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Clinical Director, CUNY School of Medicine

Do you know (1) the rationale for monitoring your blood glucose (sick day management asthma symptoms tight chest buy 5 mg montelukast with visa, insulin dose adjustments)? What herbal supplements asthma treatment in adults buy discount montelukast on-line, over-the-counter medicines asthma uncontrolled buy discount montelukast 4mg, or other treatments do you use? Meal Planning for Glycemic Management Based on Medication Medication Recommended Meal Planning No medication or oral medication* Portion control or healthful choices Secretagogues* Carbohydrate at each meal Fixed daily insulin* Consistent injection time and carbohydrate intake (time and amount) Premixed insulin* Consistent injection times and meal times Intensive flexible insulin program (basal/bolus)* Carbohydrate counting and dosage adjustments including carb:insulin ratios and correction doses Portion control and increased physical activity. Intensive lifestyle interventions (counseling, behavioral change, physical activity) with on-going support are needed for weight loss. Targeting and Monitoring Glycemic Control in Non-Pregnant Adults with Diabetes Mellitus Target A1c: assess individual’s risks and benefits of treatment. Factors heightening risk of tight control (hypoglycemia) Factors limiting benefit of tight control History of severe hypoglycemia (inability to treat without assistance). Limited life expectancy (<10 years) Adverse effects of treatment Autonomic neuropathy (especially cardiac). Functional or cognitive limitations that cause inability to safely carry out treatment regimen. If neither factors heightening risk nor limiting benefit of tight control: prevent long-term complications and early mortality. If factors limiting benefit of tight control: minimize symptoms of hyperglycemia and controlling glucose as well as possible without incurring side effects or excessive treatment burden. Measure HbA1c in: 3 months for patients not at target or with recent changes to medications or lifestyle 6 months for patients at target and who have not had a recent change in medications. Steps in Glycemic Control with Oral Agents in Patients with Type 2 Diabetes Step 1. Essential treatment for all patients with type 2 diabetes Comprehensive diabetes education Healthy eating Physical activity Metformin at maximum dose tolerated, not to exceed 2000 mg/daily*, unless not tolerated or otherwise contraindicated Re-measure A1c in 6-12 weeks after initiation or dose change of medication Step 2. With addition of second agent, if A1c: < 7% or below individualized target (Table 5), no additional agents. Headache, nausea/vomiting, Use caution when diarrhea, constipation, initiating or escalating pancreatitis, medullary doses thyroid cancer 3 Dulaglutide Trulicity ⇩ ⇩⇩ Rare1 None. Use caution when Nausea/vomiting, diarrhea, initiating or escalating abdominal pain, medullary doses thyroid cancer 3 Albiglutide Tanzeum ⇩ ⇩⇩ Rare1 None. Physicians should avoid pioglitazone in patients with active bladder cancer and with caution in patients with a prior history of bladder cancer. When administered with a sulfonylurea, a lower dose of the sulfonylurea may be required. Prescribing Essentials for Injectable Agents for Glycemic Control in Patients with Type 2 Diabetes Onset of Peak of Duration of Cost1 – 30 Type of Injectable Examples Action Action Action days Incretin mimetic Exenatide (Byetta)2 1 hour 2. If pancreatitis is confirmed, exenatide should not be restarted unless an alternative etiology is identified. It has not been determined whether exenatide causes thyroid C-cell tumors in humans, and routine monitoring is of unknown value. Steps in Pharmacologic Treatment of Hypertension in Patients with Diabetes Mellitus Step 1. If 2 of 3 Second line agents are thiazide diuretics and long-acting spot urine albumin/creatinine ratios > 30 mg/gm dihydropyridine calcium channel blockers. Check creatinine, electrolytes and estimated glomerular also be necessary but have less supporting data. Recheck creatinine and Check lipid profile – fasting or non-fasting (annually) electrolytes within 1–2 weeks of initiating therapy. Refer to a multidisciplinary team specializing in the aspirin for primary prevention in patients with diabetes. Testing Process Testing other sites (outlined circles) is at provider Show the monofilament to the patient. Ask the patient to turn his/her head and close his/her eyes or look at the ceiling. Ask the patient to say ‘yes’ when s/he feels you touching his/her foot with the monofilament. If the patient does not say ‘yes’ when you touch a given testing site, continue on to another site.

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Drugs used in the treatment of streptococcal pharyngitis and prevention of rheumatic fever asthma definition hypothesis buy 10mg montelukast amex. Pharmacokinetics of benzathine penicillin G: serum levels during the 28 days after intramuscular injection of 1200000 units zithromax asthma treatment order 10 mg montelukast overnight delivery. Allergic reactions to long-term benzathine penicillin prophylaxis for rheumatic fever asthma treatment using food order montelukast 5 mg with mastercard. Allergic reactions in rheumatic fever patients on long term benzathine penicillin G: the role of skin testing for penicillin allergy. Nature and extent of penicillin reactions, with particular reference to fatalities from anaphylactic shock. The value of skin testing for penicillin allergy in inpatient population: analisis of the subsequent patient management. Introduction of a practice guidelines for penicillin skin testing improves the appropriateness of antibiotic therapy. For these patients, prophylaxis for the infective endocarditis is thus recommended. Infective endocarditis rarely occurs without underlying cardiac pa thology, either congenital or acquired. Even though these indi viduals usually have normal valvular anatomy, infective endocarditis is not uncommon in this group, particularly of the tricuspid valve. Patients with congenital heart disease also have a higher risk of devel oping endocarditis. Although a discussion of the risks of infective endocarditis in individuals with congenital heart disease is beyond the scope of this discussion, one principle is that fluid turbulence results in endothelial damage, whether the congenital lesion is valvular, as in congenital bicuspid aortic valves, or a ventricular septal defect. In patients with rheumatic valvular heart disease, infective endocarditis usually occurs in the mitral or aortic valves since these are the most commonly damaged heart valves. Studies with animal models suggest that turbulent flow may lead to injury and/or disruption of the vascular endothelium or endocardium. As a consequence, a matrix of platelets and fibrin is laid down to form a sterile vegetation. If significant bacteremia then occurs, and bacter emia is common in humans, circulating microorganisms become 1 Source: (3). One of the most important factors determining whether bacteria infect sterile vegetation may be the concentration of bacteria circulat ing through the bloodstream during bacteremia. Early studies also suggested that Gram-positive oral flora, such as viridans group strep tococci, had a greater affinity for the vascular endothelium and en docardium than did Gram-negative organisms. This correlated well with clinical observations that Gram-negative organisms frequently cause urinary tract infections, yet rarely cause infective endocarditis. However, investigators caution that understanding of the infective process is incomplete, and point to studies demonstrating that details of the intercellular interactions are species-dependent. This pattern changed in the latter half of that century, with an increase in the number of episodes of infective endocarditis associated with staphylococci, particularly in industrialized countries. Increasingly, Staphylococcus aureus and co agulase-negative staphylococci were recovered from infective en docarditis patients, probably because the patients had undergone medical or surgical procedures that required extended hospitaliza tions. Similarly, yeast and fungi are also more common for rea sons previously mentioned. In developing countries, the continuing predominance of viridans streptococci in patients with endocarditis has been attributed to the poor dental hygiene among children and adults in socially and economically disadvantaged populations. Since the clinical signs and symptoms commonly associ ated with infective endocarditis are often nonspecific and overlap with many other illnesses, a diagnosis of infective endocarditis can be difficult using clinical observations alone. In 1994, to facilitate patient evaluation, more objective clinical criteria were published for assess ing infective endocarditis (6). It is beyond the scope of this document to discuss the use of these criteria in detail. It thus important to confirm clinical suspicions of endocarditis with data from the microbiology laboratory. If there are no supporting microbiology laboratory facilities, or if existing ones are substandard, this makes a diagnosis of endocarditis especially difficult. A compli cating factor is that patients with nonspecific symptoms at the onset of infective endocarditis are often given antibiotics or take antibiotics on their own. Consequently, even with microbiology laboratory facilities, it can be difficult to confirm a suspected infection. Laboratory studies for assisting the clinician can be divided into two major categories.

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Position the patient in a high fowlers position asthma symptoms pdf 5mg montelukast for sale, if health permits to support head on pillow asthma symptoms in 3 month old order montelukast online pills. In infant asthmatic bronchitis during pregnancy buy montelukast online, place in infant seat or with rolled towel or pillow under the head and shoulders. Ask the client to hyperextend the head, and using a flash light observe the intactness of the tissue of the nostrils. Examine the nares for any obstructions or deformities by asking the client to breath through one nostril while occluding of the other. Determine how far to insert Use the tube to mark off the distance from the tip of the client’s nose to the tip of the ear lobe and from the tip of the ear lobe to the tip of the sternum. Lubricate the tip of the tube well with water solution lubricant or water to ease insertion. Insert the tube with its natural curve toward the client in to the selected nostril. Ask the client to hyper extend the neck, and gently advance the tube toward the nasopharynx. If the tube meets resistance, withdraw it, rubricate it and insert it in the other nostril. Once the tube reaches the oropharynix (throat) the client will feel the tube in the throat and may gag or retch. Ask the client to tilt the head forward and encourage the client to drink and swallow. In the cooperation with the client, pass the tube 5 to 10 cm (2 to 4 in) with each swallow, until the indicated length is inserted. If the client continuous to gag and the tube does not advance with each swallow, with draw it slightly, and inspect the throat by looking through the mouth. As certain correct placement of the tube: Aspirate stomach content, and check their acidity. Attach the tube to the suction source or feeding apparatus as ordered, or clamp the end of the tubing. Loop an elastic band around the end of the tubing, and attach the elastic band to the gown with a safety pin or attach a piece of adhesive tape to the tube, and pin the tape to the gown. Document relevant information, means by which correct placement was determined and client responses. Establish a plan for providing daily nasogastric tube care Inspect the nostril for discharge and irritation Clean the nostril and tube with moistened cotton tipped applicators Apply water-soluble lubricant to the nostril if it appears dry or encrusted. If suction is applied, ensure that the patency of both the nasogastric and suction tubes in maintained 25. Purposes To restore or maintain nutritional status To administer medications Equipment Correct amount of feeding solution Pacifier 20 to 50 mL syringe with an adapter Emesis basin Bulb syringe (for an intermittent feeding) Calibrated plastic feeding bag and a drip chamber, which can be attached to the tubing or Pre-filled bottle with a drip chamber, tubing, and a flow regulator clamp. Prepare the client and the feeding Explain the patient about the feeding Provide privacy Position the patient in Fowler’s position in bed or sitting position in a chair Position a small child or infant in your lap, and provide a pacifier during feeding 2. Assess residual feeding contents Aspirate all the stomach contents, and measure the amount prior to administering the feeding. If 50 mL or more undigested formula is withdrawn in adults, or 10 ml or more in infants, check with the nurse in charge before proceeding. Remove the syringe bulb or plunger, and pour the gastric contents via the syringe in to the nasogastric tube. Administer the feeding Before administering feeding: a) Check the expiration date of the feeding b) Warm the feeding to room temperature Bulb syring Remove the bulb from the syringe, and connect the syringe to a pinched or clamed nasogastric tube Add feeding to the syringe barrel Permit the feeding to flow in slowly at the prescribed rate. Pinch or clamp the tubing to stop the flow for a minute if the client experiences discomfort. Feeding Bag Hang the bag from an infusion pole about 30 cm above the tube’s point of insertion in to the client Clamp the tubing, and add the formula to the bag, if it is not pre-filled. Rinse the feeding tube immediately before all the formula has run through the tubing: 220 Basic Clinical Nursing Skills Instill 60 mL of water the feeding tube Be sure to add the water before the feeding solution has drained from the neck of a bulb syringe or from the tubing of an administration set. Before adding water to a feeding bag or prefilled tubing set, first clamp and disconnect both feeding and administration tubes. Clamp and cover the feeding tube Clamp the feeding tube before all of the water is instilled Cover the end of the feeding tube with gauze held by an elastic band 7. Ensure client comfort and safety Pin the tubing to the clients gown Ask the client to remain sitting upright in Fowler’s position or in slightly elevated right lateral position for at least 30 minutes.