Etodolac

By P. Aschnu. Kenyon College.

Each day the patient losses: • 400 mL to 500 mL of water through evaporation from the skin generic etodolac 200mg overnight delivery. This means that each day the patient must take in between 1900 mL and 2400 mL of fluid in order to maintain fluid-electrolyte balance purchase etodolac 300 mg on line. However, dis- ease and the treatment of disease can increase the patient’s output of water requiring that the patient increase the intake of water. For example, a patient who has a fever loses as much as 15% more water than the normal daily water loss. That is, the patient loses between 2185 mL and 2760 mL of water each day when he or she has a fever. Potential nursing diagnoses for a patient that is receiving fluid volume replacement therapy are: • Risk for fluid volume excess. This can occur when the patient is given too much replacement fluid, fluid is infused too rapidly, or the volume is too much for the patient’s physical size or condition. The patient should be taught: • To recognize signs and symptoms of fluid volume excess and fluid volume deficit. Potassium Potassium is an electrolyte cation that is more prevalent inside cells than it is in extracellular fluid. It is used to transmit and conduct neurological impulses and to maintain cardiac rhythms. In order for a muscle to contract, the concentration of potassium inside the cell moves out and is replaced by sodium, which is the prevalent electrolyte out- side the cell (see Sodium). The concentration of potassium and sodium is maintained by the sodium-potassium pump found in cell membranes. Patients receive potassium from their diet and excrete potassium in urine (90%) and feces (8%). Serum potassium is measured to determine if the patient has a normal range of potassium. When this happens, the patient will exhibit specific signs and symptoms and the serum potassium will be outside the normal range. Hyperkalemia Hyperkalemia occurs when a patient has a serum potassium level greater than 5. A number of factors can cause this condition including: • Impaired renal excretion (most common). The nurse must respond quickly once signs and symptoms of hyperkalemia develop as the patient is at risk for seizures, injury related to muscle weakness, and cardiac arrhythmias. Hypokalemia Hypokalemia occurs when a patient has a serum potassium level of less than 3. The patient may have the following signs and symptoms when experienc- ing hypokalemia: • Leg cramps. The nurse must respond with the following interventions as the patient is a risk for injury related to muscle weakness and cardiac arrhythmias. Take with at least a half a glass of fluid (juice or water) because potassium is extremely irritating to the gastric and intestinal mucosa. The infusion should not exceed 10 to 20 mEq per hour or the patient may experience hyperkalemia and can experience cardiac arrest. Potassium Supplements Description 10% potassium chloride 20 mEq/15 mL oral 20% potassium chloride 40 mEq/16 mL oral 10% Kaochlor Oral Potassium triplex (potassium Oral, rarely used actetate, bicarbonate, citrate) Kaon (potassium gluconate) Enteric-coated tablet. Maintenance: 20 mEq in 1–2 divided dose Kaon-Cl (potassium chloride) Enteric-coated tablet. Maintenance: 20 mEq in 1–2 divided dose Slow-K (potassium chloride) Enteric-coated tablet. Maintenance: 8 mEq Kaochlor (potassium chloride) Correction: 40–80 mEq in 3–4 divided doses K-Lyte (potassium bicarbonate) Effervescent tablet. Correction: 40–80 mEq in 3–4 divided doses K-Lyte/Cl (potassium chloride) Effervescent tablet. Correction: 40–80 mEq in 3–4 divided doses K-Dur (potassium chloride) Effervescent tablet. Correction: 40–80 mEq in 3–4 divided doses Micro-K (potassium chloride) Effervescent tablet. Don’t give potassium if the patient suffers from renal insufficiency, renal failure, or Addison’s disease. Do not give potassium if the patient has hyper- kalemia, severe dehydration, acidosis, or takes potassium-sparing diuretics. Sodium Sodium is the major cation in extracellular fluid found in tissue spaces and ves- sels. Sodium plays an important role in the regeneration and transmission of nerve impulses and affects water distribution inside and outside cells. When it shifts into the cell, depolarization (contraction) occurs; when it shifts out of the cell, potas- sium goes back into the cell and repolarization (relaxation) occurs. The kidneys regulate the sodium balance by retaining urine when the sodium concentration is low and excreting urine when the sodium concentration is high.

Possible causes for shock Types of shock Example Hypovolaemic shock Blood loss Cardiogenic shock Myocardial infarction Extracardiac obstructive shock Pulmonary embolism Vasodilatory (distributive) shock Sepsis All these causes are possible in this woman with abdominal problems and a history of ischaemic heart disease order etodolac 400mg online. The fact that the cardiac output is high makes blood loss and cardiogenic shock unlikely generic etodolac 300 mg visa. The most likely cause is septic shock where peripheral vasodi- latation would lead to a high cardiac output but a falling blood pressure and rising pulse rate. Vasoconstriction and reduced blood flow occurs in certain organs, such as the kid- neys, leading to the term ‘distributive shock’ with maintained overall cardiac output but inappropriate distribution of blood flow. The rise in central temperature and the lack of a marked fall in peripheral temperature would fit with this cause of the shock. The patient was stabilized with fluid replacement and antibiotics before going to theatre where the diagnosis of ischaemic bowel from an embolus was confirmed. Arteriography can confirm the diagnosis but confirmation is often at laparotomy which is usually required to remove the necrotic bowel. She complains that her muscles feel stiff, and it is taking her longer than it did to walk to the local shops. She is anxious about these problems since she lives alone and has to do every- thing for herself. Her daughter has told her that it is becoming increasingly difficult to read the small writing in the letters she sends. She complains that she has been sleeping poorly and is, consequently, rather tired. She has generally increased muscle tone throughout the range of movement and equal in flexors and extensors. There is a slight tremor affecting mainly her right hand, which is suppressed when she tries to do something. When asked to walk she is a little slow to get started and has difficulty stopping and turning. Her writing shows micrographia secondary to the rigidity and slowness of movement. Beta-blockers can cause tiredness and slowness but not to the extent seen in this woman. This woman has Parkinson’s disease presenting with the classic triad of tremor, rigidity and hypokinesia. There is difficulty starting to walk (freezing) and the patient uses small steps and has difficulty stopping (festination). The characteristic pathological abnormality is degeneration of dopamine-secreting neurones in the nigrostriatal pathway of the basal ganglia. Parkinsonian features (parkinsonism) may occur in a variety of diseases: • Parkinson’s disease • postencephalitic parkinsonism • neuroleptic drug-induced Parkinson’s disease • parkinsonism in association with Alzheimer’s/multi-infarct dementia. Classification of tremor • Rest tremor: the tremor is worse at rest and is typical of parkinsonism. Benign essential tremor is not present at rest, but appears on holding the arms outstretched but is not worse on movement (finger–nose testing). There is usually a family history of tremor and the tremor is helped by alcohol and beta-blockers. It is usually caused by brainstem or cerebellar disease caused by such diseases as multiple sclerosis, localized tumours or spinocerebellar degeneration. Selegiline, an inhibitor of monoamine oxidase B may delay the need to start levodopa and may slow the rate of progression of the disease, but has significant side-effects. Levodopa is usually used in combination with a selective dopa decarboxylase inhibitor which does not cross the blood–brain barrier and reduces peripheral adverse effects. The commonest side-effects are nausea, vomiting, dizziness, postural hypotension and neuropsychiatric problems. After many years of treatment the effects tend to diminish and the patient may develop rapid oscillations in control – the ‘on–off’ effect. When these develop, a sustained release for- mulation of levodopa or a dopamine agonist, e. Because of the loss of effect with time, treatment should not be started too early. She should be assessed by a physiotherapist and occupational therapist and provided with advice and aids. This has progressed so that she is now short of breath on walking up one flight of stairs and walks more slowly on the flat than other people her age. She has two children aged 8 and 10 years and they have a cat and a rabbit at home. In the respiratory system expansion of the lungs seems to be reduced but sym- metrical. It is often difficult to be sure of the exact length of history when a symptom such as breathlessness has an insidi- ous onset. There is a history of asthma but the absence of wheezing or obstruction on the respiratory function tests rule that out.

If the carbon chain has less than its full number of hydrogen atoms generic etodolac 200mg with visa, the fatty acid is unsaturated (examples include margarine and vegetable oils) generic etodolac 200 mg with mastercard. Phospholipids, as the name suggests, contain phosphorus and often nitrogen and form a layer in the cell membrane. Steroids are fat-soluble compounds such as vitamins A or D and hormones that often serve to regulate metabolic processes. Glucose Fructose (C6H12O6) (C6H12O6) O H H H H H H H H H H H H H H H (a) Saturated Fatty Acids H O C C C C C C C C C C C C C C C H H H H H H H H H H H H H H H H O H H H H H H H H H H H H H H H H H Figure 1-5: (b) Unsaturated Fatty Acids H O C C C C C C C C C C C C C C C C C H Fatty acids. H H H H H H H H H H H H H Proteins: Among the largest molecules, proteins can reach molecular weights of some 40 million atomic units. The human body builds protein molecules using 20 different kinds of smaller molecules called amino acids (see Figure 1-6). Amino acids link together by peptide bonds to form long molecules called polypeptides, which then assemble into proteins. Examples of proteins in the body include antibodies, hemoglobin (the red pigment in red blood cells), and enzymes (catalysts that accelerate reactions in the body). Each nucleotide, in turn, is composed of a five-carbon sugar (deoxyri- bose or ribose), a phosphate group, and a nitrogenous base. Strand 1 Part I: Building Blocks of the Body 14 The following is an example question dealing with chemical reactions: Q. Nucleic acids Chapter 1: The Chemistry of Life 15 Cycling through Life: Metabolism Metabolism (from the Greek metabole, which means “change”) is the word for the myriad chemical reactions that happen in the body, particularly as they relate to gen- erating, storing, and expending energy. Catabolic reactions break food down into energy (memory tip: it can be cata- strophic when things break down). Anabolic reactions require the expenditure of energy to build up compounds that the body needs. The chemical alteration of mole- cules in the cell is referred to as cellular metabolism. Enzymes can be used as catalysts, accelerating chemical reactions without being changed by the reactions. Oxidation-reduction reactions are an important pair of reactions that occur in carbohy- drate, lipid, and protein metabolism (see Figure 1-10). When a substance is oxidized, it loses electrons and hydrogen ions, removing a hydrogen atom from each molecule. When a substance is reduced, it gains electrons and hydrogen ions, adding a hydrogen atom to each molecule. Oxidation and reduction occur together, so whenever one sub- stance is oxidized, another is reduced. The body uses this chemical-reaction pairing to transport energy in a process known as the respiratory chain, or the electron transport chain. All food carbohydrates are eventually broken down into glu- cose; therefore, carbohydrate metabolism is really glucose metabolism. The oxidation process in which energy is released from molecules, such as glucose, and transferred to other molecules is called cellular respiration. It occurs in three stages: glycolysis, the Krebs cycle, and the electron transport chain: 1. Glycolysis From the Greek glyco (sugar) and lysis (breakdown), this is the first stage of both aerobic (with oxygen) and anaerobic (without oxygen) respiration. Taking place in the cell’s cytoplasm (see Chapter 2), glycolysis doesn’t require oxygen to occur. Krebs cycle Also known as the tricarboxylic acid cycle or citric acid cycle, this series of energy- producing chemical reactions begins in the mitochondria after pyruvate arrives from glycolysis. Before the Krebs cycle can begin, the pyruvate loses a carbon dioxide group to form acetyl coenzyme A (acetyl CoA). During the conversion, two carbon atoms are lost as carbon dioxide and energy is released. The cycle goes through eight steps, rearranging the atoms of citric acid to produce different intermedi- ate molecules called keto acids. Electron transport chain The electron transport chain is a series of energy compounds attached to the inner mitochondrial membrane. Hydrogen from oxidized food sources attaches to coenzymes that in turn com- bine with molecular oxygen. Oxidative phosphorylation is important because it makes energy available in a form the cells can use. At the end of the chain, two positively charged hydrogen molecules combine with two electrons and an atom of oxygen to form water. Respiration Lipid metabolism only requires portions of the processes involved in carbohydrate metabolism. Lipids contain about 99 percent of the body’s stored energy and can be digested at mealtime, but as people who complain about fats going “straight to their hips” can attest, lipids are more inclined to be stored in adipose tissue — the stuff gen- erally identified with body fat. Those reactions continue to strip two carbon atoms at a time until the entire fatty acid chain is con- verted into acetyl CoA.

Nitrates relax some non-vascular or a controlled-release preparation of nifedipine) are often smooth muscles and therefore sometimes relieve the pain of used in this setting buy etodolac 200mg without prescription. This can be min- and the antiplatelet uses of aspirin and clopidogrel are dis- imized by omitting the evening dose of isosorbide mono- cussed in Chapter 30 discount etodolac 200 mg overnight delivery. There is no evidence that the efficacy of nitrate (or by removing a patch at night). Accordingly, the lower Use in ischaemic heart disease dose should be used routinely for chronic prophylaxis. In practice, even much higher doses given once Key points daily or every other day achieve considerable selectivity for platelet vs. Organic nitrates, infarction, including streptokinase, alteplase, reteplase and 2 nicorandil and Ca -antagonists do this by relaxing tenecteplase. Streptokinase works indirectly, combining with vascular smooth muscle, whereas β-adrenoceptor plasminogen to form an activator complex that converts the antagonists slow the heart. Treatment using streptokinase (usually low-molecular-weight heparin nowadays), which improve outcome, and with intravenous glyceryl with aspirin is effective, safe and relatively inexpensive. It is treated cost than streptokinase, such drugs have been used increas- by early (primary) angioplasty where this is available; ingly over streptokinase in recent years, because of the where not available, fibrinolytic drugs (with or without heparin/low-molecular-weight heparin) should be occurrence of immune reactions and of hypotension with given. Being a streptococcal protein, individuals who and clopidogrel, inhaled oxygen and opoids. Individuals eplerenone) each improve outcome in patients with ventricular dysfunction; whether the use of all three of who have previously received streptokinase (more than a few these treatment modalities in combination confers days ago) should not be retreated with this drug if they additional benefit over maximal dosage with one of reinfarct. The situation regarding previous streptococcal infec- these agents remains a matter of debate. Such infections (usually in the form of sore • After recovery from myocardial infarction, secondary throats) are quite common and often go undiagnosed; the prophylaxis is directed against atheroma, thrombosis (aspirin) and dysrhythmia (β-adrenoceptor antagonists, impact that such infections (along with more severe strepto- which also prevent re-infarction) and in some patients coccal infections, such as cellullitis or septicaemia) have on the is used to improve haemodynamics (angiotensin- efficacy of streptokinase treatment is uncertain, but likely to converting enzyme inhibitors, angiotensin receptor be significant. He should con- symptoms of active peptic ulcer disease or evidence of severe tinue to exercise, but would be wise to switch to a less liver disease (especially if complicated by the presence of extreme form of exertion. A long-acting nitrate may improve his exercise severe uncontrolled hypertension, have a significant bleeding tolerance, and low-dose aspirin will reduce his risk of diathesis, have suffered recent substantial trauma (including myocardial infarction. In view of the history of ulcer and vigorous chest compression during resuscitation) or require indigestion, consideration should be given to checking for invasive monitoring (e. The position Helicobacter pylori (with treatment if present) and/or reinsti- tution of prophylactic acid suppressant treatment. If ophthalmological advice is locally and immediately despite his high alcohol intake and regular exercise. It will available, this is no longer universally regarded as an absolute almost certainly necessitate some form of drug treatment contraindication to fibrinolysis. His blood pressure should improve with weight reduction and reduced alcohol intake. However, if it does not and if the angina persists despite the above measures, a β-adrenoceptor antagonist may be useful despite its undesirable effect on serum lipids. A 46-year-old advertising executive complains of exercise- related pain when playing his regular daily game of squash for the past three months. Postgraduate Medicine 2005; 118: that he drinks half a bottle of wine a day plus ‘a few gins’. Physical examination is notable only for obesity (body mass index 30kg/m2) and blood pressure of 152/106mmHg. Cardiac catheterization shows a significant narrow- ing of the left circumflex artery, but the other vessels are free from disease. The clini- is an endogenous fibrinolytic system that dissolves thrombus cal pharmacology of the anticoagulants and antiplatelet drugs is that has done its job. Anticoagulants inhibit the times go wrong, resulting in bleeding disorders, such as coagulation cascade. Their main use is to treat and prevent haemophilia or thrombocytopenic purpura, or in thrombosis. Coagulation involves the between platelet activation and the coagulation cascade, so it is sequential activation of a cascade of clotting factors which not surprising that anticoagulants can also have beneficial effects amplifies a small initial event to produce a macroscopic plug in the prevention of coronary artery disease, or that antiplatelet of fibrin. Each factor is present in blood as an inactive zymo- drugs have some (albeit a minor) effect on venous thrombosis. After activation (indicated by the letter ‘a’ after the Roman numeral that designates the zymogen), several of the Haemostasis is achieved by an exquisitely balanced series factors acquire proteolytic activity. The unfractionated prepara- least as safe and effective as unfractionated products, except tion is extracted from the lung or intestine of ox or pig, in patients with renal impairment. They have largely replaced unfractionated heparin in unfractionated heparin in a meta-analysis of six trials) and pul- therapy. They are at least as effective as unfractionated • to prevent formation of thrombus (e. It is administered • Administration should be stopped and the bleeding site either as an intravenous infusion (to treat established disease) compressed. Intramuscular • Protamine sulphate is given as a slow intravenous injection injection must not be used because it causes haematomas.