dis- arette smoke can precipitate or aggravate asthma and ease, accidental injuries, and psychiatric problems of upper respiratory disorders in children. These disorders may be caused by • Inform smokers with nonsmoking spouses or other mem- other factors, of course, and are nonspecific. Nursing Diagnoses Evaluation • Ineffective Coping related to reliance on alcohol or other • Observe for improved behavior (eg, less impulsiveness, drugs improved judgment and thought processes, commits no • Risk for Injury: Adverse effects of abused drug(s) injury to self or others). CHAPTER 15 SUBSTANCE ABUSE DISORDERS 249 Efforts to change attitudes and decrease demand Nursing Notes: Apply Your Knowledge for drugs can be made through education and coun- seling about such topics as drug effects and nondrug ways to handle the stresses and problems of daily life. She tells you she has tried to quit smoking many times be- fore but this time she is determined. She went to her physician for drinking alcoholic beverages and taking mind-altering a prescription for the patch and she even bought some nicotine drugs. Initially, conscious, voluntary choices are made gum at the drug store in case the cravings get really bad. Since This period varies somewhat, but drug dependence de- you are an RN, as well as the mother of a friend, what advice can velops in most instances only after prolonged use. When mind-altering drugs are prescribed for a legiti- mate reason, the client must use them in prescribed doses and preferably for a short time. Physicians can help prevent drug abuse by prescribing PRINCIPLES OF THERAPY drugs appropriately, prescribing mind-altering drugs in limited amounts and for limited periods, using nondrug Prevention of Alcohol measures when they are likely to be effective, educat- and Other Drug Abuse ing clients about the drugs prescribed for them, partic- ipating in drug education programs, and recognizing, Use measures to prevent substance abuse. Although there are as early as possible, clients who are abusing or are difficulties in trying to prevent conditions for which causes likely to abuse drugs. Nurses can help prevent drug abuse by administering individual measures may be helpful: drugs appropriately, using nondrug measures when pos- 1. Decrease the supply or availability of commonly sible, teaching clients about drugs prescribed for them, abused drugs. Most efforts at prevention have tried to and participating in drug education programs. For example, laws desig- resources for information and educational materials nate certain drugs as illegal and provide penalties for include the following: possession or use of these drugs. Other laws regulate National Institute on Drug Abuse circumstances in which legal drugs, such as opioid 6001 Executive Blvd analgesics and barbiturates, may be used. Also, laws Bethesda, MD 20892-9561 regulate the sale of alcoholic beverages. Many current attitudes seem to Information (NCADI) promote drug use, misuse, and abuse, including: Center for Substance Abuse Prevention a. The belief that a drug is available for every mental 5600 Fishers Lane and physical discomfort and should be taken in pref- Rockwall II erence to tolerating even minor discomfort. Conse- Rockville, MD 20857 quently, society has a permissive attitude toward Phone: (301) 443-0365 taking drugs, and this attitude is probably perpetuated E-Mail: nnadal@samhsa. Parents can help prevent drug abuse in their children by there are many appropriate uses of drugs, and clients minimizing their own use of drugs and by avoiding certainly should not be denied their benefits. Children are more likely to ficulties emerge when there is excessive reliance on use illegal drugs if their parents have a generally per- drugs as chemical solutions to problems that are not missive attitude about drug taking, if either parent amenable to chemical solutions. Pregnant women should avoid alcohol, nicotine, and by alcoholic beverages of some kind. The apparently prevalent view that drug abuse refers effects on the fetus. The acceptance and use of illegal drugs in certain subgroups of the population. This is especially Treatment measures for alcohol and other drug abuse are not prevalent in high school and college students. Even people who have been institutionalized 250 SECTION 2 DRUGS AFFECTING THE CENTRAL NERVOUS SYSTEM and achieved a drug-free state for prolonged periods are apt chanical ventilation. Removal of some drugs can be to resume their drug-taking behavior when released from the hastened by hemodialysis. Treatment of substance abuse may be complicated by holics Anonymous and Narcotics Anonymous, have been the presence of other disorders. For example, depres- more successful than health professionals in dealing with sion is common and may require antidepressant drug drug abuse. As a general rule, treatment depends on the type, ex- tent, and duration of drug-taking behavior and the particular Review and Application Exercises situation for which treatment is needed. Psychological rehabilitation efforts should be part of alcohol and other substance abuse? What are signs and symptoms of overdose with alcohol, Several approaches may be useful, including psy- benzodiazepine antianxiety or hypnotic agents, cocaine, chotherapy, voluntary groups, and other types of emo- and opiates? What are general interventions for treatment of drug over- several reasons. What are specific antidotes for opiate and benzodiazepine narcotics (naloxone). Second, there is a high risk of overdoses, and how are they administered? Which commonly abused drugs may produce life- are significant drawbacks to giving CNS stimulants threatening withdrawal reactions if stopped abruptly? How can severe withdrawal syndromes be prevented, Fourth, there is often inadequate information about the minimized, or safely managed? What are the advantages of treating substance abuse dis- ical indications for drug therapy, including treatment of orders in centers established for that purpose? Even when drug therapy is indicated, there are few guidelines for opti- SELECTED REFERENCES mal use. General care of clients with drug overdose is primarily disease management, 7th ed. In the review of natural prod- and circulation, until the drug is metabolized and elim- ucts, pp. The neurologic complications and be treated by inserting an artificial airway and me- consequences of ethanol use and abuse. Cardiovascular complications of co- Nursing Notes: Apply Your Knowledge caine use. Answer: Although you are not in a formal professional relation- Philadelphia: Lippincott Williams & Wilkins. Marijuana: A decade and a half later, still a crude health care provider if she has additional questions or concerns. Discuss reasons for decreased use of amphet- recognize, and treat stimulant overdose.

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Demeclocycline may be used to inhibit antidiuretic • For burns purchase minocycline 50 mg without a prescription flagyl antibiotic for sinus infection, assess the size of the wound cheap minocycline online american express bacteria growth temperature, amount and type hormone in the management of chronic inappropriate of drainage buy generic minocycline line virus free download, presence of edema, and amount of eschar. Additional uses include ulcerative colitis and uncommon infections such as chancroid, Nursing Diagnoses lymphogranuloma venereum, nocardiosis, toxoplasmosis, and • Risk for Injury: Hypersensitivity reaction, kidney, liver, trachoma. Topical sulfonamides are used in prevention of burn or blood disorders with sulfonamides wound infections and in treatment of ocular, vaginal, and other • Deficient Knowledge: Correct administration and use of soft tissue infections. For specific clinical indications of indi- tetracyclines, sulfonamides, and urinary antiseptics vidual drugs, see Drugs at a Glance: Sulfonamide Preparations. The client will: • Receive or self-administer the drugs as directed Contraindications to Use • Receive prompt and appropriate treatment if adverse ef- fects occur Both tetracyclines and sulfonamides are contraindicated in clients with renal failure. Tetracyclines are also contraindi- Interventions cated in pregnant women and in children up to 8 years of • During tetracycline therapy for systemic infections, mon- age. In the fetus and young child, tetracyclines are deposited itor laboratory tests of renal function for abnormal values. If given during ac- • During sulfonamide therapy, encourage sufficient fluids tive mineralization of these tissues, tetracyclines can cause to produce a urine output of at least 1200 to 1500 mL permanent brown coloring (mottling) of tooth enamel and daily. A high fluid intake decreases the risk of crystalluria can depress bone growth. With the exception of doxycy- (precipitation of drug crystals in the urine). The urinary Increased photosensitivity is a common side effect, and tract is normally sterile except for the lower third of the clients should be warned to take precautions against sun- urethra. Introduction of any bacteria into the bladder may burn while on these drugs. With in- than 2 months of age (except for treatment of congenital dwelling catheters, bacteria colonize the bladder and toxoplasmosis), and people who have had hypersensitivity produce infection within 2 to 3 weeks, even with metic- reactions to them or to chemically related drugs (eg, thi- ulous care. Sulfasalazine • When indwelling catheters must be used, measures to (Azulfidine) is contraindicated in people who are allergic decrease UTI include using a closed drainage system; to salicylates and people with intestinal or urinary tract keeping the perineal area clean; forcing fluids, if not con- obstruction. CHAPTER 36 TETRACYCLINES, SULFONAMIDES, AND URINARY AGENTS 543 levels (12 to 15 mg/100 mL) more rapidly. The amount traindicated, to maintain a dilute urine; and removing the is usually twice the maintenance dose. Urine pH is important in drug therapy with sulfonamides and irrigate the catheter unless obstruction is suspected. With sulfonamide therapy, alkaline urine increases • Force fluids in anyone with a UTI unless contraindicated. In ad- also increases the rate of sulfonamide excretion and dition, emptying the bladder frequently allows it to refill the concentration of sulfonamide in the urine. This decreases the bacterial popu- urine can be alkalinized by giving sodium bicarbon- lation of the bladder. Alkalinization is not needed with sulfisoxazole • Teach women to cleanse themselves from the urethral area (because the drug is highly soluble) or sulfonamides toward the rectum after voiding or defecating to avoid used to treat intestinal infections or burn wounds contamination of the urethral area with bacteria from the (because there is little systemic absorption). With mandelamine therapy, urine pH must be acidic helps cleanse the lower urethra and prevent UTI. At a higher pH, Evaluation mandelamine does not hydrolyze to formaldehyde, the antibacterial component. Urine can be acidified • Observe for improvement in signs of the infection for by concomitant administration of ascorbic acid. Urine cultures and sensitivity tests are indicated in sus- • Interview and observe for adverse drug effects. The best results are obtained with drug therapy indi- cated by the microorganisms isolated from each client. Culture and susceptibility studies are needed before Tetracyclines should not be used in children younger than tetracycline therapy is started because many strains of 8 years of age because of their effects on teeth and bones. In organisms are either resistant or vary greatly in drug sus- teeth, the drugs interfere with enamel development and may ceptibility. Cross-sensitivity and cross-resistance are cause a permanent yellow, gray, or brown discoloration. The oral route of administration is usually effective and tissue and may interfere with bone growth. Intravenous (IV) therapy is used when oral Systemic sulfonamides are contraindicated during late administration is contraindicated or for initial treat- pregnancy, lactation, and in children younger than 2 months. Tetracyclines decompose with age, exposure to light, tal transfer, in breast milk, or by direct administration, the and extreme heat and humidity. Because the break- drug displaces bilirubin from binding sites on albumin. As a down products may be toxic, it is important to store result, bilirubin may accumulate in the bloodstream (hyper- bilirubinemia) and central nervous system (kernicterus) and these drugs correctly. Few data are available regarding the effects of long-term or recurrent use of sulfamethoxazole in chil- Sulfonamides and Urinary Antiseptics dren younger than 6 years of age with chronic renal disease. With systemically absorbed sulfonamides, an initial prim (Bactrim, Septra), although trimethoprim has not been loading dose may be given to produce therapeutic blood established as safe and effective in children younger than 12 years of age. Some clinicians recommend that asymptomatic bacteriuria be treated in children younger than 5 years of age to decrease How Can You Avoid This Medication Error? Trimethoprim-sulfamethoxazole (Bactrim) DS bid is ordered for a client after urologic surgery. He takes no medications and reports an allergy to eggs, nuts, sulfa, and morphine. The unit dose provided Use in Older Adults from the pharmacy is a tablet containing 160 mg of trimethoprim and 800 mg of sulfamethoxazole. A major concern with the use of tetracyclines and sulfon- amides in older adults is renal impairment, which commonly 544 SECTION 6 DRUGS USED TO TREAT INFECTIONS CLIENT TEACHING GUIDELINES Oral Tetracyclines General Considerations Self-Administration ✔ Because tetracyclines inhibit rather than kill bacteria, ✔ Take most tetracyclines on an empty stomach, at least they must be taken correctly to achieve desired effects. Doxycycline and ✔ These drugs increase sensitivity to sunlight and risks minocycline may be taken with food (except dairy prod- of sunburn. These symptoms may indicate a need for changing or stopping the tetracycline. Except for doxycycline and minocy- antianabolic effect increases tissue breakdown (catabolism) cline, tetracyclines are contraindicated in clients with renal and the amount of waste products to be excreted by the kid- impairment. As with younger adults, a fluid intake of 2 L daily functioning kidneys, but waste products are retained when is needed to reduce formation of crystals and stones in the renal function is impaired. Severe skin reactions and bone mar- microbial drugs, doxycycline or minocycline may be given. Folic acid deficiency Systemic sulfonamides should probably be avoided in may also occur because both of the drugs interfere with folic clients with renal impairment, if other effective drugs are acid metabolism. Acute renal failure (ARF) has occurred when the drugs or their metabolites precipitated in renal tubules and caused obstruction. ARF is rarely associated with newer Use in Renal Impairment sulfonamides, which are more soluble than older ones, but has increased with the use of sulfadiazine to treat toxoplas- As discussed previously, most tetracyclines are contraindi- mosis in clients with acquired immunodeficiency syndrome cated in clients with renal impairment. Preventive measures include a fluid intake of 2 to tetracyclines inhibit protein synthesis in human cells. CLIENT TEACHING GUIDELINES Oral Sulfonamides General Considerations Self-Administration ✔ Sulfonamides inhibit rather than kill bacteria.

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Ribot-Ciscar minocycline 50 mg for sale antibiotics linked to type 2 diabetes, Vedel & Roll order minocycline 50 mg without prescription infection questions, 1989) buy discount minocycline 50mg on line xcell antimicrobial wound dressing, and there is a constant force of application to the mov- it is probable that Ruffini endings in joints do so as ing tendon (Cordo et al. Motor tasks and physiological Contracting muscles implications In contractingmuscles,fusimotordrivecanenhance the spindle response to vibration (Burke et al. First, the application of the vibra- Remote contractions may be of limited functional tor to the tendon is not exactly the same as in the significance, but the mechanisms responsible for relaxed state, secondly, the spread of the vibration the widespread reflex enhancement accompanying wave to the muscle belly is altered when the mus- such contractions have long been a matter of dis- cle contracts and the tendon stiffens, and thirdly, the pute, and the manoeuvre is important in the clin- contraction may not be associated with a sufficient ical examination. It was previously thought that per- increase in drive to offset these effects. Indeed, if formance of the Jendrassik manoeuvre potentiated thecontractionisareflexcontractiontothevibration tendonjerksinuninvolvednon-contractingmuscles (tonic vibration reflex, TVR), unloading is the rule, in duetowidespreadactivationofdynamic motoneu- human subjects (Burke et al. Similarly, the reflex potentiation accompany- (Clark, Matthews & Muir, 1981). These problems are ing other alerting stimuli, such as a warning cue, has even greater if overt movement occurs at the joint, been attributed to the same mechanism. However, because movement can displace the vibrator and attractive as it may be, this hypothesis is seriously because the responses of different endings are not flawed for a number of reasons. For (i) It is based on the belief that the H reflex is not example, the response of primary endings is maxi- potentiated to the same extent by the reinforcement malduringthestretchingphaseofpassiveoscillating manoeuvre. The effects of alternating passive movements on the spindle response to vibration. The response increases more gradually through subharmonics during the stretching phase to 1:2. With shortening, the response gradually decreases again through subharmonics. If a mechanism was responsible Increased spindle discharge for the reflex reinforcement, one would expect the during contraction effects on spindle activity to be large, not small, not restricted to a few afferents, and one would expect Evidence for activation of γ motoneurones all studies to have no difficulty demonstrating this When movement is prevented so that contractions same finding. Panel (b ) plots the size sure block experiments suggest that this increase in of the muscle afferent volley from soleus against the spindle discharge is mediated, at least in part, by the intensity of tendon percussion. The round symbols activation of motoneurones (Burke, Hagbarth & represent data when the subject was at rest and the Skuse,1979). Theunloadingreflexprovidesevidence triangles when the subject performed the Jendrassik that muscle afferent feedback (presumably mainly manoeuvre. There is no difference in the relation- of spindle origin) contributes to the maintenance ships. However, the manoeuvres were effective re- of motor firing during a tonic isometric contrac- inforcing manoeuvres because a tendon jerk tion. When a muscle is pulling against a fixed resis- occurred (filled symbols) with weaker percussion tancethatsuddenlygivesway,asilentperiodappears and a lesser afferent volley. Panel (c ) plots, for the in the EMG of the contracting muscle at a latency same data, the size of the reflex response against the appropriate for the withdrawal of Ia afferent support intensity of the afferent volley. Jendrassikmanoeuvre(triangles),thereflexresponse Thus, overall the fusimotor-driven inflow from pri- was obtained at lower threshold than at rest (circles) maryandsecondaryendingsduringavoluntarycon- and was larger for any given size of afferent volley. Decreased presynaptic inhibition of Ia terminals has been suggested (Zehr & Stein, 1999), but, if any- Spindle acceleration after the onset of EMG thing,presynapticinhibitionofIaterminalstosoleus motoneurones is slightly increased at the onset of With brisk phasic contractions, the increase in spin- abrisk ECR contraction (Meunier & Morin, 1989; dle discharge follows the appearance of EMG in the Chapter8,p. Teethclenchinghasbeenreported contracting muscle by up to 50 ms (Vallbo, 1971), to enhance the H reflexes of both soleus and tibialis evidence that is inconsistent with the follow-up anterior (as might be expected for a reinforcement length servo hypothesis (Merton, 1951, 1953; see manoeuvre) but also to decrease peroneal-induced Matthews, 1972). Attempts to produce consistent reciprocalIainhibitionofthesoleusHreflex(Takada spindle activation in advance of EMG by, e. However, reciprocal Ia viding a warning cue, by using biofeedback train- inhibition is only one of a number of circuits that ing or in learning paradigms, have been unsuc- could be involved in the reflex potentiation due to a cessful (Burke, McKeon, Skuse & Westerman, 1980; remote muscle contraction. Gandevia & Burke, 1985;Al-Falahe & Vallbo, 1988; 134 Muscle spindles and fusimotor drive (b) (a) (c) Fig. Effects of the Jendrassik manoeuvre on muscle afferent discharge and the size of the tendon jerk. During the Jendrassik manoeuvre, there is a descending excitatory influence that enhances reflex transmission to motoneurones (MN), but not (or minimally) to MNs. Taps that failed to produce a tendon jerk are shown as open symbols alongside the appropriate afferent volley size. Dashed lines are linear regression lines for the taps that produced reflex EMG. The data obtained during reinforcement manoeuvres (filled triangles) differ significantly (P < 0. Motor tasks – physiological implications 135 Al-Falahe, Nagaoka & Vallbo, 1990a,b;Vallbo & is shortening against a load, the discharge pattern Al-Falahe, 1990). Spindles in nearby inactive synergists may be amplitudeandvelocitybecausethefusimotoreffects unloaded (Vallbo, 1973, 1974;Burke et al. The discharge of muscle of movement (Bergenheim, Ribot-Ciscar & Roll, spindle endings in the contracting muscle declines 2000;Roll, Bergenheim & Ribot-Ciscar, 2000). Co- during long-lasting contractions by about one-third contractions may involve greater fusimotor drive to over 60 s, even when the presence of increasing EMG the contracting muscles than occurs during isolated activityindicatessomefatigue-MACROS-. During platform, there is little or no EMG activity in the unloaded phasic shortening contractions, it is likely pretibial muscles, there is a poorly sustained spin- that muscle spindle endings in the contracting mus- dle afferent activity, and manoeuvres that increase clewillbesilenced,andanyperceptualorreflexcues the reliance on the proprioceptive feedback do not will come from other receptors, particularly spin- significantly alter the fusimotor drive in the absence dles in the antagonist (see Ribot-Ciscar & Roll, 1998). However, when the receptor- Spindle endings in the contracting muscle may dis- bearing muscles are activated tonically or phasically charge, but this occurs after the appearance of the to maintain balance their contraction is accompan- first EMG potentials and before the limb has actually ied by an increase in fusimotor drive sufficient to commenced moving. Static fusimotor motoneurones the discharge of both primary and secondary spin- Possible role of the fusimotor system dle endings increases during voluntary contractions during normal movement (Figs. Further evidence indicating a of debate, and it is likely that its importance in the s action consists of an increase in static sensitivity, moment-to-moment control of movement differs in a decrease in the dynamic response of primary end- the cat and man – in part because of the species dif- ings to stretch (though this could be due to a change ferences discussed earlier (see pp. The view in the damping effect of the stiffness of muscle and that some movements can be initiated by first acti- tendon), and a loss of the pause in discharge that vating efferents is now rejected for both species, primaryendingsundergofollowingpassiveshorten- but the extent to which the fusimotor system pro- ing (Vallbo, 1973, 1974;Vallbo et al. In addi- vides a necessary support to voluntary contractions tion, there is an increase in the variability of spindle has not been clarified. Microneurography has been discharge, and the appearance of a negative serial used for ∼35 years, but in this time we have learnt a correlation between successive interspike intervals lot about what the fusimotor system does not do and (Burke, Skuse & Stuart, 1979), something that is a relatively little about its essential contribution to the feature of s drive (see Matthews & Stein, 1969; control of human movement. Role of afferent feedback Dynamic fusimotor motoneurones Is movement possible without afferent feedback? There is some evidence that d drive is increased in addition to s (Kakuda & Nagaoka, 1998). How- Movement is possible without any afferent feed- ever, the study compared the dynamic responses to back from the contracting muscle. This has been stretch of spindle endings in relaxed and contracting demonstrated in patients with large-fibre sensory muscles. Subjects were still able to activate motor axons directed to acutely dener- vated muscles and could voluntarily modulate their Skeleto-fusimotor motoneurones firing rates. There is also some evidence that voluntary activity activates motoneuronesinadditionto motoneu- Necessity for afferent feedback rones during wrist extension (Kakuda, Miwa & Nagaoka, 1998). This finding relied on the use of However, in the absence of afferent feedback, sub- spike-triggeredaveragingtodefineanEMGpotential jects were unable to maintain a steady discharge of closely linked to the afferent spikes, a technique that motoneurones, and the discharge rates in weak, Motor tasks – physiological implications 137 moderate and strong contractions were less than merely indicates that the nervous system will always those reached in control experiments on the same compensateaswellasitcanbeforethesystembreaks subjects. Afferent feedback is also critical when there Speculations on the functional role of drive areunexpecteddisturbancestomovement,suchthat in various motor tasks there is a mismatch between the intended and the achieved movement. Disturbances to the expected Accepting that muscle afferent feedback is critical movement trajectory may be external (due, e.