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However purchase 500mg cefuroxime overnight delivery, pressure area care interventions should be planned against risks from stimulation cefuroxime 500mg free shipping. Any positions impeding jugular venous drainage 250 mg cefuroxime free shipping, such as head rotation (Hudak et al. Slight head elevation encourages venous drainage, so reducing intracranial hypertension. Lockhart-Wood 1996)), but most emphasise the need for individual assessment (Chudley 1994; Simmons 1997) based on parameters such as intracranial and cerebral perfusion pressures. Patients should be positioned to minimise risk from falls, furniture or equipment. Patients with raised intracranial pressure are often hypersensitive to environmental stimuli, developing photophobia. Unless otherwise indicated, it is generally kinder to reduce light levels to the minimum necessary. Hyperthermia increases metabolic rate, so increasing ■ reduces intracranial blood flow ■ intracranial pressure (each extra degree centigrade increases cerebral blood flow by 6 per cent (Hickey 1997a) ■ cerebral oxygen consumption in already hypoxic tissue; antipyretic drugs (e. Hyperglycaemia increases osmotic pressure, so provoking ischaemia; hypoglycaemia deprives neurones of fuel. Drugs used therefore include: Neurological monitoring and intracranial hypertension 227 analgesia : for comfort and to reduce agitation which would increase intracranial pressure sedative agents : while sedation both provides comfort and reduces intracranial pressure, it makes pupil assessment unreliable (Price 1998). As thiopentone is negatively inotrope, reducing cerebral perfusion pressure and increasing intracellular acidosis (Price 1992), its use remains controversial (Hall 1997). Propofol reduces intracranial hypertension through systemic hypotension, but may reduce cerebral perfusion pressure (Hall 1997) and so is usually avoided. Fluid management Cerebral oedema, responsible for most complications of intracranial hypertension, is aggravated by movement of intravascular proteins into intracellular fluid. The resulting rise in intracellular osmotic pressure can be effectively countered with osmotic diuretics. With repeated doses, osmotic diuretics may cross the blood-brain barrier, reversing osmotic pressures to draw further plasma into extravascular spaces (Adam & Osborne 1997). Twenty per cent mannitol has replaced earlier osmotic diuretics (Allen & Ward 1998). Its effect begins within 15 to 30 minutes and can last for up to six hours (Allen & Ward 1998). Transfer of water from intracellular to intravascular compartments may cause hyperkalaemia, while reduced renal water reabsorption may cause hypernatraemia (Wingard et al. One per cent of patients with head injuries develop diabetes insipidus (Matta & Menon 1997) from direct pituitary pressure/damage. While easily detected, fluid replacement to prevent total body dehydration (to keep serum osmolarity below 320 mmol/l) must be incorporated with fluid management to treat intracranial hypertension. Fluid replacement should be limited to 3 litres/day, with no more than 1 litre being crystalloid (Smith 1994). Nasogastric tubes could herniate through existing fractures into brain tissue, and so until base of skull fractures have been definitively excluded, oral rather than nasal tubes should be used. Additional pituitary gland control can be disrupted by head injury, central nervous system infection, intracranial hypertension and other factors. Family support Presence of anyone can cause stress or provide reassurance/relaxation. Studies of how conversation affects intracranial pressure remain inconclusive; familiar voices, such as family, may reduce anxiety (Odell 1996), but more studies suggest they have no significant effect (Treloar et al. Where visitors do cause undue distress, nurses may need to intervene to enable patients to rest, but visits that provide therapeutic benefits should be encouraged. Good nursing documentation can be a valuable means to communicate the effects of visitors. While the prime duty of nurses is to their patients, care of relatives is an important, albeit secondary, nursing role. They also need adequate rest themselves; they may feel obliged to stay by the bedside, exhausting both themselves and the patient; thus, planning care with the next-of-kin can prove beneficial to all. Providing somewhere to stay and access to catering facilities can greatly reduce the stress experienced by relatives. More invasive methods of assessment inevitably incur greater risks, but may provide more useful information to guide treatment. As with monitoring any aspect of patient care, benefits and burdens of each approach should be individualised to the patient, and justified by the extent to which they usefully guide treatments and the care given. Further reading Menon (1997) offers a useful overview of neurological monitoring, while Odell (1996) offers a comprehensive nursing perspective. Feldman and Robertson (1997) describe jugular venous oxygen saturation monitoring. North and Reilly (1994) offer a reasonable overview of intracranial pressure and monitoring, which can be usefully supplemented by Hickman et al. Nurses should consider the effects of their activities on intracranial pressure; Rising (1993) and Price (1998) give useful overviews of potential problems.
On the road to understanding and changing your life-lenses discount 250mg cefuroxime, it helps to reﬂect on what caused you to acquire the lenses you look through in the ﬁrst place buy cefuroxime australia. When you understand these origins buy cefuroxime master card, you can release the notion that you’re crazy, weird, or messed up. Self-forgiveness releases energy that you can use for grinding new lenses for better vision. She takes the Problematic Life-Lenses Questionnaire shown in Worksheet 7-1 and identiﬁes the life-lenses of intimacy-avoidant and entitled. She also realizes that she’s perfectionistic but ﬂips to feeling inadequate when she makes a mistake. She then completes the Childhood Origins of Life-Lenses exercise shown in Worksheet 7-8 and reﬂects on her ﬁndings in Worksheet 7-9. Worksheet 7-8 Hannah’s Childhood Origins of Life-Lenses Lens Opposite Lens Unworthy: Entitled: This life-lens doesn’t My mother always made me feel like our family was apply to me. Abandonment-fearful: Intimacy-avoidant: This life-lens doesn’t Although I was told I was special, I never felt anyone really ﬁt. Whenever I was sad or lonely, my parents told me how lucky I was to have all the toys, clothes, and luxuries I did. Worksheet 7-9 Hannah’s Reﬂections When I look back on my childhood, I realize that my family was pretty cold. It’s no wonder I feel anxious about being perfect and feel depressed when I’m not. There wasn’t a lot of love in my family, so I’ve learned to keep my distance from others. I was taught that possessions and status are more important than people, so I’ve invested too much time and effort on getting the things I want. To uncover the origins of your life-lenses in the same way that Hannah did, follow these instructions and complete Worksheets 7-10 and 7-11. Review each life-lens that you rated as 3 or above on your Problematic Life-lens Questionnaire (see Worksheet 7-1). Feel free to look back at Chapter 2 for help with ways of recalling past feelings and events. Jot down anything from your childhood that you believe may have contributed to each of your problematic life-lenses. After you complete this exercise, take some time to reﬂect on any new insights you’ve discovered and record them in Worksheet 7-11. Worksheet 7-10 Childhood Origins of Life-Lenses Lens Opposite Lens Unworthy: Entitled: Abandonment-fearful: Intimacy-avoidant: Inadequate: Perfectionistic: Guilty and blameworthy: Guiltless: Chapter 7: Correcting Your Life-Lenses: A New Vision 107 Lens Opposite Lens Vulnerable: Invulnerable: Help-seeking: Help-avoidant: Under-control: Over-control: Worksheet 7-11 My Reﬂections Changing the Prescription of Your Life-Lenses After you complete the exercises in the preceding sections, you should know which life- lenses cause you problems. It would be nice if you could toss the old lenses in the trash or throw them on the ground and stomp on them. But these lenses consist of almost shatterproof material — after all, they’re cast from the emotional turmoil of childhood (see “The origins of life- lenses”). You may ﬁnd the task of changing your life-lenses more challenging than you expected. Even if you put a lot of time and work into it, when you’re tired or stressed, you may ﬁnd yourself looking through your outdated prescription. Your goal is simply to use the new lenses more often than the old ones (until you can’t even ﬁnd the old ones). Distinguishing the past from the present Life-lenses develop from emotionally signiﬁcant events in childhood, and they make sense when viewed in conjunction with those events. Your world has no doubt changed a great deal over the years, but you probably still look through many of the same old lenses. As a kid, she was harshly criticized when she wasn’t perfect, so the lens helped her avoid some of that criticism. But today, as an adult, her perfectionistic life-lens causes her anxiety, stress, and even depression when she fails. Hannah completes the Then and Now Exercise in Worksheet 7-12 in order to help her under- stand how her past experiences cause her to overreact to current triggers. Worksheet 7-12 Hannah’s Then and Now Exercise Problematic Life-Lens Childhood Image(s) Current Triggers Perfectionistic: My mother would scream If I get a snag or a run in I feel like I must do at me if I got my clothes my hose, I freak. My father was never I can’t stand being satisﬁed with anything but evaluated at work. Both of my parents always I judge everything talked about other people I do — my hair, my critically. Tragically, one beautiful fall day a highly disturbed classmate brought a gun to school and shot three students.
His focus shifted after exposure to the teach- years of lecturing all over the world quality cefuroxime 500mg. His goal was ings of Sri Ramakrishna and Swami Vivekananda generic cefuroxime 250 mg with mastercard, to convince people that the possibility for peace among others order cefuroxime visa, who inspired him to renounce his throughout the world depended on change in each worldly possessions and follow God. Krishnamurti, who lived to be 90 years that his desire was attainable through God. That is why he did not cre- founder of the Divine Life Society located in the ate an organization or authorize anyone to inter- Himalayas, characterized him as follows: “Ramdas pret his work His only wish was that his written is the living example of one that has realized Cos- and recorded talks be made available to the public. Two years The author of the well-known Autobiography of a later she became a ﬁlm actress and adopted her Yogi and founder of the Self-Realization Fellowship name after Indira Gandhi. At 31 she ended her ﬁlm in 1920, Paramhansa Yogananda was the ﬁrst yoga career, married a diplomat and took up yoga in master of India to live and teach in the West. Eventually she studied with Sri Krishna- arrived in America in 1920 and created a tremen- macharya in Mysore. She became a popular yoga dous stir with what he called a “spiritual cam- teacher among Hollywood movie stars in the 1940s paign. She now in possession of the kingdom of God; that you do lives and teaches in Argentina. She is known to not have to pray that it come to you; that God’s have said, “The solution to a better and full life is in omnipresence is your omnipresence; and that all the practice of yoga, where you can ﬁnd all the that you need to do is improve your knowing. You can also transmit peace through He continued to lecture and write up to his pass- yoga. As a leader of monk who offered information on yoga and the struggle for India’s independence from British Vedanta. He was moved to help people heal not 168 yoga only on a physical level, but on a spiritual level. He in Kriya yoga and yoga techniques according to became a monk and founded the Divine Life Soci- Yogananda. His teachings can be summarized as “Serve, communities on the West Coast, retreat centers Love, Give, Purify, Meditate, Realize. Anusara yoga: A blend of hatha yoga techniques most recognized yoga practitioners. He has written and biomechanics; Anusara, meaning “to step many books on the subject, including Light on Yoga, into the current of divine will,” was developed (New York: Schocken Books, 1995) and Light on in 1997 by John Friend, who studied yoga with Pranayama, (New York: Crossroad/Herder and Sri K. Anusara yoga is based on the philoso- bouts of malaria, tuberculosis, and typhoid. At 15 phy that all people are divine in body, mind, and he was introduced to yoga by his brother-in-law, spirit regardless of their individual limitations, Sri T. Krishnamacharya, who offered him basic and that it is best to see the good in all things. Friend cited attitude, alignment, and action as By 1937 he was ready to teach yoga himself. His popular- hatha yoga text, the “Yoga Korunta,” and later ity soared in 1966 when Light on Yoga became an rediscovered by the sage Patanjali in the “Yoga international best-seller. The culmination of more Sutras,” ashtanga is called the “eight-limbed than 60 years of dedication to yoga is his most yoga,” which is based on stamina, strength, and recent book, Yoga: The Path to Holistic Health, pub- ﬂexibility. Bikram yoga: Developed by the brother of The physical aspect of yoga called Hatha yoga has Yogananda, Bishnu Ghosh, and Bikram Choud- been incorporated into mainstream ﬁtness and hury, Bikram yoga requires that the 26 postures health programs. Sanskrit for Sun and Moon, and deep breathing exercises be done in a room Hatha yoga focuses on balancing yin and yang, or heated to approximately 104–105°F and opposite universal forces, for the purpose of repeated twice. Integral yoga: A meditative practice structured and boosting the immune and nervous systems. Integral yoga lowing are types of Hatha yoga: has evolved into an international organization, with more than 40 institutes and centers 1. Ananda yoga: a system of “energization exer- throughout the United States and abroad that cises” that incorporates the use of silent afﬁrma- offer Hatha yoga, meditation, yoga philosophy tions. The concept is that the affirmations and various branches of yoga practice, and veg- consciously direct energy and raise the individ- etarian diet. Integrative yoga therapy: The use of gentle bliss) was founded in the 1960s by Swami postures, guided imagery, and breathing tech- Kriyananda (J. Donald Walters), who became a niques for the treatment of heart disease, disciple of Paramhansa Yogananda in 1948. Kripalu yoga: Kripalu yoga is the form of yoga Le Page in San Francisco, California. Le Page practiced at its homebase, the Kripalu Center designed a teacher-training program specifi- for Yoga and Health, a nearly 30-year-old non- cally for conventional and medical settings proﬁt education fellowship located in Lenox, aimed at rehabilitation. The Yoga Zone has four The center was renamed to honor Yogi Desai’s studios in New York for more than 1,700 stu- guru, Swami Kripalvananda. Finger began his yoga studies better known as Bapuji, which means beloved as a teenager in his native South Africa under grandfather.
Thus purchase online cefuroxime, their selectivity for malignant cells is only independent of the amount by which it is exceeded best cefuroxime 500 mg. Folinic acid rescue bypasses the dihydrofolate reductase blockade and minimizes methotrexate toxicity safe 250 mg cefuroxime. Methotrexate is curative for choriocarcinoma, also induces Monitoring of the plasma methotrexate concentrations has remission in acute lymphocytic leukaemia and is often active in improved the safe use of this drug and allows identification of breast cancer, osteogenic sarcoma and head and neck tumours. If a patient develops severe tox- Methotrexate is also an immunosuppressant (Chapters 26 and icity with protracted elevation of methotrexate concentrations, 50) and is used to inhibit cellular proliferation in severe psoria- methotrexate metabolism can be rapidly increased by adminis- sis (Chapter 51). About 80–95% of a dose of methotrexate These include the following: is renally excreted (by filtration and active tubular secretion) • myelosuppression; as unchanged drug or metabolites. It is partly metabolized • nausea and vomiting; by the gut flora during enterohepatic circulation. Other weak acids including furosemide palsies and a chronic demyelinating encephalitis. Pharmacokinetics Methotrexate absorption from the gut occurs via a saturable Mechanism of action transport process, large doses being incompletely absorbed. It 5-Fluorouracil is a prodrug that is activated by anabolic phos- is also administered intravenously or intrathecally. Adverse effects antimetabolites that are used clinically include tioguanine, fludarabine and 2-chlorodeoxyadenosine [cladrabine] (see • Oral ulceration and diarrhoea is an adverse event in Table 48. Adverse effects • Patients with dihydropyridine dehydrogenase deficiency These include the following: (enzyme activity 5% of normal) have an increased risk of severe mucositis/haematologic suppression. It is effect- Drug interactions ive as part of combination therapy for acute leukaemias. This is Mechanism of action important because allopurinol pretreatment is used to reduce Cytotoxic actions of anthracyclines lead to apoptosis, and the risk of acute uric acid nephropathy due to rapid tumour include: lysis syndrome in patients with leukaemia. Uses Doxorubicin is a red antibiotic produced by Streptomyces Anthracycline cardiotoxicity peucetius. It is the most widely used drug of the anthracycline • Acute: this occurs shortly after administration, with the group, with proven activity in acute leukaemia, lymphomas, development of various dysrhythmias that are occasionally sarcomas and a wide range of carcinomas. It is The camptothecins are active against a broad range of tumours, determined by the cumulative dose. They are cardiomyopathy include prior mediastinal irradiation, age given intravenously. Agents to protect against anthracycline cardiomyopathy Mechanism of action and allow dose intensification are under investigation. Hepatic extrac- tion is high, with 40% appearing in the bile (as unchanged Pharmacokinetics drug and metabolites, e. Topotecan is hydrolysed by disease, particularly if accompanied by hyperbilirubinaemia. Despite their close structural A component of the cytotoxic action of anthracyclines (e. Etoposide and teniposide, synthetic derivatives of omas and the initial treatment of acute lymphoblastic podophyllotoxin (which is extracted from the American man- leukaemia. Vinblastine is a component of the cytotoxic combin- drake or May apple, and is topically effective against warts), ations used to treat testicular cancer and Hodgkin’s disease. Uses Mechanism of action Etoposide is one of the most active drugs against small-cell Vinca alkaloids bind to β-tubulin, a protein that forms the micro- lung cancer and is used in combination therapy. It is also used tubules which are essential for the formation of the mitotic spin- to treat lymphomas, testicular and trophoblastic tumours. They prevent β-tubulin polymerizing with α-tubulin and Mechanism of action thus inhibit mitosis. Key points Adverse effects Practical ‘do’s and don’ts’ of cytotoxic therapy These include the following: • Patients should have recovered fully from the toxic • nausea and vomiting; effects of the previous cycles of cytotoxic therapy • alopecia; before starting the next treatment cycle. Pharmacokinetics • Haematopoietic growth factors (for myelosuppression) Etoposide is given by intravenous injection or orally (50% reduce the duration of the nadir neutropenia, but bioavailability). They are classified Pharmacokinetics into tyrosine kinases, serine-threonine kinases and tyrosine- Paclitaxel is poorly absorbed orally and requires intravenous serine-threonine kinases. It is administered orally on a daily molecules or cellular processes on or within the malignant basis. In the non- Adverse effects ligand-binding domain of these receptors, there is a tyrosine These include the following: kinase which phosphorylates the receptor. Adverse effects Pharmacokinetics These include the following: Oral absorption is very good with almost 100% bioavailabilty. The kinetics do not change with chronic dosing and • hepatitis; little drug appears unchanged in the urine.