Tag: Clinical-Nursing

As an advanced practice nurse, you will examine patients presenting with a variety of disorders. You must, therefore, understand how the body normally functions so that you can identify when it is reacting to changes. Often, when changes occur in body systems, the body reacts with compensatory mechanisms. These compensatory mechanisms, such as adaptive responses, might be signs and symptoms of alterations or underlying disorders. In the clinical setting, you use these responses, along with other patient factors, to lead you to a diagnosis.

Consider the following scenarios:

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Scenario 1:

Jennifer is a 2-year-old female who presents with her mother. Mom is concerned because Jennifer has been “running a temperature” for the last 3 days. Mom says that Jennifer is usually healthy and has no significant medical history. She was in her usual state of good health until 3 days ago when she started to get fussy, would not eat her breakfast, and would not sit still for her favorite television cartoon. Since then she has had a fever off and on, anywhere between 101oF and today’s high of 103.2oF. Mom has been giving her ibuprofen, but when the fever went up to 103.2oF today, she felt that she should come in for evaluation. A physical examination reveals a height and weight appropriate 2-year-old female who appears acutely unwell. Her skin is hot and dry. The tympanic membranes are slightly reddened on the periphery, but otherwise normal in appearance. The throat is erythematous with 4+ tonsils and diffuse exudates. Anterior cervical nodes are readily palpable and clearly tender to touch on the left side. The child indicates that her throat hurts “a lot” and it is painful to swallow. Vital signs reveal a temperature of 102.8oF, a pulse of 128 beats per minute, and a respiratory rate of 24 beats per minute.

Scenario 2:

Jack is a 27-year-old male who presents with redness and irritation of his hands. He reports that he has never had a problem like this before, but about 2 weeks ago he noticed that both his hands seemed to be really red and flaky. He denies any discomfort, stating that sometimes they feel “a little bit hot,” but otherwise they feel fine. He does not understand why they are so red. His wife told him that he might have an allergy and he should get some steroid cream. Jack has no known allergies and no significant medical history except for recurrent ear infections as a child. He denies any traumatic injury or known exposure to irritants. He is a maintenance engineer in a newspaper building and admits that he often works with abrasive solvents and chemicals. Normally he wears protective gloves, but lately they seem to be in short supply so sometimes he does not use them. He has exposed his hands to some of these cleaning fluids, but says that it never hurt and he always washed his hands when he was finished.

Scenario 3:

Martha is a 65-year-old woman who recently retired from her job as an administrative assistant at a local hospital. Her medical history is significant for hypertension, which has been controlled for years with hydrochlorothiazide. She reports that lately she is having a lot of trouble sleeping, she occasionally feels like she has a “racing heartbeat,” and she is losing her appetite. She emphasizes that she is not hungry like she used to be. The only significant change that has occurred lately in her life is that her 87-year-old mother moved into her home a few years ago. Mom had always been healthy, but she fell down a flight of stairs and broke her hip. Her recovery was a difficult one, as she has lost a lot of mobility and independence and needs to rely on her daughter for assistance with activities of daily living. Martha says it is not the retirement she dreamed about, but she is an only child and is happy to care for her mother. Mom wakes up early in the morning, likes to bathe every day, and has always eaten 5 small meals daily. Martha has to put a lot of time into caring for her mother, so it is almost a “blessing” that Martha is sleeping and eating less. She is worried about her own health though and wants to know why, at her age, she suddenly needs less sleep.

To Prepare

Review the three scenarios, as well as Chapter 6 in the Huether and McCance text.

Identify the pathophysiology of the disorders presented in each of the three scenarios, including their associated alterations. Consider the adaptive responses to the alterations.

Review the examples of “Mind Maps—Dementia, Endocarditis, and Gastro-oesophageal Reflux Disease (GERD)” media in this week’s Learning Resources. Then select one of the disorders you identified from the scenarios. Use the examples in the media as a guide to construct a mind map for the disorder you selected. Consider the epidemiology, pathophysiology, risk factors, clinical presentation, and diagnosis of the disorder, as well as any adaptive responses to alterations.

Review the Application Assignment Rubric found under Course Information

To Complete

Write a 2- to 3-page paper excluding the title page, reference page and Mind Map that addresses the following:

For each of the three scenarios explain the pathophysiology, associated alterations and the patients’ adaptive responses to the alterations caused by the disease processes. You are required to discuss all three scenarios within the paper component of this assignment.

Construct one mind map on a selected disorder presented in one of the scenarios. Your Mind Map must include the epidemiology, pathophysiology, risk factors, clinical presentation, and diagnosis of the disorder, as well as any adaptive responses to alterations

Simulations

The era of advanced technology has finally integrated its way into nursing programs across national and international shores. Nurse educators have found that simulations offered a unique way to bridge the gap between clinical experience for nursing student when finding adequate clinical sites poses as a challenge (Jefferies, Swoboda, & Akintade, 2016). Simulations portray real-world events in the form of activities or events. Simulations can be further categorized regarding low, medium, or high fidelity (the degree of realism associated with the simulation). Low fidelity includes methods such as role-playing or case studies to instruct nursing students about patient situations and what Eyikara & Baykara (2017) describes as a partial task trainer or static manikin. Examples include inserting an indwelling urinary catheter or performing central line dressing changes on a manikin using aseptic technique. Medium fidelity involves a two-dimensional active learning experience where nursing students are presented with situations that involves the recollection of learned concepts and apply these concepts to scenarios to problem solve. For example, nursing students being able to assess adventitious breath sounds on a manikin without being able to visualize the rise and fall of the chest. High fidelity simulations are highly sought after in the nursing school setting. It is considered the most realistic of simulations. High fidelity simulations involve the usage of full-body patient simulators, eSimulations (virtual reality), or standardized patients (i.e., stand-in actor or nursing faculty).

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Significance of Simulations

With the shortage of adequate clinical sites for undergraduate nursing program, many states have approved the use of simulations to replace nearly 50% of traditional clinical hours (Fey & Kardong-Edgren, 2017). Simulations are proven to enhance nursing students’ knowledge bases and skills. According to Eyikara & Baykara (2017), simulations bridge a link between theory and clinical application by presenting patient scenarios that closely mimic what could happen at the actual patient bedside. A well-constructed simulation (especially that of a high-fidelity caliber) has resulted in the improvement of nursing student levels of confidence and learner self-satisfaction as documented in numerous of research manuscripts. The overwhelming positive results associated with learner’s outcomes, simulations, and undergraduate nursing students has prompted researches to expand research into studying how to apply quality simulations to match the learner needs of graduate nursing students (Fey & Kardong-Edgren, 2017). Graduate level nursing clinical sites are also a challenge for even the most prestigious universities. If you combine this with the expansion of distance-learning nursing program you can see how simulations can prove to be beneficial to nurse educators, nursing students, and most importantly patients whose quality of care is partially dependent on the knowledge, skill, and expertise of the nurse clinician (regardless of the scope of practice).

Attributes to Simulations (Li, 2007)

Low and medium fidelity is considered User-friendly

Low fidelity simulations are considered suitable for 1
st
-year undergraduate nursing students

Low Cost (Low and Medium Fidelity)

Limited physical interaction (Low Fidelity)

Limited application of learning theories (Low Fidelity)

Allow for nursing students to work at their own pace

High Fidelity simulations are not cost-efficient; estimated cost $100,000.00

Limited access (high fidelity)

High Fidelity simulations are considered suitable for thi
rd
and 4
th
-year undergraduate nursing students

Nursing students experience with simulations is dependent on faculty expertise

 

 

Advantages and Disadvantages of Simulations as an Educational Tool

Simulations often require nursing students to work together in small groups which is a form of cooperative learning. Cooperative learning encourages active and reflective learning while cultivate a sense of comradery and teamwork amongst nursing students which is necessary for the development of interpersonal skills and communication (Phillips, 2016). Procedural knowledge is cultivated in nursing students by the use of simulations (especially those of low-fidelity methods). Simulations such as manikins used for nursing students to practice their intravenous insertion skills is an example of acquisition of procedural knowledge. Lastly, simulation all incorporates active learning by demonstration (Phillips, 2016). Video-taping simulations allow for reflective learning and evaluation of skill by performance feedback. Retention of performed skill increases when nursing students can dissect their performance with constructive feedback from peer, self, and nurse educators to understand the complexities problem-solving and critical thinking. In a qualitative study by Au, Lo, Cheong, Wang, & Van (2016) revealed that nursing faculty viewed simulations (with bias to high-fidelity simulations) as a unique tool to achieve learning outcomes while instilling the importance patient safety. Nursing students view simulations of high-fidelity tier as a bonafide learning experience. Qualitative data included nursing students expressing the desire to have high-fidelity simulations as a prerequisite before entering the clinical setting.

The experience nursing students receive during simulations unfortunately dependent on the expertise of the nursing faculty facilitating the learning activity. Nursing students feeling as if one person is not putting as much effort as the other could lead to a breakdown in communication, rise in stress levels, and the possibility group conflict leading to the non-retention of nursing concepts and applications. These barriers to learning can develop if the facilitator is ineffectively monitoring the simulation. Faculty not accounting for the difference in skill procurement amongst nursing students can lead to feelings of anxiety and inadequacy in students participating. High fidelity simulations are costly which can result in a limited equipment usage and practice time to preserve on the cost of restocking supplies and possible maintenance work related to high fidelity manikins and other advanced technology. Au et al. (2016) reported nursing students expressing feelings of anxiety and lack of communication between students and faculty during simulations. Since these simulations are represented as real-world situations, these negative experiences could cause students to correlate any poor performance during simulations with their ability to successfully transition into the role of the clinical nurse at the bedside (Au et al., 2016).

National League for Nurses: Nurse Educator Competencies

The National League for Nursing (NLN) developed eight competencies to offer guidance, framework, and role development in nurse educators. In this blog, I will highlight two of the eight competencies that is relatable to nurse educators implementing simulations in the classroom to meet the learner needs of nursing students. The first competency is nurse educators as facilitators of learning. The use of simulations requires nurse educators to possess content mastery regarding the content being taught to students (Halstead, 2007).  Simulations require the nurse educator to understand the flow of patient care including the correct course of action to take when things go astray. The nurse educator must possess clinical competency, content mastery, and be adaptable of various teaching styles to meet the learner needs of a diverse nursing student audience (Halstead, 2007).

The successful facilitation of simulations by nurse educators build confidence within the novice and experienced educator. A nurse educator competency presented by the NLN encourages nurse educators to aim for continuous quality improvement when teaching tomorrows nurses (Halstead, 2007). Faculty feeling inadequate in regards to technology is an identified barrier to the incorporation of simulation in the classroom. Nursing faculty, as well as nursing administration, should invest in the continuous enrichment of faculty. The investment in faculty will increase job satisfaction, reduce role strain, and increase faculty productivity (Halstead, 2007). Nurse educators must commit to being lifelong learners to ensure that tomorrow’s nurses enter the workforce prepared to withstand the ever-changing flow of healthcare and patient care.

References

Au, M. L., Lo, M. S., Cheong, W., Wang, S. C., & Van, I. K. (2016). Nursing students’perception of high-fidelity simulation activity instead of clinical placement: A      qualitative study. 
Nurse Education Today
, 3916-21.

Eyikara, E., & Baykara, Z. G. (2017). The importance of simulation in nursing education. 
World

Journal On Educational Technology: Current Issues
, 9(1), 2-7.

Fey, M. K., & Kardong-Edgren, S. (2017). State of research on simulation in nursing education

programs. 
Journal Of Professional Nursing
, 33(6), 397-398. doi:10.1016/j.profnurs.2017.10.009

Halstead, J. (2007). 
Nurse Educator Competencies: Creating an Evidence-Based Practice for

Nurse Educators .
 New York: National League for Nursing.

Jeffries, P., Swoboda, S., & Akintade, B. (2016). Teaching and learning using simulations. In D. Billings, J. Halstead, & 5th (Ed.), 
Teaching in Nursing: A Guide for Faculty
 (pp. 304-323). St. Louis, Missouri: Elsevier.

Li, S. (2007). 
The role of simulation in nursing education: A regulatory perspective
. Retrieved from National Council of State Boards of Nursing: 
https://www.ncsbn.org/Suling2.pdf

Phillips, J. (2016). Strategies to Promote Student Engagement and Active Learning. In D. Billings, J. Halstead, & 5th (Ed.), 
Teaching in Nursing
 (pp. 245-263). St. Louis, Missouri: Elsevier.

Increasingly, health policymakers are becoming aware of the social determinants of health and the role they play in prevention disease and promoting health and wellness. In the “Frameworks for Action in Policy and Politics” chapter, examine Box 1-1 (Political Aspects of the Social Determinants of Health) and Figure 1-6 (The Who, What, Where, When, and Why of Nursing’s Policy Influence). Then compare these with the story about Lilian Wald’s work in New York City. Reflect on the “what” of Wald’s strategies. In your opinion, which did she use effectively?

Looking further at the “what” in Figure 1-6 and answer any one of the following questions:

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Discuss at least three competencies/strategies that you have used effectively.

Identify three competencies/strategies that you don’t currently use and discuss how you might incorporate them into your advocacy toolbox.

Med list For CoA- common medications drug list

 

Acetaminophen (Tylenol)

Adult dose: The FDA limits total daily doses to 4000 mg; however the manufacturer of Tylenol suggests a limit of 3000mg per day pts with liver disease or chronic alcohol consumption are advised not to exceed 2000mg per day.

Class: Nonopioid analgesics

MOA: It blocks peripheral pain impulses by inhibition of prostaglandin synthesis Also lowers febrile body temperatures by acting on the hypothalamus, the structure in the brain that regulates body temperature.

Major side effects: blood disorders or dyscrasias (anemia’s), and nephrotoxicity’s, and
hepatotoxicity’s
(most serious), more common: skin disorders, N/V

Nursing considerations: allergy to acetaminophen, impaired hepatic function, chronic alcoholism, pregnancy, and lactation. Skin color, lesions.

Therapeutic monitoring: CBC, renal function and trough levels

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Acetaminophen/Hydrocodone  (Vicodin)

Adult dose: 325mg/2.5mg, 300mg/5mg

Class: Analgesics, Opioid combo

MOA: Acetaminophen- Acts on the hypothalamus to produce antipyresis; inhibits prostaglandin synthesis

Hydrocodone- Opioid analgesic agonist; blocks pain perception in the cerebral cortex; decreases synaptic chemical transmission throughout the CNS, which in turn inhibits pain sensation into higher centers

Major side effects: Hallucinations, bradycardia, confusion, dizziness, drowsiness, fatigue

Nursing considerations: Black box warning for addiction, abuse, and misuse. Long acting hydrocodone exposes pts and other users to the risks of opioid addiction, abuse, and misuse, which can lead to overdose and death

Therapeutic effect: HR, CBC, renal and kidney function

 

Amlodipine (370)

Adult dose: 5-10mg a day

Class: Calcium Channel Blocker

MOA: Calcium plays a major role in excitation-contraction of the heart/smooth/skeletal muscles. When blocked this causes relaxation of the muscles and therefore causes coronary arteries to dilate this increases blood flow to the ischemic heart, which in turn increases oxygen supply an helps shift demand ratio back to normal.

Major side effects: Hypotension, palpitations, tachycardia/bradycardia, constipation, nausea, dyspnea, rash, flushing, peripheral edema

Nursing considerations:
contraindicated with grapefruit juice also a Look like sound alike drug

Therapeutic monitoring: moniter bp at baseline and then periodically

 

Ampicillin (608)

Adult dose: 1-12g/day divided every 4-6 hours

Class: Aminopenicillin (antibiotic)

MOA: Involves the inhibition of bacterial cell wall synthesis. Once distributed by the pts bloodstream to infected areas, penicillin molecules slide through bacterial cell walls to get to their site of action. Some are too large to pass through openings. Some bacteria make the openings to their cell walls small so penicillin can’t get through to kill them. Once they do get through they bind to appropriate sites (penicillin-binding proteins). The molecules then interfere with normal cell wall synthesis, causing formation if defective cell walls that are unstable and easily broken down.

Major side effects: Anaphylaxis, C. difficile colitis, erythema multiform (Steven Johnson syndrome- life threatening skin reaction), N/V, thrush, yeast infection, rash, eosinophilia

Nursing considerations: Many pts have a drug allergy to this medication and it is important to figure out the type of reaction the pts experience to this medication

Therapeutic monitoring: CBC and renal function

 

Aspirin (420)

Adult dose: 81-325mg once daily

Class: antiplatelet

MOA: Aspirin inhibits cyclooxygenase in the platelet irreversibly so that the platelet cannot regenerate this enzyme. Therefore, the effects of aspirin last the lifespan of a platelet (7 days). This irreversible inhibition of cyclooxygenase in the platelet prevents the formation of TXA2, a substance that causes blood vessels to constrict and platelets to aggregate. Thus, by preventing TXA2 formation, aspirin prevents these actions, which results in the dilation of the blood vessels and prevention of platelets from aggregating or forming a clot.

Major side effects: Drowsiness, dizziness, confusion, flushing, N/V, gastrointestinal bleeding, thrombocytopenia, agranulocytosis, leukopenia, neutropenia, hemolytic anemia, bleeding

Nursing considerations: Do not give to pts with thrombocytopenia, leukemia, active bleeding, traumatic injury GI ulcer, vitamin K deficiency or any pt who has had a recent stroke.

Therapeutic monitoring: CBC, renal and liver function as well as ototoxicity

Atorvastatin (442)  statin

Adult dose: 10-80mg/day

Class: Antilipemic- HMG-COA reductase inhibitors

MOA: Lower the blood cholesterol level by decreasing the rate of cholesterol production. The liver requires HMG-CoA reductase to produce cholesterol. The statins inhibit this enzyme, thereby decreasing cholesterol. The statins inhibit this enzyme thereby decreasing cholesterol production. When less cholesterol is produced, the liver increases the number of LDL receptors to recycle LDL from the circulation back into the liver where it is needed for the synthesis of other required substances such as steroids, bile acids, and cell membranes.

Major Side Effects: mumyopathy (muscle pain), rhabdomyolysis (breakdown of muscle protein), myoglobinuria (urinary elimination of the muscle protein myoglobin), renal failure, death, headache, dizziness, blurred vision, fatigue, constipation, diarrhea, skin rashes.

Nursing considerations: pregnancy category X drug. Once a day doses usually with the evening meal or at bedtime.

Therapeutic monitoring: cholesterol and triglyceride levels as well as liver function

 

Carvedilol (315)

Adult dose: 6.25- 100mg/day

Class: Adrenergic blocking- Beta Blocker

MOA: Block SNS stimulation of the beta-adrenergic receptors by competing with norepi and epi. It has many effects including acting as a non selective beta blocker, an alpha1 blocker, a calcium channel blocker and even an antioxidant. Used primarily in the treatment of heart failure but also beneficial for hypertension and angina.

Major side effects: MI, rebound hypertension, chest pain, irregular heart beat, difficulty breathing/swallowing, and fainting.

Nursing considerations: do not suddenly discontinue medication. Stand up slowly from sitting or lying

Therapeutic monitoring: BP, HR, kidney function

 

Chlordiazepoxide (253)

Adult dose: 5-10mg (mild-moderate pain) 20-25 for severe anxiety

Class: Benzodiazepine- Anxiolytic

MOA: Binds receptors at several sites within the CNS, including the limbic system and reticular formation. Effects may be mediated through the GABA receptor system. Increase in neuronal membrane permeability to chloride ions enhances the inhibitory effects of GABA; the shift in chloride ions causes hyperpolarization (less excitability) and stabilization of the neuronal membrane

Major side Effects: Memory impairment, muscle weakness, drowsiness, ataxia, sedation, confusion, dizziness

Nursing considerations: Black box warning- concomitant use of benzodiazepines and opioids may result in profound respiratory depression, coma, and death; administer concomitantly when there are no alternative options; limit dosages and durations to minimum required; monitor for signs and symptoms of respiratory depression and sedation

Therapeutic Effects: BP, HR

 

Ciprofloxacin (628)

Adult dose: PO-250-750mg every 12 hr. IV- 200-400mg every 8-12 hr. IV/PO- 250-750 mg once daily

Class: Antibiotic- Fluoroquinolone

MOA: Destroy bacteria by altering their DNA. First broad coverage, potent quinolones to become available. Capable of killing a wide range of gram-negative bacteria. Can kill some anaerobic bacteria as well as atypical organisms such as chlamydia, mycoplasma, and mycobacterium. Also drug of choice for the tx of anthrax.

Major side effects: bacteria overgrowth,
prolongation of QT intervals,
pins and needles

Nursing considerations: Black box warning for increased tendinitis and tendon rupture with use. Can cause peripheral neuropathy, avoid milk produces and antiacids

Therapeutic monitoring: Liver function, CBC, and renal function

 

Clopidogrel (420) Plavix

Adult dose: 75mg once daily

Class: coagulation modifier (ADP Inhibitor)- Antiplatelet

MOA: It works by altering the platelet membrane so that it can no longer receive the signal to aggravate to form a clot. This signal is in the form of fibrinogen molecules, which attach to glycoprotein receptors on the surface of the platelet. Clopidogrel inhibits the activation of this receptor.

Major side effects: chest pain, edema, flu like symptoms, abdominal pain, headache, dizziness, serious bleeding episode.

Nursing considerations: It must be avoided in patients taking more than 100mg of aspirin daily, It is indicated in pts with acute coronary syndrome. Do not suddenly discontinue. Bruising or bleeding is more common.

Therapeutic monitoring: CBC, liver and kidney function,

 

Dextrose 5% (500/877)

Adult dose: IV- 10-25 g. PO- 4-20g as a single dose

Class:

MOA: Parenteral dextrose is oxidized to carbon dioxide and water, and provides 3.4 cal/g of d-glucose

Major side effects: Hyperosmolality, edema, venous thrombosis, and fever

Nursing considerations: Use with caution in pts with DM

Therapeutic monitoring: glucose levels, monitor electrolytes

 

Docusate Sodium (Colace) (821)

Adult dose: 50-300mg/day

Class: Laxitives- Fecal softner, emollient laxative

MOA: Lower the surface tension of GI fluids, so that more water and fat are absorbed into the stool and the intestines. The lubricant type works by lubricating the fecal material and the intestinal wall and preventing absorption of water from the intestines. Instead of being absorbed, this water in the bowel softens and expands the stool. This promotes bowel distention and reflex peristaltic actions, which ultimately lead to defecation.

Major side effects: Electrolyte imbalances, skin rashes, lipid pneumonia, difficulty breathing, and swelling of mouth/face/lips, rash or hives.

Nursing Considerations: caution use in the following: acute surgical abdomen, appendicitis, symptoms such as abdominal pain, nausea and vomiting; fecal impaction, intestinal obstruction and undiagnosed abdominal pain.

Therapeutic Effect: monitor intake and output closely. Type of stool.

 

Enalapril (350)

Adult dose: 2.5-5 mg/day and increase to target dose of 10-40 mg/day as a single does or in two equal doses

Class: Antihypertensive- ACE inhibitor

MOA: Inhibit the angiotensin converting enzyme which converts angio1 to angio2. A2 is a potent vasoconstrictor and induces aldosterone secretion by the adrenal glands. Aldosterone stimulates sodium and water reabsorption which can raise blood pressure by inhibiting this process, blood pressure is lowered.

Major side effects: fatigue, dizziness, mood changes, headaches, angioedema, and fainting, dry cough

Nursing considerations: Report any signs of fever or a sore throat to your doctor who may carry out further tests to ensure it is not neutropenia (a decrease in white blood cells). Look alike sound alike drug.

Therapeutic effect: Kidney and renal function, CBC, BP, blood sugar if diabetic

 

Enoxaparin Sodium (414/415) levonix-low molecular weight heprin

Adult dose: Subcut: 30 mg/ 12 hr or 40 mg/day

Class: Coagulation modifier- Anticoagulant

MOA: An antithrombotic that inhibits factor Xa by increasing inhibition rate of clotting proteases that are activated by antithrombin III

Major side effects: Elevation of serum aminotransferases, Fever, hemorrhage, thrombocytopenia

Nursing considerations: Black box warning for pts receiving epidural or spinal hematoma, Pts should be frequently monitored for signs and symptoms of neurologic impairment (tingling, numbness, muscular weakness)

Therapeutic Effect: Serum aminotransferases, CBC

 

Ferrous Sulfate (864-866)

Adult dose: 3-4 tablets daily

Class: Anemia- Iron

MOA: oxygen carrier in both hemoglobin and myoglobin and is critical for tissue respiration. Corrects iron deficiency symptoms.

Major side effects: N/V, diarrhea, constipation, cramps, stomach pain, temporary discoloration of teeth and eyes.

Nursing considerations: Educate the pt on keeping the medication out of the reach from children considering they look like candy. Take w ascorbic acid (orange juice) aniacids or calcium might cause black, tarey stool

Therapeutic Effect: iron levels

 

Furosemide (455) lasix

Adult dose: IM/IV- 20-40 mg/dose. PO-20-120 mg/day

Class: Loop diuretic

MOA: have renal cardiovascular and metabolic effects. Theses drugs act primarily along the thick ascending limb of the loop of Henle blocking chloride and secondarily sodium resorption. Activate renal prostaglandins, which results in dilation of the blood vessels of the kidneys lugs and rest of the body. Useful in the treatment of edema associated with heart failure hepatic cirrhosis and renal disease.

Major side effects: Hypokalemia, thrombocytopenia, agranulocytosis, leukopenia, and neutropenia, and steven-johnsons syndrome (severe skin disorder)

Nursing considerations: If pt has diabetes this medication may increase serum glucose levels. Stand up slowly.

Therapeutic Effect: CBC, potassium levels, all electrolyte levels, uric acid, glucose, alanine aminotransferase, and aspartate aminotransferase.

Gabapentin 

PO: 900-3600 mg/day

Antiepileptic drugs: Miscellaneous

Mechanism of Action: A chemical analogue of GABA, a neurotransmitter that inhibits brain activity. Exact MOA is not known with certainty, but is believed to work by increasing the synthesis and synaptic accumulation of GABA between neurons.

Major side effects: Dizziness, drowsiness, nausea, visual and speech changes, edema.

Nursing Considerations: Airway maintenance is critical because the tongue relaxes during seizure activity, falling backward and blocking the airway. Intake of alcohol and caffeine are to be avoided, as is smoking.

Close monitoring of dosing is important to attain therapeutic blood levels. For example, if an antiepileptic drug is ordered to be administered every 6 hours, it is crucial to dose the drug so that it is given around the clock to maintain blood levels

 

Glucophage 

PO: IR: 500-1000 mg bid (max dose 2550 mg/day)

Oral Antidiabetic drug: Biguanide

Mechanism of Action: Decreasing glucose production by the liver. It may also decrease intestinal absorption of glucose and improve insulin receptor sensitivity

Major Side Effects: Abdominal bloating, nausea, cramping, a feeling of fullness, and diarrhea-especially at the start of therapy.

Nursing Considerations: Metformin with iodinated radiologic contrast media has been associated with both acute renal failure and lactic acidosis. For these reasons, metformin therapy is to be discontinued the day of the test and for at least 48 hours after the patient undergoes any radiologic study that requires the use of such contrast media.

Therapeutic Monitoring: Monitor blood glucose levels.

Heparin 

Prophylaxis: Subcut: 5000 units every 8-12 hour. Treatment: IV infusion: 80 unit/kg bolus, then 18 units/kg/hr (depending on indication)

Anticoagulant Drug

Mechanism of Action: Heparin works by binding to a substance called anti-thrombin III, which turns off three main activating factors: activated factor II (also called thrombin), activated factor X, and activated factor IX. Of these, thrombin is the most sensitive to the actions of heparin. Anti-thrombin III is the major natural inhibitor of thrombin in the blood. The overall effect of heparin is that it turns off the coagulation pathway and prevents clots from forming.

Major Side Effects: Bleeding is a main complication of anticoagulation therapy. Hematoma, anemia, thrombocytopenia. Heparin induced thrombocytopenia (HIT). There are two types of HIT. Type I is characterized by a more gradual reduction in platelets. In this type, heparin therapy can generally be continued. In contrast, in type II HIT there is an acute fall in the number of platelets. Heparin therapy must be discontinued in patients with type II HIT.

Nursing Considerations: Avoid any area within 2 inches of the umbilicus, open wounds, scars, open or abraded areas, incisions, drainage tubes, stomas, or areas of bruising or oozing. These sites would be at higher risk for further tissue damage with injection of the anticoagulant.

Therapeutic Monitoring: Protamine sulfate for toxicity of heparin. aPTT, PT, and INR. *** aPTT levels are measured with heparin, and PT and INR are measured with warfarin.

Hydromorphone 

IV/IM: 0.25-1mg IV every 4-6hr prn. Oral: 2-4 mg PO every 6 hr prn.

Opioid analgesic

Mechanism of Action: The mechanism of action of hydromorphone is as a Full Opioid Agonist. Hydromorphone is the hydrogenated ketone of morphine, a semi-synthetic opioid with analgesic effects. Hydromorphone selectively binds the mu-opioid receptor which is linked through G-proteins.

Major Side Effects: Hypotension, flushing, bradycardia, sedation, disorientation, euphoria, lightheadedness, nausea, vomiting, constipation, itching, rash, resp. depression, and possible aggravation of asthma. ****MOST serious effect of opioid use is CNS depression, which may lead to respiratory depression.

Nursing Considerations: 7 times more potent than morphine. 1 mg hydromorphone= 7 mg morphine. ABCs. Not to be used with alcohol or other CNS depressants.

Therapeutic Monitoring: Naloxone, naltrexone-reverses analgesia as well as CNS depressant effects, such as respiratory depression.

Ibuprofen 

1200-3200mg/day divided 3-4 times daily

One of the most commonly used NSAID: Propionic acid derivative

Mechanism of Action: Work through inhibition of the leukotriene pathway, or both. More specifically, NSAIDs relieve pain, headache, and inflammation by blocking the chemical activity of the enzyme called cyclooxygenase (COX)

Major Side Effects: GI intolerance, bleeding (often GI bleeding) and renal impairment. May cause anaphylaxis. Therapy should be discontinued after first sign of rash

Therapeutic Monitoring: Monitor renal and liver labs. Patient should avoid using alcohol instruct the patient that these drugs, if in sustained release or enteric coated dosage forms- are NOT to be crushed or chewed

Insulin-rapid action (Insulin lispro) 

Subcut: 0.5-1 unit/kg/day; doses are individualized to desired glycemic control; rapid acting insulins are best given at least 15 min before a meal. May be given per sliding scale or as a basal/bolus; may also be given via continuous subcutaneous infusion pump.

Human recombinant. Rapid-acting insulin analogue

Mechanism of Action: Restores the patients’ ability to metabolize carbohydrates, fats, and proteins; to store glucose in the liver; and to convert glycogen to fat stores.

Major Side Effects: Hypoglycemia resulting from excessive insulin dosing can result in brain damage, shock, and possible death. (MOST SERIOUS ADVERSE EFFECT OF INSULIN) weight gain, lipodystrophy at the site of repeated injections, and in rare cases allergic reactions.

Nursing Considerations: Insulin is to NEVER be administered to an already hypoglycemic patient. Blood glucose must ALWAYS be tested prior to administration Give at least 15 minutes before meals & only after monitoring the patients fasting serum glucose level. Administer subQ at a 90 degree angle, unless the patient is emaciated, in which case you may give the insulin at a 45 degree angle. Rotate sites within the same general location for about 1 week before moving to a new location (e.g. all injections for a week in the upper right thigh before moving a little lower on the right thigh) This technique allows for better insulin absorption.

Therapeutic Monitoring: Blood glucose levels. Fasting blood glucose level of 70 to 130 mg/dL and or higher hemoglobin A1C less than 7% for the diabetic patient

Insulin-short action (Regular Insulin) 

Subcut: Same dosage as insulin lispro; subcut doses of regular insulin are best given 30 mins before a meal. Regular insulin may also be given per sliding scale or basal/bolus and is the insulin usually given IV as continuous infusion

Human recombinant. Short-acting insulin

Mechanism of Action: Restores the patient’s ability to metabolize carbohydrates, fats, and proteins; to store glucose in the liver; and to convert glycogen to fat stores

Major side effects: Hypoglycemia resulting from excessive insulin dosing can result in brain damage, shock, and possible death. (MOST SERIOUS ADVERSE EFFECT OF INSULIN) weight gain, lipodystrophy at the site of repeated injections, and in rare cases allergic reactions.

Nursing Considerations: Insulin is to NEVER be administered to an already hypoglycemic patient. Blood glucose must ALWAYS be tested prior to administration Administer subQ at a 90 degree angle, unless the patient is emaciated, in which case you may give the insulin at a 45 degree angle. Rotate sites within the same general location for about 1 week before moving to a new location (e.g. all injections for a week in the upper right thigh before moving a little lower on the right thigh) This technique allows for better insulin absorption.

Therapeutic Monitoring: Blood glucose levels. Fasting blood glucose level of 70 to 130 mg/dL and or higher hemoglobin A1C less than 7% for the diabetic patient

Insulin-intermediate action (Insulin isophane suspension (NPH)) 

Mechanism of Action: Restores the patients ability to metabolize carbohydrates, fats, and proteins; to store glucose in the liver; and to convert glycogen to fat stores

Major Side Effects: Hypoglycemia resulting from excessive insulin dosing can result in brain damage, shock, and possible death. (MOST SERIOUS ADVERSE EFFECT OF INSULIN) weight gain, lipodystrophy at the site of repeated injections, and in rare cases allergic reactions.

Nursing Considerations: ***Do not shake NPH (cloudy) and premixed insulin mixtures, but roll them between the hands before administering the prescribed dose. Onset of action of 1-2 hours, so serve meals at least 30-45 mins prior to its administration. Insulin is to NEVER be administered to an already hypoglycemic patient. Blood glucose must ALWAYS be tested prior to administration. Administer subQ at a 90 degree angle, unless the patient is emaciated, in which case you may give the insulin at a 45 degree angle. Rotate sites within the same general location for about 1 week before moving to a new location (e.g. all injections for a week in the upper right thigh before moving a little lower on the right thigh) This technique allows for better insulin absorption.

Therapeutic Monitoring: Blood glucose levels. Fasting blood glucose level of 70 to 130 mg/dL and or higher hemoglobin A1C less than 7% for the diabetic patient

Insulin-long action. Insulin glargine 

Subcut only: 0.2 units/kg/day given once or twice daily. (basal dosing)

Human Recombinant long acting insulin analogue

Mechanism of Action: Restores the patients ability to metabolize carbohydrates, fats, and proteins; to store glucose in the liver; and to convert glycogen to fat stores

Major Side Effects: Hypoglycemia resulting from excessive insulin dosing can result in brain damage, shock, and possible death. (MOST SERIOUS ADVERSE EFFECT OF INSULIN) weight gain, lipodystrophy at the site of repeated injections, and in rare cases allergic reactions.

Nursing Considerations: Insulin is to NEVER be administered to an already hypoglycemic patient. Blood glucose must ALWAYS be tested prior to administration Administer subQ at a 90 degree angle, unless the patient is emaciated, in which case you may give the insulin at a 45 degree angle. Rotate sites within the same general location for about 1 week before moving to a new location (e.g. all injections for a week in the upper right thigh before moving a little lower on the right thigh) This technique allows for better insulin absorption.

Therapeutic Monitoring: Blood glucose levels. Fasting blood glucose level of 70 to 130 mg/dL and or higher hemoglobin A1C less than 7% for the diabetic patient

Lactated Ringer’s 

This solution is for intravenous use only. Dosage is to be directed by a physician and is dependent upon age, weight, clinical condition of the patient and laboratory determinations. Frequent laboratory determinations and clinical evaluation are essential to monitor changes in blood glucose and electrolyte concentrations, and fluid and electrolyte balance during prolonged parenteral therapy.

Mechanism of Action: Lactated Ringer’s is a sterile solution for fluid and electrolyte replenishment. It restores fluid and electrolyte balances, produces diuresis, and acts as alkalizing agent (reduces acidity)

Major side effects: chest pain, abnormal heart rate, decreased blood pressure, troubled breathing, cough, sneezing, rash, itching, and headache.

Nursing Considerations: Solutions containing lactate are not for use in the treatment of lactic acidosis. Solutions containing lactate should be used with great care in patients with metabolic

or respiratory alkalosis, and in those conditions in which there is an increased level or an impaired utilization of lactate, such as severe hepatic insufficiency.

Therapeutic Monitoring: Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in fluid balance, electrolyte concentrations, and acid-base balance during prolonged parenteral therapy or whenever the condition of the patient warrants such evaluation. Significant deviations from normal concentrations may require tailoring of the electrolyte pattern, in this or an alternative solution.

Lactulose 

PO: 15-30 ml daily or twice daily

Hyperosmotic laxative

Mechanism of Action: Work by increasing fecal water content, which results in distention, increased peristalsis, and evacuation. Their site of action is limited to the large intestine

Major side effects: Abdominal bloating, rectal irritation, electrolyte imbalances

Nursing Considerations: Contraindicated in patients on a low-lactose diet. May be taken with juice, milk, or water to increase palatability

Therapeutic Monitoring: Assess baseline fluid and electrolyte levels to identify any deficits prior to use.

Lanoxin (Digoxin) 

PO/IV: Loading dose: PO 10-15mcg/kg or IV 8-12 mcg/kg divided into 3 doses; usual oral maintenance dose: 0.125-0.25 mg/day

Digitalis Cardiac Glycoside

Mechanism of Action: The beneficial effect of Dig is thought to be an increase in myocardial contractility-known as positive inotropic effect. This occurs secondarily to the inhibition of the sodium potassium adenosine triphosphate pump. When the action of this enzyme complex is inhibited, the cellular sodium and calcium concentrations increase. The overall result is enhanced myocardial contractility. Enhance cardiac efficiency and output.

Major Side Effects: Bradycardia or tachycardia

Nursing Considerations: Indicated for the treatment of heart failure and atrial fib and flutter. Before administering any dose of Dig, check the serum potassium and mag levels to be sure they are within normal limits to help prevent toxicity. May be administered with meals, but not meals high in fiber because the fiber will bind to the digitalis and lead to altered absorption/bioavailability of the drug.

Therapeutic Monitoring: Low therapeutic index. Dig levels are monitored when the patient first starts taking the drug. 0.5-2 ng/mL (normal therapeutic levels) Frequent monitoring of electrolytes. Toxicity- therapy is digoxin immune Fab.

Levothyroxine sodium 

PO: 25-200 mcg/day. IM/IV: 50% of oral dose. IV: 200-500 mcg in a single dose; repeat next day 100-300 mcg if necessary; continue 75-100 mcg/day until changed to oral dosing.

Synthetic thyroid hormone (T4)

Mechanism of Action: At the cellular level, they work to induce changes in the metabolic rate, including the rate of protein, carbohydrate, and lipid metabolism, and to increase oxygen consumption, body temp, blood volume, and overall cellular growth and differentiation. They also stimulate the CV system by increasing the number of myocardial beta-adrenergic receptors. This in turn increases the sensitivity of the heart to catecholamine’s and ultimately increased cardiac output. In addition, thyroid hormones increase renal blood flow and the glomerular filtration rate, which results in diuretic effect.

Major Side Effects: The most significant adverse effect is cardiac dysrhythmia with the risk for life threatening or fatal irregularities. Tachycardia, palpitations, angina, hypertension, insomnia, tremors, headache, anxiety, nausea, diarrhea, cramps, etc.

Nursing Considerations: Assess levels of T3, T4 and TSH before and during therapy as ordered. When administered, it is important that the drug be given at the same time every day to help maintain consistent blood levels of the drug. ***Extremely important to take in the morning and on an empty stomach, preferably at least 30 mins before breakfast. Avoid taking these drugs with vitamins or supplements containing iron and or calcium within a 4 hour time frame. Antacids and OTC preparations with iodine must also be avoided.

Therapeutic Monitoring: monitoring of serum TSH and free thyroid hormone levels are required to determine the appropriate dose of thyroid replacement drugs Patients need to report the occurrence of excitability, irritability, or palpitations to the prescriber because these symptoms may indicate toxicity.

Lorazepam 

The usual range is 2 to 6 mg/day given in divided doses, the largest dose being taken before bedtime, but the daily dosage may vary from 1 to 10 mg/day.

For anxiety, most patients require an initial dose of 2 to 3 mg/day given b.i.d. or t.i.d.

Antianxiety Agents, Benzos, Anxiolytics, Anticonvulsants.

Mechanism of Action: Lorazepam is a benzodiazepine with anxiolytic, anti-anxiety, anticonvulsant, anti-emetic and sedative properties. Lorazepam enhances the effect of the inhibitory neurotransmitter gamma-aminobutyric acid on the GABA receptors by binding to a site that is distinct from the GABA binding site in the central nervous system. This leads to an increase in chloride channel opening events, a facilitation of chloride ion conductance, membrane hyperpolarization, and eventually inhibition of the transmission of nerve signals, thereby decreasing nervous excitation. Major Side Effects: Drowsiness, Dizziness, Tiredness, Muscle weakness, Headache, Blurred vision, Sleep problems (insomnia), Loss of balance or coordination, Forgetfulness or amnesia, Difficulty concentrating, Nausea, Vomiting, Constipation, Changes in appetite, Skin rash.

Nursing Considerations: In general, benzodiazepines should be prescribed for short periods only (e.g., 2 to 4 weeks). Extension of the treatment period should not take place without reevaluation of the need for continued therapy. Continuous long-term use of product is not recommended. Withdrawal symptoms (e.g., rebound insomnia) can appear following cessation of recommended doses after as little as one week of

Abrupt discontinuation of product should be avoided and a gradual dosage-tapering schedule followed after extended therapy. Ativan (lorazepam) is not recommended for use in patients with a primary depressive disorder or psychosis.

Therapeutic Monitoring: Lorazepam should be used with caution in patients with compromised respiratory function (e.g. COPD, sleep apnea syndrome). Elderly or debilitated patients may be more susceptible to the sedative effects of lorazepam. Therefore, these patients should be monitored frequently and have their dosage adjusted carefully according to patient response; the initial dosage should not exceed 2 mg. Some patients on Ativan (lorazepam) have developed leukopenia, and some have had elevations of LDH. As with other benzodiazepines, periodic blood counts and liver function tests are recommended for patients on long-term therapy.

Losartan 

PO: 25-100 mg as a single dose or divided bid

Angiotensin II receptor blocker (ARBs)

Mechanism of Action: The ARBs block the binding of AII to type 1 AII receptors. ARBs affect primarily vascular smooth muscle and the adrenal gland. By selectively blocking the binding of AII to the type 1 AII receptors in these tissues, ARBs block vasoconstriction and the secretion of aldosterone. ***The therapeutic effects of ARBs are related to their potent vasodilating properties.

Major side effects: Chest pain, fatigue, hypoglycemia, diarrhea, UTI, anemia, and weakness. Hyperkalemia and cough are less likely to occur than with the ACE inhibitors.

Nursing Considerations: Used in caution in patients with renal artery stenosis and with renal or hepatic dysfunction. Breastfeeding women must NOT take this drug. Must be taken exactly as prescribed. Often tolerated best with meals. Losartan is also an option for patients at risk for stroke and for those who are hypertensive and have left ventricular hypertrophy.

Therapeutic Monitoring: Monitoring the serum potassium levels

Metoprolol 

PO: 50-400 mg/day depending of form used. IV/PO: 3 bolus injections of 5mg at 2 min intervals followed in 15 min by 50 mg PO every 6 hr for 48 hrs; thereafter 50-100 mg PO bid

Beta1 Blocker

Mechanism of Action: The beta adrenergic blocking drugs (beta blockers) block SNS stimulation of the beta adrenergic receptors by competing with epi and norepi. The beta blockers can be selective or nonselective. Beta1 adrenergic receptors are located in the heart. Beta blockers that are selective for these receptors are called cardioselective beta blockers, or beta1 blocking drugs.

Other beta blockers block both beta1 and beta2 adrenergic receptors and are referred to as nonselective beta blockers. Beta2 receptors are located on the smooth muscles of the bronchioles and blood vessels. Cardioselective beta1 blockers block the beta1 receptors on the surface of the heart. This reduces myocardial stimulation which in turn reduces heart rate, slows conduction through the AV node, prolongs SA node recovery, and decreases myocardial oxygen demand by decreasing contractility. Nonselective beta blockers not only have these cardiac effects, but they block beta2 receptors on the smooth muscle of the bronchioles and blood vessels as well.

Major side effects: bradycardia, depression, impotence, constipation and fatigue. Some of the most serious undesirable effects can be caused by acute withdrawl of the drug. For example: underlying angina, precipitate an MI or cause rebound hypertension.

Nursing Considerations: When given IV, it is considered a high alert drug and patient should be monitored. To help minimize dry mouth, encourage intake of water within any restrictions and frequent rinsing/spraying of mouth with over the counter dental products indicated for dry mouth. Sugarless gum/candy may also be helpful with dry mouth. ****Nursing considerations for patients taking alpha and beta blockers include teaching patients that they must weigh themselves daily, avoid sudden changes in position and increase intake of fluids and fiber. ****Weight gain, dizziness, fainting and/or decrease in HR below 60 beats/min or a BP of less than 100mm Hg systolic or less than 80mm Hg diastolic need to be reported immediately! Caffeine and other central nervous system stimulants must be avoided while taking adrenergic blocking drugs to prevent

Therapeutic Monitoring: When metoprolol is given IV, it is considered a high alert drug and the patient should be monitored.

Metoclopramide

IV: 1-2mg /kg (30 min before chemotherapy; repeat every 2 hr x 2 doses, then every 3 hr x doses) IM: 10-20 mg x 1 dose near end of surgery; repeat every 4-6 as needed

Dopamine antagonist- Prokinetic Drugs.

Mechanism of Action: Act as antiemetics by blocking dopamine receptors in the chemoreceptor trigger zone (CTZ), which desensitizes the CTZ to impulses it receives from the GI tract. Their primary action is to stimulate peristalsis in the GI tract. This enhances the emptying of stomach contents into the duodenum, as well as the intestinal movements.

Major Side Effects: Hypotension, supraventricular, tachycardia, sedation, fatigue, restlessness, headache, dystonia, dry mouth, nausea and vomiting, diarrhea

Nursing Considerations: FDA posted a public health advisory regarding the potential for developing tardive dyskinesia with long term use of metoclopramide. Given orally is best taken 30 mins before meals and at bedtime.

Therapeutic Monitoring: Action of this drug is decreased when it is taken with anticholinergics or opiates, therefore assess for this interaction as well as for interactions with alcohol.

 

 

Metronidazole (Flagyl)-
   COMEBACK

Adult dosing- IV/PO: 250-500 mg every 6-12 hrs

Pharmacologic classification and mechanisms- Class: Nitromidazole(antibiotics)

MOA: works by interfering with microbial DNA synthesis, and in this regard is similar to quinolones

Major side effects-reversible neutropenia and thrombocytopenia

Nursing considerations- Pregnancy category B, although not recommended for using during first trimester of pregnancy

Therapeutic monitoring- cytochrome P-450 liver enzyme that results in altered drug metabolism when drugs are taken concurrently with metronidazole.

 

Morphine Sulfate

Adult dosing- PO: 10-30 mg every 4 hr prn, IV/IM/ subcut: 2.5-10 mg every 2-6 hr prn, continuous release PO: 15 mg every 8 hrs 2- 200 mg every 8-12 hr

Pharmacologic classification and mechanisms-Class: Opioid Agonists/analgesic MOA: agonists binds to an opioid pain receptor in the brain and causes an analgesic response- the reduction of pain sensation

Major side effects- most serious adverse effects of opioid use is CNS depression, which may lead to respiratory depression. Bradycardia may also be seen. GI adverse affects are common in pts receiving opioids due to stimulation of GI receptors (constipation). Urinary retention

Nursing considerations- When opioids are given, care must be taken to titrate the dose so that the patients pain is controlled without affecting respitory function.

Therapeutic monitoring- Narcan (naloxone) is reversal drug for opioids. Monitor urinary output (should be at least 600mL/ 24 hr) and monitor bowel sounds as well.

 

Naloxone

Adult dosing- IV: 0.4-2 mg, repeat in 2-8 mins if needed. IV: 0.1-0.2 mg, repeat at 2-3 min intervals. PO: 50 mg every 24 hrs or 100 mg every other day

Pharmacologic classification and mechanisms- Class: opioid antagonist MOA: binds to a pain receptor but does not reduce the pain signals. It functions as a competitive antagonist bc it compete with and reverses the effects of agonist and agonist-antagonist drugs at the receptor site.

Major side effects- opioid withdrawal syndrome, which can occur with abrupt over- reversal in opioid- tolerant patients. Also raised or lowered BP, dysrhythmias, and pulmonary edema.

Nursing considerations- remembered that the antagonist drug may not work with just one dosing and that repeated doses are generally needed to reverse the effects of the opioid.

Therapeutic monitoring- Assess and document vital signs before, during, and after the use of antagonist so that the therapeutic can be further assessed and documented and the need for further doses determined

 

Nifedipine

Adult dosing- 10 mg PO q8hr or 30-60 mg (extended relsease PO once a day may be increased every 14 days PRN

Pharmacologic classification and mechanisms- Class: Calcium channel blocker MOA: calcium channel blocker; inhibits transmembrane influx of extracellular calcium ions across myocardial and vascular smooth muscle cell membranes without changing serum calcium concentrations; this results in inhibition of cardiac and vascular smooth muscle contraction, thereby dilating main coronary and systemic arteries which increases clood flow to the ischemic heart which in turn increases o2 supply helps shift the supply/demand ratio back to normal

Major side effects- adverse affects are limited and primarily relate to over expesrrion of their therapeutic effects. Used to be used to lower bp in acute hypertensive emergencies however, negative outcomes came out of dramatic reduction of bp

Nursing considerations- bc of safety and acceptable adverse affects they are considered first line drugs for tx of conditions like angina, htn, svt, and coronary spasms. GRAPEFRUIT REDUCES THE MEABLOISM OF NIFEDIPINE, leading to possible toxicity

Therapeutic monitoring-dosage form. Carefully administer and closely monitor the pt, weight, monitor pt for edema

 

Normal Saline

Adult dosing-

Pharmacologic classification and mechanisms-Class: Crystalloid MOA: Crystalloid solutions contain fluids and electrolytes that are normally found in the body. Crystalloids are also substances in a solution that diffuse though a semipermeable membrane.

Major side effects-Crystalloid are very safe and effective means of replacing needed fluids. However one unwanted side effect is edema bc since they contain no large particles, such as protein, they do not stay within blood vessels and can leak out of the plasma into the tissue and cells, resulting in edema.

Nursing considerations- hypertonic saline is considered high-risk drug bc deaths have occurred when infused properly.

Therapeutic monitoring- intravascular volume, plasma volume, fluid volume and electrolyte status, vital signs, urinary specific gravity and intake and output

 

Ondansetron
(Zofran)

Adult dosing- PO: 8 mg tid IV: 0.15 mg/kg every 4 hr usually given over 2 to 5 min push

Pharmacologic classification and mechanisms- Class: Antiserotonergic MOA: serotonin blockers work by blocking serotonin receptors in the GI tract, the CTZ, and the vomiting Also called 5-HT3 receptor blockers bc they block the 5-HT3 receptor subtype

Major side effects- Ondansetron has the warning of its use and the risk of cardiac dysrhythmias. HA, diarrhea, rash, broncospam

Nursing considerations- oral forms are well tolerated regardless of the relation of dosing to meals. Encourage pts to avoid alcohol and other CNS depressants during this therapy and to avoid activates requiring mental alertness or motor skill.

Therapeutic monitoring- requires assessment of signs and symptoms of dehydration and electrolye disturbance.

 

 

Pantoprazole
(Protonix)

Adult dosing- PO/IV: 20-80 mg/day

Pharmacologic classification and mechanisms- Class: Proton Pump Inhibitor MOA: PPI’s bind irreversibly to the proton pump. This inhibition prevents movement of hydrogen ions out of the parietal cell into the stomach and thereby blocks all gastric acid secretion.

Major side effects- PPI’s are generally well tolerated The frequency of adverse effects has been similar to that for placebo or H2 receptor antagonist. There are concerns that these drugs may be over prescribed and may redispose pts to GI tract infections bc reduction or normal acid.

Nursing considerations- New concerns have risen over the potential for long- term users of PPI’s to develop osteoporosis

Therapeutic monitoring- Since concerns about thoroughly asses bones for this disorder and monitor GI tract infections due to decreased acid-mediated antimicrobial` protection.

 

Phenytoin
(Dilantin)

Adult dosing- PO: 300-400 mg/kg

Pharmacologic classification and mechanisms- Class: anticonvulsants- hydantoins MOA:

Major side effects- analeptic drugs are plagued by many adverse effects which often limit their usefulness. Adverse effects include nystagmus, ataxia, gingival hyperplasia, dysarthria and encephalopathy thrombocytopenia, hypertrophy of subcutaneous facial tissue hepatitis, GI upset

Nursing considerations- Phenytoin has may advantages for long term therapy. It is usually well tolerate, highly effective can be given IV but, it is very irritating to veins when injected and must be given by slow IV push

Therapeutic monitoring- phenytoin levels, serum albumin, liver enzyme P-450 enzyme, neurologic function with any CNS altering medication, CBC

 

Potassium

Adult dosing- Fluid and electrolyte therapy involves replacing any deficits or losses and/or providing maintenance levels for specific pt requirements. Suggested dosage guide lines

Pharmacologic classification and mechanisms- Class: Electrolytes MOA: Potassium supplements are administered Potassium is also essential for the maintenance  of acid-case balance, isotonicity, and the electrodynamics characteristics of the cell and is the primary intracellular electrolyte

Major side effects- GI bleeding and ulceration. Cases of phlebitis have been associated

Nursing considerations- if given with potassium supplements can cause adverse hyperkalemia and possible cardiac dysrhythmias

Therapeutic monitoring- Serum Potassium 3.5-5 mEq/L

 

Prednisone

Adult dosing- 5-60 mg/day

Pharmacologic classification and mechanisms- Class: adrenal Corticosteroids MOA: Glucocorticosteroid; elicits mild mineralocorticoid activity and moderate anti-inflammatory effects; controls or prevents inflammation by controlling rate of protein synthesis, suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts, reversing capillary permeability, and stabilizing lysosomes at cellular level; in physiologic doses, corticosteroids are administered to replace deficient endogenous hormones; in larger (pharmacologic) doses, they decrease inflammation

Major side effects- The most serious adverse effect of glucocorticoids is adrenal suppression

Nursing considerations- Glucocorticoids should be used with caution on pts with heart failure, due to their ability to cause fluid retention

Therapeutic monitoring- water and salt retention, weight nutritional hydration, intake and output,

 

Promethazine
(Phenergan)

Adult dosing- IV, IM, PO, PR: 12.5-25 mg every 4-6 hrs

Pharmacologic classification and mechanisms- Class: Antidopaminergics MOA: block dopamine receptors in the CTZ and may also have anticholinergic actions and calm the CNS

Major side effects- orthostatic hypertension, tachycardia constipation

Nursing considerations- Encourage pt to avoid alcohol and other CNS depressants during this therapy. Also avoid activates requiring mental alertness or motor skills.

Therapeutic monitoring- monitor vital signs, BP, and pulse rate due to adverse effects of orthostatic hypertension and tachycardia

 

Sulfamethoxazole/Trimethoprim

Adult dosing- IV/PO: 8-20 mg/kg/day in divided doses

Pharmacologic classification and mechanisms- Class: Sulfonamides MOA: They do not destroy bacteria, rather they inhibit their growth (bacteriostatic antibiotics) by preventing bacterial synthesis of folic acid. Folic acid is required for proper synthesis pf purines a component of nucleic acids (DNA and RNA)

Major side effects- necrosis, photosensitivity which can result in severe sunburn

Nursing considerations- resistant bacterial strains are growing the combination of these two drugs allows for a synergistic antibacterial effect

Therapeutic monitoring- therapeutic efficacy and adverse drug effects, WBC count, sulfa allergy, bun/creatinine

 

 

Tramadol

Adult dosing- PO: 50-100 mg every 2-4 hrs not to exceed 400mg/day

Pharmacologic classification and mechanisms- class: nonopioid analgesic MOA: It is centrally acting analgesic with a dual MOA. It creates a weak bond to the mu opioid receptors and inhibits the reuptake of both norepinephrine and serotonin. Although it does have weak opioid receptor activity, tramadol is not currently classified as a controlled substance.

Major side effects-similar to those od opioids: respiratory depression, constipation nausea, dizziness, drowsiness, HA. Seizures have been reports in pts taking tramadol and can occur in pts taking both normal and excessive dosages

Nursing considerations- With tramadol assessment of age is important bc this drug is not recommended for use in individual 75 years of age or older.

Therapeutic monitoring- monitor for respiratory depression, especially during inital or following a does increase, ultra rapid metabolism, cytochrome P-450 liver enzyme

 

 

 

Vancomycin

Adult dosing- IV: 15-20 mg/kg/day PO: 125-500 mg every 6 hrs

Pharmacologic classification and mechanisms- Class: Tricyclic Glycopeptide lass MOA: It destroys bacteria by binding to the bacterial cell wall, producing immediate inhibition of cell wall synthesis and death.

Major side effects- ototoxicity (hearing loss) and nephrotoxicity (kidney damage) red man syndrome seen when administered to rapidly, not harmful just bothersome.

Nursing considerations- assess pt for history of preexisting renal dz. Vanc may be used orally but is poorly absorbed by this route, and is only used to treat GI treat microbes (C-diff). Is drug of choice for MRSA infection and infections cause ny many other gram + bacteria. Is not active against gram – bacteria

Therapeutic monitoring- kidney function, trough levels, possible hearing loss, skin color

 

Warfarin(Coumadin)

Adult dosing- INR determines maintenance dosage, usually 1-10 mg/day orally

Pharmacologic classification and mechanisms- Class: Anticoagulants MOA: sometimes also called antithrombotic bc they work to prevent the formation of a clot or thrombus a condition known as thrombosis, All anticoagulants work in the clotting cascade but do at different points. Warfarin works by inhibiting vitamin K synthesis in GI tract. This in turn inhibits clotting factors II, VII IX, & X that are normally synthesized in the liver and are vitamin K dependent.

Major side effects- Warfarin can cause necrosis and “purple toes” syndrome.

Nursing considerations- Combining Warfarin and Amiodarone will lead to 50% increase in the INR. When Amiodarone is added to therapy, it is recommended that warfarin be cut in half. Genetic testing for these genes CYP2CP and VKORC1 bc 1/3 of pts taking this drug with these genes metabolize it differently, it is helpful in determining the appropriate initial dosage of warfarin. Caution with Vitamin K rich foods (leafy greens) could cause reversal.

Therapeutic monitoring- careful monitoring of PT/INR

Advanced registered nursing graduates are entering the profession at dynamic time when roles and scope of practice are shifting based on developments in legislation and policy in response to the evolving needs of the health care system. Professional nursing organizations play an important role in making sure the perspectives of advanced registered nurses are heard, and in supporting nurse specialties in their efforts to expand their scope of practice and their full participation throughout the health care system.

For this assignment, you will conduct research on the current scope of practice for your specialty and efforts that are being made to expand that scope and the role of the advanced nurse in positively influencing the health care system. Write a 1,250-1,500-word paper that includes the following:

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

A discussion of the scope of your future role as an advanced registered nurse, including any regulatory, certification, or accreditation agencies that define that scope.

A discussion of three professional nursing organizations that you think are most influential in advancing the scope and influence of advanced nursing. Of these organizations, evaluate the one that you would most like to join. How do its goals and mission fit in with your worldview and philosophy of care? How might membership in this organization improve your practice?

A discussion of a controversial or evolving issue that is most likely to affect your scope of practice or role in the next few years. How do you think this issue could influence the profession and other stakeholders, and why does it matters to the advanced registered nurse?

You are required to cite five to 10 sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.

My speciality is – Nurse Educator

I will upload the rubic for this project

Course Code

Class Code

Assignment Title

Total Points

NUR-513

NUR-513-O502

Benchmark – Future Scope, Role, and Professional Obligations Paper

250.0

Criteria

Percentage

Unsatisfactory (0.00%)

Less than Satisfactory (80.00%)

Satisfactory (88.00%)

Good (92.00%)

Excellent (100.00%)

Content

70.0%

The Scope of Your Future Role as an Advanced Registered Nurse, Including Any Regulatory, Certification, or Accreditation Agencies That Define That Scope

20.0%

A discussion of the scope of the future role as an advanced registered nurse, including any regulatory, certification, or accreditation agencies that define that scope, is not included.

A discussion of the scope of the future role as an advanced registered nurse, including any regulatory, certification, or accreditation agencies that define that scope, is present, but it lacks detail or is incomplete.

A discussion of the scope of the future role as an advanced registered nurse, including any regulatory, certification, or accreditation agencies that define that scope, is present.

A discussion of the scope of the future role as an advanced registered nurse, including any regulatory, certification, or accreditation agencies that define that scope, is clearly provided and well developed.

A comprehensive discussion of the scope of the future role as an advanced registered nurse, including any regulatory, certification, or accreditation agencies that define that scope, is thoroughly developed with supporting details.

Three Professional Nursing Organizations Identified as the Most Influential in Advancing the Scope and Influence of Advanced Nursing

15.0%

A discussion of three professional nursing organizations identified as the most influential in advancing the scope and influence of advanced nursing is not included.

A discussion of three professional nursing organizations identified as the most influential in advancing the scope and influence of advanced nursing is present, but it lacks detail or is incomplete.

A discussion of three professional nursing organizations identified as the most influential in advancing the scope and influence of advanced nursing is present.

A discussion of three professional nursing organizations identified as the most influential in advancing the scope and influence of advanced nursing is clearly provided and well developed.

A comprehensive discussion of three professional nursing organizations identified as the most influential in advancing the scope and influence of advanced nursing is thoroughly developed with supporting details.

Evaluate the Professional Organization That Is Most Appealing, Including How Its Goals and Mission Fit in With Worldview, Philosophy of Care, and Ability to Improve Practice (5.3)

15.0%

An evaluation of the professional organization that is most appealing, including how its goals and mission fit in with worldview, philosophy of care, and ability to improve practice, is not included.

An evaluation of the professional organization that is most appealing, including how its goals and mission fit in with worldview, philosophy of care, and ability to improve practice, is present, but it lacks detail or is incomplete.

An evaluation of the professional organization that is most appealing, including how its goals and mission fit in with worldview, philosophy of care, and ability to improve practice, is present.

An evaluation of the professional organization that is most appealing, including how its goals and mission fit in with worldview, philosophy of care, and ability to improve practice, is clearly provided and well developed.

A comprehensive evaluation of the professional organization that is most appealing, including how its goals and mission fit in with worldview, philosophy of care, and ability to improve practice, is thoroughly developed with supporting details.

A Controversial or Evolving Issue That Is Most Likely to Impact Scope of Practice or Role in the Next Few Years, Including How This Issue Could Influence the Profession and Other Stakeholders and Why It Matters to the Advanced Registered Nurse

15.0%

A discussion of a controversial or evolving issue that is most likely to impact scope of practice or role in the next few years, including how this issue could influence the profession and other stakeholders and why it matters to the advanced registered nurse, is not included.

A discussion of a controversial or evolving issue that is most likely to impact scope of practice or role in the next few years, including how this issue could influence the profession and other stakeholders and why it matters to the advanced registered nurse, is present, but it lacks detail or is incomplete.

A discussion of a controversial or evolving issue that is most likely to impact scope of practice or role in the next few years, including how this issue could influence the profession and other stakeholders and why it matters to the advanced registered nurse, is present.

A discussion of a controversial or evolving issue that is most likely to impact scope of practice or role in the next few years, including how this issue could influence the profession and other stakeholders and why it matters to the advanced registered nurse, is clearly provided and well developed.

A comprehensive discussion of a controversial or evolving issue that is most likely to impact scope of practice or role in the next few years, including how this issue could influence the profession and other stakeholders and why it matters to the advanced registered nurse, is thoroughly developed with supporting details.

Required Sources

5.0%

Sources are not included.

Number of required sources is only partially met.

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Number of required sources is met. Sources are current, but not all sources are appropriate for the assignment criteria and nursing content.

Number of required resources is met. Sources are current, and appropriate for the assignment criteria and nursing content.

Organization and Effectiveness

20.0%

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7.0%

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Argument Logic and Construction

8.0%

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Clear and convincing argument that presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.

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5.0%

Surface errors are pervasive enough that they impede communication of meaning. Inappropriate word choice or sentence construction is used.

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Prose is largely free of mechanical errors, although a few may be present. The writer uses a variety of effective sentence structures and figures of speech.

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5.0%

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Documentation of Sources (citations, footnotes, references, bibliography, etc., as appropriate to assignment and style)

5.0%

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Sources are documented, as appropriate to assignment and style, although some formatting errors may be present.

Sources are documented, as appropriate to assignment and style, and format is mostly correct.

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Total Weightage

100%

PICO Research Assignment – Xerostomia, xylitol & biotiene

PICO Research Assignment

This paper is a brief essay that discusses dental hygiene in terms of whether xylitol as compared to biotiene mouth spray can help to increase salivation in the oral cavity for patients with xerostomia. This essay adopts the PICO tool to analyze this dental issue and provide viable solutions.

PICO Question: For client with Xerostomia, will xylitol as compared to biotiene mouth spray help to increase salivation in the oral cavity?
 

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Article One:

Stack, K. M., & Papas, A. S. (2014). Xerostomia: Etiology and Clinical Management.  Nutrition In Clinical Care, 4(1), 15-21.

This article talks about the different clinical methods that can be used to treat xerostomia as one of the common dental problems. The author explains that xerostomia mainly manifests in the form of dryness of the mouth and if it is not treated early it can lead to more severe oral cavity diseases (Stack et al, 2014). The article highlights the common symptoms of this disease such as difficulty in chewing, swallowing and even burning sensations. At the same time, the paper provides various forms of therapy and treatment for xerostomia (Ship et al, 2014) PICO Research Assignment – Xerostomia, xylitol & biotiene.

The application of the PICO tool to analyze this paper would show that the population being referred to in this case are the patients or victims of xerostomia. The intervention that is recommended is the various ways of treating this dental malfunction and they include use of fluoride therapy, regular dental visits as well as using dental products that contain xylitol, biotene and even olive oil (Stack et al, 2014).  The author insists that both biotene and xylitol are very helpful and efficient when it comes to treating xerostomia (Ship et al, 2014). In terms of the comparison aspect, xylitol happens to be more effective. PICO Research Assignment – Xerostomia, xylitol & biotiene.

This is shown in the outcome of this essay that illustrates how patients who used dental products with xylitol were able to benefit from curing and reducing the occurrence of xerostomia. This is because they are able to stimulate the salivary glands and increase flow of saliva in the mouth (Stack et al, 2014). Hence, the issue of dryness in the mouth and other uncomfortable symptoms are totally eradicated.

Article Two:

 Danhauer, J. L., Johnson, C. E., Baker, J. A., Ryu, J. A., Smith, R. A., Umeda, C. J., & … Pratt, S. (2015). Will Parents Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis Media in Their Children?. Language, Speech & Hearing Services In Schools, 46(2), 127-140. Doi: 10.1044/2015_LSHSS-14-0048

This paper highlights the importance of using xylitol so as to control acute otitis which is one of the symptoms associated with xerostomia. The article indicates that if a child was placed on xylitol which mainly contains natural sugars and alcohol, they are able to prevent the effects of xerostomia from spreading and keep them minimized (Danhauer et al, 2015). This is because this dental condition is quite severe and its effects can result in chronic infections in the nasopharyngeal regions such as the nose and middle ear. The author of this paper recommends the use of this treatment as opposed to other dental therapies that are mostly obtained over the counter (Bruce, 2009). PICO Research Assignment – Xerostomia, xylitol & biotiene.

In terms of using the PICO tool, the target population are people and children that constantly suffer from xerostomia. The intervention used is xylitol in trying to treat xerostomia as compared to using biotene or other products like olive oil (Danhauer et al, 2015).  The comparison to be drawn in this case would be how the different dental products can be effective in treating this oral problem (Bruce, 2009). The outcome shows that children that were placed on this form of treatment were able to have the symptoms and occurrence of xerostomia relieved among a large population (Bruce, 2009). Conclusively, dental products and mouth sprays that contain xylitol can effectively help in increasing production of saliva within the oral cavity for patients suffering from xerostomia.

 

References

Bruce, S. D. (2009). Radiation-Induced Xerostomia: How Dry Is Your Patient?. Clinical Journal of Oncology Nursing, 8(1), 61-67. doi:10.1188/04.CJON.61-67

Danhauer, J. L., Johnson, C. E., Baker, J. A., Ryu, J. A., Smith, R. A., Umeda, C. J., & … Pratt, S. (2015). Will Parents Participate in and Comply With Programs and Regimens Using Xylitol for Preventing Acute Otitis Media in Their Children?. Language, Speech & Hearing Services In Schools, 46(2), 127-140. Doi: 10.1044/2015_LSHSS-14-0048 PICO Research Assignment – Xerostomia, xylitol & biotiene

Ship, J. A., Mccutcheon, J. A., Spivakovsky, S., & Kerr, A. R. (2014). Safety And effectiveness of topical dry mouth products containing olive oil, betaine, and xylitol in reducing xerostomia for polypharmacy-induced dry mouth. Journal Of Oral Rehabilitation, 34(10), 724-732. doi:10.1111/j.1365-2842.2006.01718.x

Stack, K. M., & Papas, A. S. (2014). Xerostomia: Etiology and Clinical Management. Nutrition In Clinical Care, 4(1), 15-21. PICO Research Assignment – Xerostomia, xylitol & biotiene.

Lactobacillus Casei

Relevant issue/subject identified and appropriately introduced

In the backdrop of high cases of civilization diseases, industry and science in general direct their effort toward food products. In particular, interest is directed toward research beyond the regular nutritional function to deliver additional health benefits. In essence, science is trying to minimize risk of diseases. This has led to the emergence of what is commonly referred to as functional foods. The term encompasses a broad range of products and relates to foods that possess a potentially positive impact on health past basic nutrition. Probiotics or bifidobacteria are an example. The consumption of lyophilized or living cultures of bifidobacteriais known to have several benefits including enhancing the immune system action and prevent coronary diseases as well as cancer. The beneficial consequences of bifidobacteria on gastroeneteretis, bowel syndrome, hyperlipidemia, inflammatory bowel disease, diarrhea and hepatic disease are well known. Nevertheless, the most frequently used probiotic products include bio-yoghurts retailed by wholesalers and others. Worth noting is that besides the archetypal yoghurt strains including Streptococcus thermophilus and lactobacillus delbrueckii ssp bulgaricus, bio-yoghurts contain cultures of live bifidobacteria such as lactobacillus casei and others. This indicates a rising consumer interest in such products in addition to commercial competition that has meant that producers are competing in diversifying range of goods/products. In most cases, the assortment takes the form of new and exciting flavor achieved through adding rare fruit. Without a doubt, such actions are taken to ensure competiveness in the complex market of today’s world. However, while research on probiotics has increased over the last decades, few works exist describing the manner in which they function leading to the desired health benefits. In essence, majority of researchers are yet to establish the manner in which such probiotics as lactobacillus casei function thus affecting human health. Rather, available scientific studies on probiotics focuses on the products containing them including yoghurts. This has meant that the effects lactobacillus and others on human system has been given a peripheral role in the studies. It follows that while consumers are aware of some of the benefits derived from consuming related products, many do not know the best products to choose from the saturated market. In sum, studies are yet to provide concrete evidence on the manner in which lactobacillus casei and others function thus enhancing the human system in one way or the other.

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Concise and clear discussion of the current status of knowledge in the chosen subject area.

Lactobacillus casei strains represent gram-positive, facultative anaerobic, industrially significant LAB (lactic acid bacteria) that has been principally used as fibidobacterias and specialty cultures for various products development. In fact, it has been suggested that their wide commercial applications may be a reflection of their extraordinary ecological adaptability to different habitats. Nevertheless, Lactobacillus casei may be isolated out of raw as well as fermented dairy products (including yoghurts) and animal products.  Despite all these findings, many dimensions or subjects involving the topic of Lactobacillus casei are at infancy or unknown altogether. As mentioned above, few works exist describing the manner in which probiotics function leading to the desired health benefits. In most cases, such a situation results from the failure to understand the genetic basis regarding the ecological flexibility in lactobacillus casei and others. Currently, the field of probiotics is filled with comparative genomic studies suggesting extensive gene loss as well as gene acquisitions throughout evolution of lactobacilli –presumably through bacteriophage or conjugation mediated hgts (horizontal gene transfers) that may have facilitated the adaptation to different ecological niches (Makarova 2006, p 15611-15616). For instance, milk as well as vegetable-associated sub-species of lactobacillus has been found to contain high level of genetic heterogeneity. As well, correlations have been demonstrated between specific gene acquisition or loss and the capacity of the species to inhabit specific habitats. Worth noting is that these are pure attempts to explain the manner in which probiotics including lactobacillus casei may affect human system (Makarova 2006, p 15611-15616). What is more, comparative genomic examination on lactobacillus strains of different sources show genomic regions with atypical base composition pinpointing evolutionarily recent acquisitions (Makarova 2006, p 15611-15616). In sum, it becomes evident that current knowledge does not add up and the manner in which lactobacillus casei and others affect human system is far from clear.

Worth noting is that molecular typing of Lactobacillus casei is vital to comprehending the evolutionary adaptation of the species to various ecological niches including the manner in which it helps our body system. What is more, definitive identification of Lactobacillus casei at the strain level is crucial for a range of industrial applications because it facilitates tracking of various strains with such industrially relevant characteristics as probiotic and antimicrobial elements. Currently, a number of molecular typing methods including randomly amplified polymorphic DNA, temporal temperature-gradient electrophoresis as well as pulsed-filed gel electrophoresis have been used in Lactobacillus casei (Farnworth 2008, p 49-54). The latter approach has been reported to show the highest discriminatory influence. Nevertheless, these the approaches have less effectiveness in describing underlying phylogenetic associations and thus making it difficult to establish how Lactobacillus casei and others work leading to health benefits. In essence, current approaches have proved to be of little use as far as the area of human health is concerned. In total, current knowledge in the area of probiotics is non-conclusive with regard to the manner in which it positively influences body system.

Evidence of wide range of reading

Most strains related to lactobacillus casei including shirota are rod-spaped and occur either singly or in pairs. In addition, they have been found to occur in short chains constituting 3 or 4 cells. Normally, lactobacillus casei strains are capable of growing at temperatures ranging from 27 through 43 degrees (Gaynor 2012, p 10). The strains can grow at low ph level of 3.5, but optimal ph is 6.5. Lactobacillus casei is a facultative homo-fermentative lactic acid bacteria, and produces 2 lactic acid molecules out of every glucose molecule – though it also generates small quantities of ethanol, acetate and diacetyl. Nevetheles, regarding the fermentative characteristic of lactobacillus casei strains, lactic acid is generated from adonitol, ribose, d-glucose, galactose, mannitol, D-mannose, salicin, turanose and sorbitol (Gaynor 2012, p 10). In addition, it is weakly generated from sucrose and inositol, but from inulin, glycerol, glycogen, starch and xylitol.

Lactobacillus casei relates to a harmless and non-pathogenic microorganism that is broadly recognized for its properties and attributes that have been shown to be beneficial to the human body. As a type of bacteria, lactobacillus casei helps to boost human body defense system through restricting the development of certain types of dangerous bacteria that lead to infection. This means that lactobacillus casei is beneficial and occurs naturally in human’s mouth as well as intestines. Essentially, the bacteria is known to produce amounts of lactic acid which is helpful in lowering the levels of ph in human’s digestive system thus impending the development of harmful bacteria. In addition, lactobacillus casei may be present if fermented dairy as well as fermented and fresh plant products. Such sources may include yoghurt and other food sources including fermented green olives. Different findings indicate that scientists have found the bacteria to have beneficial characteristics that improve human health. In particular, the bacteria is not only able to improve but also promote digestion. In addition, some strains associated with lactobacillus casei help manage diarrhea and others have an anti-inflammatory influence on the gut (Probiotic.org 2009, web). There are several other benefits linked to the bacteria as far as human health is concerned including alleviating constipation, lactose intolerance and general modulation of human immune system. In sum, lactobacillus casei is classified under friendly bacteria that are significant to proper functioning of the immune system, digestion and absorption of nutrients as well as protection against microorganisms that lead to disease. As such, ensuring that the body receives an appropriate level of lactobacillus casei is important. Nonetheless, probiotic strains including lactobacillus casei are selected to give beneficial impacts on the host as well as on the metabolism or composition of the intestinal microbiota without necessarily inflicting adverse transformations including production of toxins and epithelial cell invasion –effects that would imperil the nutritional or health status of the host. Resultantly, lactobacilli have been ingested on a daily basis since fermentation of milk was discovered. This includes the probiotic utilization of various lactobacillus species for decades, and possibly was ingested from the earliest history since they normally inhabit green plant material (Gaynor 2012, p 20). Research indicates that lactobacilli are ever-present because they are found in virtually all carbohydrate rich substances. Several authors also report that in healthy persons, lactobacilli are normal and found in the ileum, the oral cavity as well as the colon. In addition, they are dominant microorganism in human’s vagina. In sum, their close relation with human health is evident and their long application as probiotics without risk to humans has been noted. In fact, their significance is underlined by the fact that no pathogenic characteristic has been associated with them.

A discussion by Cabana et al (2006, p 407) observed that while probiotic’s optimal dose remains an area under investigation, there exists no reports of toxicity linked to exceeding a specific dose. This indicates that their pathogenic characteristic is quite low or non-existent altogether. On the other hand, Vandenplas et al (2007, p 46) noted that such probiotics as lactobacillus casei never colonize human’s grastro-intestinal tract because they become undetectable shortly after stopping the administration. The outcome is the absence of risks for long-term side effects. Bearnadeu et al (2008, p 157) noted that the risk –if any- of bacteremia from bifidobacteria and probiotic lactobacilli is 1 in a million. It can be concluded that the overall risk from lactobacillus and others presents a negligible imperil to consumers of such products as yoghurt. This also includes negligible risk to immune- compromised hosts. In addition, the bibliographical data has been shown to promote the hypothesis that the consumption of lactobacillus strains is not in any hazardous because lactobacillemia induced through food (including fermented dairy products) is extremely rare (Bearnadeu et al 2008, p 157).

According to Guerin-Danan et al (2000, 111-117 am jpdf), yoghurt is explained as a fermented milk obtained through specific fermentation of lactic acid –via the action of streptococcus thermophilus as well as lactobacillus bulgaricus. Ingestion of related products induces transformations in the equilibrium as well as metabolism of the microflora and may therefore a healthful effect on the host. Nevertheless, Guerin-Danan et al (2000, 111-117) notes that fermented milks including yoghurt have substantial health benefits and can be included in human’s diet from an early age. In fact, they act as good sources of vitamins and minerals and have small amounts of lipids. What is more, fermented milks including yoghurt help control the intake of dietary nitrogen elements in human body as well as supply many lactic acids. Nonetheless, the consumed lactic acid bacteria in some measure resist gastric acidity as well as bile salts. This means that it passes live via the gastrointestinal tract in which they may regulate the metabolism and balance of endogenous microflora. The regulation of such modifications is crucial to health because microflora (mouth and intestinal) can exert either advantageous or disadvantageous effects on the host. Guerin-Danan et al (2000, 111-117) also note that other lactic acid bacteria –particularly those related to lactobacillus – can be included in yoghurt to create fermented milks with definite desirable characteristics including new flavor. Additionally, various lactic acid bacteria are incorporated for the properties – signifying that probiotics can lead to benefits beyond basic nutrition.

According to Wu et al (2011, 1031-1039), lactobacillus casei strains have conventionally been recognized as probiotics. In addition, they have been frequently utilized as adjunct culture in fermented milks in which lactic acid stress is a commonly encountered environmental condition. Lactic acid bacteria relates to a heterogeneous group of bacteria that are applied to create fermented foods (including yoghurt), and are generally accepted as safe. In addition, lactic acid bacteria comprise a collection of microbes related via common metabolic functionality (i.e the creation of lactic acid as a major metabolic end product related to carbohydrate metabolism) and common physiological characteristics. These microbes are Gram positive, catalase-negative, non-spore forming as well as devoid of cytochromes all of which underline their potential in promoting health (Gaynor 2012, p 20). As well, they are preferential non-aerobes, but are acid- tolerant, aero tolerant and strictly fermetative. Even though they are not a closely efined group, lactic acid bacteria usually are considered to constitute a phylogenetically related general such as streptococcus and others. As a result of resemblance in its physiology, ecology and biochemistry, the genus (bifidobacterium) is frequently considered as a lactic acid bacteria – though it may be phylogenetically unrelated. With the exception of some species and strains including streptococcus and enterococcus, most lactic acid bacteria strains are deemed to have no pathogenic potential. Indeed, they are normally found in human’s oral cavity as well as digestive tract. In addition, the bacteria has conventionally known as a probiotic thus used in such commercial products as yoghurts for its health promoting as well as nutritional characteristics. Yet, similar to other lactic acid bacteria, lactobacillus casei encounters a number of stress conditions through industrial processes as well as in the gastrointestinal tract- among which acid stress is an important challenge to its survival. This means that lactobacillus strains including casei are faced with many challenges from the environment and may not survive after all. In some cases, combination of environmental factors may make them harmful altogether.

Attempts to evaluate/appraise cited literature

Besselink et al (2008, p 651-659) cite a publication which claimed to have found higher mortality among persons with acute pancreatitis when treated with strains from bifidobacterium species. In fact, some people questioned the safety of such probiotics as lactobacillus casei. However, a review of the study was conducted and established that- for various reasons- the findings should not make anyone call into question the usefulness of lactobacillus casei and other species. First, it was revealed that the subject in the study were critically ill with a condition that had a mortality rate of up to 30 percent (Besselink et al 2008, p 651-659). In addition, the path of probiotic administration was nasojejunal, rather than oral. In sum, sources that have attemped to disapprove the usefulness and safety of lactobacillus strains have been found to have fundamental flaws as indicated above. In fact, several reserachers have subsequently analyzed such studies and suggested that the high mortality may have been caused by the introduction of enteral solution into the intestine with a huge number of lactic acid-generating bacteria. Worth noting is that fermentation of the enteral nutrition solution via the bacteria may have resulted in the development of semi-solid mass, and lead to bowel ischemia. Besselink et al (2008, p 651-659) notes that the fermented nutrition solution could have remained in the small intestines at the optimal condition with the bacteria without being absorbed. All of this points to a widespread misunderstanding as to the manner in which lactobacillus strains function, thus improving human health.

Other researchers have supported the fact that lactobacillus strains have little or no risk to human health. In fact, Nissen et al (2009, p 290) notes that mucins secreted for intestinal cell membrane are highly complex glycoproteins offering structures as well as viscosity to the mucus layer covering the intestinal epithelial surface. Primarily, this layer is meant to safeguard the underlying cells from such dangers as corrosive gastric acids, invasion by harmful microflora as well as shear forces created by the digestive system. Nevertheless, Nissen et al (2009) claims that probiotic lactic acid bacteria has been evaluated and found to have no ability to corrupt gastric mucin. Indeed, cases of lactic acid bacterial infection are quite rare. The safety associated with strains such as lactobacillus casei and others has been labeled as remarkable given that up to 20 billion administrations are done yearly (Reid and Hammond 2005, p 1491). In sum, as literature indicates, it is evident that lactobacillus strains including casei not only have benefits to human health but also are considered generally safe. The majority of cases questioning safety and usefulness of lactobacillus strains occur in subjects with severely compromised immune status or those with underlying conditions including diabetes, heart disease and other terminal illnesses. In particular, lactobacillus casei found in various food products including yoghurt has been shown to have additional health benefits. Lastly, while some strains of lactobacillus may lead to questions as far as safety is concerned, lactobacillus casei has been found to be quite useful in virtually all environments.

Gap in knowledge identified which could form a project/dissertation

As evidenced in the above literature review, there exists considerable gap in knowledge as far as safety of lactobacillus strains is concerned. In essence, existing studies are yet to link the dots and provide a conclusive report indicating the manner in which such lactobacillus strains as casei lead to improved human health. This also means that different studies often give conflicting findings as evidenced above. For instance, Besselink et al (2008, p 651-659) note cases in which studies want us to believe that some products of lactobacilli- including lactobacillus case- could lead to adverse effects. However, a closer look into the study reviews provided in this paper reveal that lactobacillus strains are rather safe. In fact, the gap in the knowledge is evidenced by studies claiming that lactobacillus species have no detrimental effect whatsoever. This means that humans should consume them is large quantities without the fear that they could affect them in one way or the other. Possibly, this gap, results from the fact that few studies have ventured into investigating the manner in which lactobacillus casei functions, and thus helping humans. In essence, studies are yet to reveal the chemical reactions and or combinations of these strains in humans leading to desired health benefits. nonetheless, this calls for further investigation or projects to test various bifidobacteria-containing products and show how they help improve one’s health.

Specific purpose of your proposed investigation

The purpose of the proposed investigation is to bridge the gap in knowledge specifically by illustrating whether and how lactobacillus casei –and other lactobacillus species- work to improve overall health. In turn, the investigation will provide useful information on whether we should trust lactobacilli-containing products’ safety.

Specific data/information to be investigated identified

Some of the data and or information making up the proposed investigation include strains and growth conditions in which lactobacillus casei, including yoghurt, growth is to be investigated. Investigation the growth of this train is crucial in understanding the manner in which lactobacillus casei influence human health positively. In addition, acid challenge and acid tolerance analysis is to be covered in this investigation to find out the manner in which acids –including those constituting lactic acid bacteria- affect species development and or functioning given different conditions. For instance, using the information, this investigation will seek to establish whether human intestinal conditions could lead to any undesirable effects on the species. As well, information on measurement of epithelial/membrane lateral diffusion will constitute part of the investigation. This will also include investigation of conditions likely to affect the membrane in one way or the other. In addition, fatty acid extraction as well as analysis will form part of the investigation. The information in this part will include a certain technique to identify the manner in which saturation and extraction of fatty acid occurs. Last but not the least, information on examination of inner membrane permeability will be included to assess the permeability through cells. Ultimately, the information will be helpful in revealing lactobacillus species’ functionality in humans and how it leads to improved health.

How will investigation take place? Details of sampling/collection/analysis of data.

The investigation will involve a test involving the effect of lactic acid stress (LAS) on the lactobacillus casei cell membrane as well as its acid resistant mutant (Lbz-2). The test will largely involve data sampling (Cai et al, 2007, p 2655). The two strains lactobacillus casei and acid-resistant mutant will be grown under certain conditions in chemostats.  Steady-state chemostat cells –at pH 6.5- will be harvested.

Ethical issues surrounding the proposal

Ethical considerations are usually part of any project, and particularly those involving laboratory tests. In the proposal, cell integrity is crucial in maintaining cell viability as well as metabolic function. For instance, the data analysis and tests will have to ensure that subjects are handled with utmost care to ensure that wastage and stress is minimized. In addition, ethical considerations surrounding the proposal will include honesty and fairness. The two aspects are crucial in ensuring that integrity of the entire project is compromised. In conclusion, lactobacillus casei and other species are known to have myriad benefits to human health. The project will reveal the way lactobacillus species, in particular casei, affect human systems including cell membrane functionality.

 

Bibliography

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Ashley, M, 2013, Top 10 UK yoghurt brands, [online],         http://www.dairyreporter.com/Manufacturers/Top-10-UK-Yogurt-Brands-Mueller-  dominates-Danone-dwindles 26 Jul 2014.

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, Microbiology (2007), 153, 2655–2665.

Makarova, K., et al, 2006,
Comparative genomics of lactic acid bacteria
, Proc Natl Acad Sci U S             A, 103, 15611–15616.

Guerin-Danan, C et al, 2014, Milk fermented with yogurt cultures and
Lactobacillus casei           
compared with yogurt and gelled milk,
Am J Clin Nutr
1998;67:111–7.

Schiffer, C et al, 2011, A strain of lactobacillus casei inhibits the effector phase of immune           inflammation,
J Immunol
2011; 187:2646-2655; Prepublished online 1 August 2011;             http://www.jimmunol.org/content/187/5/2646 doi: 10.4049/jimmunol.1002415

Otles, S, 2013,
Probiotics and prebiotics in food, nutrition and health
, USA, CRC Press.

Fanun, M, 2011,
Colloids in biotechnology
, USA, Taylor and Francis, LLC.

Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity

I overview

Fig. 1_Clinical situation of a patient

with gingival recession. The

occurrence of gingival recession is a

precursor to the loss of cement,

owing to poor oral hygiene, the

exposure of tooth necks and dentine

hypersensitivity.

laser treatment of dental hypersensitivity

_Introduction

More than two decades ago, laser applications in

the treatment of dentine hypersensitivity were introduced to dentistry. Many clinical studies using

different laser types have been published since. This

overview summarises the basic and clinical aspects,

including treatment protocols.

_The hypersensitive dental neck

ORDER A CUSTOM-WRITTEN, PLAGIARISM-FREE PAPER NOW

Dentine hypersensitivity is a widespread painful

condition in dentistry (Orchardson et al. 2006;

Schwarz et al. 2002). Unfortunately, this clinical

condition is often poorly understood (Pesevska et

al. 2010). It is important to understand this condition in light of dental therapy because the need for

treatment is increasing (Gerschman et al. 1994;

Miglani et al. 2010). Hypersensitivity occurs when

tooth necks are exposed. Brannström’s hydrodynamic theory describes these mechanisms. Chemical, osmotic, physical or mechanical stimuli induce

movement of fluid in dental tubules, which activates pain fibres—mainly A- fibres—at the pulpdentine border (Brannström 1992). Afflicted patients describe an intense and sharp pain of short

duration that cannot be ascribed to any other form Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity

of dental defect or disease (Canadian Advisory

Board on Dentin Hypersensitivity 2003). In a huge

number of cases, these symptoms are triggered by

cold and are not related to restorative or caries

therapy. The well-being of patients who suffer from

dentine hypersensitivity is often affected. Daily

stimulation, for example eating or teeth brushing,

could induce considerable pain (Rösing et al. 2009;

Tengrungsun et al. 2008).

Today, more than 30 % of the adult population

of industrialised nations is thought to be affected

(Ritter et al. 2006; Gillam et al. 1997), but the actual

prevalence is still unknown (Rösing et al. 2009). The

reported incidence mainly depends on the population under examination and the methodology of

the studies, which vary a lot. Middle-aged patients

are most often affected (Al Sabbagh et al. 2004), but

a growing number of young persons are affected by

dentine hypersensitivity (Sykes 2007). The higher

frequency of hypersensitivity, even in middle-aged

adults, could be explained by increasing exposure of

tooth necks, which occurs increasingly early on in

young people (Dowell et al. 1983). The main reasons

for exposure are erosion, abrasion and attrition.

However, erosion is most likely to be the main factor (Addy et al. 1994; Gillam et al. 1997). This comes

from an increasing awareness of dental hygiene,

which has resulted in well-intentioned but incorrect brushing (Fig. 1). For these reasons, sensitive

tooth necks frequently occur opposite the hand

that is brushing. The loss of the thin cementum

layer in the tooth-neck area is responsible for more

than 90 % of the hypersensitive surfaces (Orchardson et al. 1987). As a result, dentine hypersensitivity can be characterised as a tooth-wear phenomenon (Bamise et al. 2008). Restorations, functional

overload and bleaching of vital teeth are also

causes of dentine hypersensitivity (Brannström

1992; Jacobsen et al. 2001; Haywood 2002). Nowadays, one therefore speaks of a multifactorial genesis of dentine hypersensitivity associated with

tooth wear.

Despite intensive research, the precise physiological mechanisms of pain production and transmission in the dental pulp have not been sufficiently determined (He et al. 2011; Bal et al. 1999;

Zhang et al. 1998). The surface texture of dentine,

that is the number of open tubules at the root neck,

is of great relevance to the process of dentine hypersensitivity (Absi et al. 1987; Markowitz 1993;

Fig. 2). The extent of hypersensitivity depends on

Laser treatment of

dentine hypersensitivity

An overview Part I

Authors_Dr Ute Botzenhart, Dr Andreas Braun & Prof Matthias Frentzen, Germany

20 I laser

1_2012

Fig. 1 Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity

overview I

the number of exposed tubules (Ngassapa 1996).

Clinical studies (Narhi et al. 1992) and SEM examinations (Absi et al. 1987) have demonstrated that

the dentine of hypersensitive teeth has a considerably higher number of exposed dental tubules

(eight times the number) with a considerably

greater aperture (twice the size) compared with

teeth with no hypersensitivity symptoms (Absi et al.

1987). Since dentine hypersensitivity can occur

even after the closure of most of the dental tubules,

other factors, like inflammatory mediators, are assumed to be involved in nerve stimulation and pain

(Narhi et al. 1992; Ngassapa 1996) in addition to the

hydrodynamic theory.

_Conventional therapy

Currently, a multitude of desensitising agents

are available on the market. Normally, the therapeutic mechanism is based upon the hydrodynamic

theory. By occluding dentinal tubules, movement of

fluid should be reduced. Furthermore, the reduction of pulpal pain-nerve fibre firing should contribute to reduced sensitivity.

The spectrum of applications ranges from

agents for topical application, dentine adhesives,

light-curing primer systems, mucogingival surgery

for soft-tissue management, conventional fillings,

to endodontics as ultima ratio. Topical applications

are the most important for desensitisation; among

them are fluorides, potassium and calcium compounds, hydroxyapatite, bioactive glass and glassceramics, oxalates, glutaraldehyde, formalin and

chlorhexidine. These ingredients are mostly found

in toothpastes, mouth rinses, gels, suspensions,

varnishes or pastes for topical application. They can

also be applied via chewing gum or iontophoresis.

Today, the application of nano-sized particles of

different mixtures is also very popular.

In 1935, Grossman formulated a set of criteria

that desensitising agents are to fulfil. These criteria

are still valid today (Renton-Harper et al. 1992):

– no irritation of pulp tissue;

– painless application;

– easy to apply;

– rapid in effect;

– sufficient efficiency;

– no side-effects; and

– long-term effectiveness.

The predominant number of compounds lead to

a rapid resolution of symptoms, but often they are

only short-lived. In most cases, a long-term occlusion of dentinal tubules cannot be attained. Thus

far, no desensitising substance or method of application has fulfilled all the criteria Grossmann postulated in 1935. There has been a constant improvement in terms of the available means of treatment and active substances, but the reports still

demonstrate difficulty in relieving the pain (Romano et al. 2011). Until recently, no universally applicable substance was available (Mitchell et al.

2011; Tirapelli et al. 2010; Dabahne et al. 1999).

_Laser application

Precipitates and surface coverings disintegrate

after some time, for example owing to the influence

of acid or toothbrush abrasion (Addy et al. 1983).

Conventional desensitising treatments had to be

applied repeatedly at regular intervals to ensure a

durable analgesia (Gillam et al. 1992; Cuenin et al.

1991). The application of laser beams of different

wavelengths and energy levels, alone or in combination with topical application, for example fluoride, is an alternative method for the treatment of

dentine hypersensitivity. Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity

_Studies on the effects of

laser application

In vitro and in vivo studies document high effectiveness rates and comparatively long-lasting pain

relief. The most commonly used types of lasers for

the treatment of dentine hypersensitivity already

determined in vivo can be divided into two groups.

Those lasers with a lower output power, low-level

lasers (He-Ne and GaAlAs diode lasers), are applied

to biostimulation and are distinguishable from

laser types with a middle-output power, middleoutput power lasers, which have the ability to morphologically alter dental hard tissue.

The middle-output power lasers include the

Nd:YAG, Er:YAG laser and CO2 lasers (Dederich et al.

1984; Melcer et al. 1985; Featherstone et al. 1987).

The effect of these laser types can probably be attributed to the sealing of the dentinal tubules, nerve

analgesia and placebo effects. The sealing has been

observed to be of long-lasting effect, whereas in

Fig. 2_SEM examination of a human

cervical dentinal surface with open

tubules, after experimental removal

of the smear layer with 50 % citric

acid for one minute

(1,000x magnification).

I 21 laser

1_2012

Fig. 2

I overview

the case of nerve analgesia and placebo effects, the

effects are not durable (Kimura et al. 2000a). Despite the precise mechanisms of laser action, the

long-term value of laser therapy in treating dentine

hypersensitivity is uncertain; current evidence is

based upon a slight superiority compared with conventional topical applications (He et al. 2011).

Laser therapy with low-output power has been

applied to humans since the 1970s and was originally used for wound healing (Kimura et al. 1991,

1993, 1997). In the 1980s, the inhibition of inflammation (Karu 1988, 1989) and the stimulation of

nerve cells were demonstrated (Kimura et al. 1993;

Jarvis et al. 1990).

_Low-level lasers:

GaAlAs laser

Thus far, GaAlAs diode lasers of three wavelengths have been used clinically to treat dentine

hypersensitivity: 780, 830 and 900 nm. The 780 nm

wavelength has been used with good clinical success (30 mW in continuous wave mode [cw] and an

application time of about 0.5 to three minutes;

Matsumoto et al. 1985a). The 830 nm wavelength

for the treatment of dentine hypersensitivity was

first described by Matsumoto in 1990. With an energy setting of 20 to 60 mW in cw mode and an application time of 0.5 to three minutes, the effectiveness of therapy was 30 to 100 %, depending on

the energy level (Matsumoto et al. 1990). The effectiveness of therapy using the 900 nm wavelength

and an output power of 2.4 mW at 1.2 Hz for 2.5

minutes was approximately 73 to 100 % (Kimura et

al. 2000b). Yamaguchi et al. (1990) compared the

application of a GaAlAs diode laser of a wavelength

of 790 nm and an output power of 30 mW and a

placebo in vivo. Significant differences between

laser application and the placebo group were

found. At two hours, one day and five days after

laser application, a significant improvement was

detected (Yamaguchi et al. 1990). Overall, compared with the placebo, an improvement of 60 to

22 % was achieved. GaAlAs laser application with a

maximal energy output of 60 mW did not damage

enamel or dentine surfaces morphologically

(Watanabe et al. 1991).

According to another in vitro study, the application of GaAlAs laser diodes with energy levels of

30 mW (cw, 780 nm), 60 mW (cw, 830 nm) and

10 W (pulsed, 900 nm) did not lead to a significant

increase in the temperature in the dental pulp

(Arrastia et al. 1994). Gerschman et al. (1994) accomplished a clinical double-blind study with

GaAlAs lasers compared with a placebo. During the

therapy, the apical and cervical regions of the tooth

were irradiated for one minute; this procedure was

repeated in one-week, two-week and eight-week

intervals. Dentine hypersensitivity evoked by tactile

and thermal stimuli was measured at each control

and compared with the placebo group. A significant

difference concerning dentine hypersensitivity

was detected during the analysis. It was therefore

deduced that the GaAlAs laser is an effective

method for dentine desensitisation (Gerschman et

al. 1994).

_Combined application of GaAlAs laser

and fluoride Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity

In another clinical study, a laser with an energy

density of 3 and 5 J/cm2was applied up to six times

in an interval of 72 hours after each application

(Marsilio et al. 2003). Dentine hypersensitivity was

measured initially after each application, and at 15

and 60 days after application. In more than 85 % of

the teeth treated, an improvement was detected.

Side-effects were not observed (Marsilio et al.

2003). In a comparative study of GaAlAs laser application (630–670 nm) at energy levels of 15 mW

in contact mode for 20 seconds and fluoride application (Fluor Protector, Ivoclar Vivadent), significant and complete relief from pain after three sessions was achieved in 86.6 % of the cases compared

with 26.6 % after fluoridation only (Pesevska et al.

2010). The clinical findings of Noya et al. (2004)

proved that just a single application of GaAlAs laser

(670 nm, 15 mW, 5 J/cm2) yields a statistically significant reduction in sensitivity to mechanical and

thermal stimuli and that two applications are

enough to reduce sensitivity to air. No other application led to any additional benefit (Noya et al.

2004).

A significant reduction in VAS scores was also

detected with laser application for 160 seconds at

an energy density of 4 J/cm2 per dental element at

24 hours and seven days after application compared with a placebo application (Orhan et al. 2010).

All teeth remained vital and no adverse effects were

found radiographically, but the results were not

significantly different from any conventional desensitiser (Gluma Desensitizer, Heraeus Kulzer;

Orhan et al. 2010).

A combined application of GaAlAs laser light

with sodium fluoride (NaF) at an energy output of

15 mW and density of 4 J/cm2 led to no statistically

significant differences between laser application

and combined laser and fluoridation treatment

(Corona et al. 2003).

Whether a combined application of GaAlAs laser

and fluoride is effective in treating dentine hyper22 I laser

1_2012

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Greater New York Dental MeeƟ ng®

570 Seventh Avenue – Suite 800

New York, NY 10018 USA

Tel: (212) 398-6922 / Fax: (212) 398-6934 ::: *1<‘0 &20 E-mail: victoria@gnydm.com ScienƟĮ c MeeƟ ng: Friday – Wednesday, November 23 – 28 Exhibit Dates: Sunday – Wednesday, November 25 – 28 MARK YOUR CALENDAR Aãã›Ä Aã NÊ CÊÝã Never a pre-registraƟ on fee at the Greater New York Dental MeeƟ ng MÊٛ ãHƒÄ 600 EXH®B®ãÊÙÝ Jacob K. Javits ConvenƟ on Center 11th Ave. between 34-39th Streets (ManhaƩ an) ,›ƒQçƒÙã›ÙÝ ,Ê㛽 New York MarrioƩ Marquis ,otel L®V› D›Äã®ÝãÙù Aٛă – NÊ Tç®ã®ÊÄ Lƒã›Ýã D›Äヽ T›‘HÄʽʦù Ι S‘®›Ä㮥®‘ AVƒÄ‘›Ý MÊٛ THƒÄ 350 S‘®›Ä㮥®‘ PÙʦكÃÝ Seminars, ,ands-on Workshops, Essays & ScienƟĮ c Poster Sessions as well as Specialty and Auxiliary Programs E瑃ã®Êă½ PÙʦكÃÝ ®Ä VƒÙ®ÊçÝ ½ƒÄ¦çƒ¦›Ý Sʑ®ƒ½ PÙʦكÃÝ ¥ÊÙ ãH› EÄã®Ù› FƒÃ®½ù EĹÊù N›ó YÊÙ» C®ãù ƒã ®ãÝ B›Ýã çٮĦ ãH› ÃÊÝã ¥›Ýã®V› ã®Ã› Ê¥ ãH› ù›ƒÙ! Sponsored by the New York County Dental Society and the Second District Dental Society GNYDM_2012_A4_engn.pdf 1 NYDM_2012_A4_engn.pdf 1 20.03.12 17:34 0.03.12 17:34 I overview 24 I laser 1_2012 sensitivity is questionable. Results are contradictory, often masked by placebo effects and highly dependent on laser parameters and the given circumstances for each patient. Both methods of treatment, GaAlAs laser application and fluoridation, are suitable for dentine hypersensitivity therapy. _Biostimulative mechanisms of GaAlAs lasers The GaAlAs laser mechanism is thought to be biostimulative rather than effecting morphological changes in dentine. It is assumed that the laser energy is transmitted to the dentine–pulp complex, interacts with the pulp tissue and causes a photobiomodulating effect, increasing the cellular metabolic activity of the odontoblasts and obliterating the dentinal tubules by means of tertiary dentine production (Ladalardo et al. 2004; Walsh 1997). Tengrungsun et al. (2008) compared the efficiency of a GaAlAs laser (790 nm, 30 mW, 1 min) with a dentine bonding agent (Scotchbond, 3M ESPE) and found a statistically significant reduction immediately and 15 days after treatment in both of the two groups. No additional reduction in the level of hypersensitivity 30 days after treatment was observed. The dentine bonding agent was significantly superior to the GaAlAs laser within all measuring periods, thus confirming the assumption that laser light may act in a different way from occluding dentinal tubules (Tengrungsun et al. 2008). The immediate laser effect is assumed to be triggered by placebo effects as a result of endorphin release induced by the activation of the pain inhibition system of the organism. This leads to the release of endorphins by the central nervous system, possibly controlling the painful stimulus at the periphery, and causing biostimulative effects that happen gradually within a few days (Tuner et al. 2002; Kimura et al. 2000b; Trowgridge et al. 1990). Another assumption is the blocking of the depolarisation of C-fibre afferences (Wakabayashi et al. 1993). The exact mechanism of action of low-intensity lasers in dentine hypersensitivity is not thoroughly understood (Orhan et al. 2010). _Infra-red wavelengths and highpower density Laser diodes, some of which have already been tested in vitro and in vivo, with wavelengths in the infra-red area and a high-power density are easily available on the market. Because of the laser–tissue interaction of this laser type with high energy per surface density, its results are comparable to that of an Nd:YAG laser. The sealing ability of this laser type was observed with the parameters 810 nm, 2 W and 30 ms, and was found to be less than that of CO2, Er,Cr:YSGG lasers and Nd:YAG lasers (Gholami et al. 2011). Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity Clinical findings with the use of a GaAlAs laser of a wavelength of 810 nm at 1.5 to 2.5 mW for one minute resulted in a rapid reduction of discomfort, 15 minutes and 30 minutes after laser irradiation (37 % after 15 minutes and 41 % after 30 minutes) compared with placebo laser application with a reduction of 9 %. The improvement remained stable until two weeks (72 %) and two months (66 %) after application compared with placebo laser application (a 28 % reduction at two weeks and 26 % at two months) and the application of 10 % potassium nitrate gel (a 36 % reduction at two weeks and 30 % at two months; Sicilia et al. 2009). _Different effects in different age groups Ladalardo et al. (2004) evaluated the clinical desensitising effect of red and infra-red GaAlAs laser light application (660 nm and 830 nm, 4 J/cm2 , cw, 114 seconds, contact mode) in adult patients of different age groups (25–35 years and 36–45 years) as an immediate (15 minutes and 30 minutes after application; four sessions with intervals of seven days between each session) and late therapeutic effect (15, 30 and 60 days after the conclusion of treatment). Significant desensitising levels were only found in patients aged between 25 to 35 with the 660 nm red laser, which was found to be more effective than the 830 nm infra-red laser immediately after and in the follow-up periods at 15, 30 and 60 days after the conclusion of treatment. In the group of 36- to 45-year-old patients, the effect of the red laser was only moderate, with recurrence of sensitivity, and the infra-red laser was ineffective. The authors concluded that the desensitising effects immediately after laser irradiation resulted from a suppression of evoked potential of the pulp nociceptive nerve fibres, with a better tissue response in the younger group. Pathological processes, regressive or atrophic alterations of the odontoblasts and the dentine pulp complex may lower the reaction potential in older patients, with reduced effectiveness of the laser biostimulation (Ladalardo et al. 2004). A significant clinical improvement was also observed after the combined application of GaAlAs laser (808 nm, cw, contact mode, 25 seconds) and desensitiser toothpaste compared with the toothpaste alone (Dilsiz et al. 2010a). _GaAlAs laser and acid resistance Recently, the GaAlAs diode laser was tested to establish enhancement of the acid resistance of dentine surfaces as a preventive method for hypersensitivity. A degree of improvement in the acid resistance of dentine specimens after laser irradiation (808 mn, cw, 60 J/cm2 ) and erosive challenge (1 M hypochlorous acid for five minutes) was found without creating thermal or structural damage (De-Melo et al. 2010). However, the exact mechanism of action remains unclear. Laser treatment can be a useful tool for rapid reduction in pain, and possibly in the improvement of acid resistance of dentine. Nevertheless, more basic research and longterm clinical trials are needed to evaluate the longterm efficiency of this method and to explain the exact mechanism of action. Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity _Low-level lasers: He-Ne laser The He-Ne laser has a wavelength of 633 nm (Moritz et al. 2006) and is a low-level laser. The first application of the He-Ne laser in the therapy of dentine hypersensitivity was described by Senda et al. (1985), who used an output power of 6 mW and chose two different modes (cw and pulsed, 5 Hz). Effectiveness ranged from 5 to 100 %. In another study, an effectiveness of 5 to 18 % was achieved (Wilder-Smith 1988). To date, the mechanism of action of the He-Ne laser has not been explained completely (Moritz et al. 2006). An energy level of 6 mW does not alter the enamel or dentinal surface structure morphologically; however, laser energy transmits through enamel and dentine and reaches the pulp tissue (Watanabe 1993). Physiological experiments have shown that the He-Ne laser application does not influence nociceptors of circumferential A– or C-fibres (Jarvis et al. 1990), but it does influence electrical activity (action potential), which in healthy nerves is enhanced by about 33 % after application (Rochkind et al. 1986). The effect is long-lasting and leads to an increase in the action potential of nerve fibres for more than eight months after laser application (Rochkind et al. 1986). _He-Ne laser compared to Nd:YAG laser In a clinical study (Gelsky et al. 1992), which was aimed at testing the effectiveness and confidence of the Nd:YAG laser in the therapy of dentine hypersensitivity in vivo (see below), the He-Ne laser was applied to one group and the He-Ne laser and the Nd:YAG laser were applied to the other group (30–100 mJ, 10 pps increments of ten to 40 seconds, total application time < two minutes, without local anaesthesia). Dentine hypersensitivity was measured mechanically (dental probe) and thermally (stream of cold air) with the aid of a VAS. Additionally, the pulpal sensibility was evoked electrically. Initially and after three months, X-rays were taken to identify possible side-effects of the laser application. Directly after laser application and three months later, a reduction in the level of discomfort was observed. After three months, dentine hypersensitivity evoked by thermal stimuli was scaled back to 63 % and hypersensitivity evoked by mechanical stimulation was scaled back to 61 %. Compared with the combined application of He-Ne and Nd:YAG lasers, there was not much difference (reduction of dentine hypersensitivity evoked by thermal stimulation to 58 %; evoked by mechanical stimulation to 61 %). All of the teeth were vital after application and no side-effects or complications could be detected. If dentine hypersensitivity is conditioned by the hydrodynamic mechanism exclusively, (thermal) effects of Nd:YAG laser application should reduce dentine hypersensitivity primarily (Gelsky et al. 1992). In contrast, He-Ne laser application should not lead to important effects. Thus, it is assumed that a surficial modification is not the only desensitising factor, but that there is apparently also a neurophysiological component (Gelsky et al. 1992), which is affected by biostimulative effects. In a study with a similar design, the reduction of dentine hypersensitivity after He-Ne laser application alone, as well as after combined He-Ne laser and Nd:YAG laser application, was detected. It remained stable for six weeks (Halket et al. 1996)._ Editorial note: To be continued in our next issue of Laser. A list of references is available from the publisher. Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity overview I I 25 laser 1_2012 Dr Ute Botzenhart Department of Orthodontics Centre of Dentistry and Oral Health Ernst Moritz Arndt University of Greifswald Germany Dr Andreas Braun/Prof Matthias Frentzen Department of Periodontology, Operative and Preventive Dentistry University of Bonn Germany _contact laser Botzenhart, U.,Braun, A., & Frentzen, M. (2012). Laser treatment of dentine hypersensitivity

Title

Your Name

Chamberlain College of Nursing

NR451 RN Capstone Course

Term and Year

Your title here

This paragraph(s) is to introduce the paper.
Explain the type of work setting you are discussing and whether interprofessional teams are present. If present, indicate a team function that could be improved.  If not present, indicate what type of team you think might work well in this setting and how it might function.
Remember this is a scholarly APA assignment so you cannot use first person. Remember also that you will keep all the bolded headings and just remove the non-bolded content when you start your paper.

NR451_iCARE_paper_outline_template__Wk_5

Compassion

In this paragraph, describe
a nursing action that could contribute to compassion
through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Advocacy

In this paragraph, describe
a nursing action that could contribute to advocacy
through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Resilience

In this paragraph, describe
a nursing action that could contribute to resilience
through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Evidence-Based Practice

In this paragraph, describe
a nursing action that could contribute to evidence-based

practice
through interprofessional team support; how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Summary

Provide a clear and concise summary. Include a summary statement of how iCARE components can support interprofessional teams and patient outcomes through nursing actions.  Address how you may be able to influence this process of support for interprofessional teams on your unit or in your organization.

 

References

Select at least one scholarly nursing article from CINAHL as a resource for your paper. Additional scholarly sources can be used but are optional.

Getting Started: Interprofessional teams are part of practice trends we see developing in all aspects of care delivery. Consider you own work environment (or recent clinical setting).

For this assignment, consider the concept of interprofessional teamwork and patient outcomes.

Look to your current workplace as an example. (If you are not currently employed, look to a past workplace or clinical practice area.)

Apply the components of the iCARE concept to interprofessional teams in a short paper. (Body of the paper to be 3 pages, excluding the title page and references page)

iCARE components are:

C ompassion

A dvocacy

R esilience

E vidence-Based Practice (EBP)

How could you contribute to an interprofessional team and patient outcomes through nursing actions of: compassion, advocacy, resilience, and evidence-based practice?

Select one scholarly nursing article from CINAHL as a resource for your paper. Additional scholarly sources can be used but are optional.

Use APA format throughout, particularly in citations and on the References page.

Please paraphrase throughout. One short quote is permitted.

The prepared
paper template
is RECOMMENDED for this assignment.

 

 

 

 

 

 

Title

Your Name

Chamberlain College of Nursing

NR451 RN Capstone Course

Term and Year

 

 

Your title here

This paragraph(s) is to introduce the paper.
Explain the type of work setting you are discussing and whether interprofessional teams are present. If present, indicate a team function that could be improved.  If not present, indicate what type of team you think might work well in this setting and how it might function.
Remember this is a scholarly APA assignment so you cannot use first person. Remember also that you will keep all the bolded headings and just remove the non-bolded content when you start your paper.

Compassion

In this paragraph, describe
a nursing action that could contribute to compassion
through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Advocacy

In this paragraph, describe
a nursing action that could contribute to advocacy
through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Resilience

In this paragraph, describe
a nursing action that could contribute to resilience
through interprofessional team support; describe how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Evidence-Based Practice

In this paragraph, describe
a nursing action that could contribute to evidence-based

practice
through interprofessional team support; how this might impact the culture of your unit or organization; and possible impact on patient outcomes.

Summary

Provide a clear and concise summary. Include a summary statement of how iCARE components can support interprofessional teams and patient outcomes through nursing actions.  Address how you may be able to influence this process of support for interprofessional teams on your unit or in your organization.

 

References

Select at least one scholarly nursing article from CINAHL as a resource for your paper. Additional scholarly sources can be used but are optional.