S. Topork. Xavier University, Cincinnati, OH.

Individuals with bulimia are usually within normal weight range lanoxin 0.25 mg on line, some a few pounds underweight effective lanoxin 0.25 mg, some a few pounds overweight. Obsession with body image and appearance is a predominant feature of this disorder. Individuals with bulimia display undue concern with sexual attractiveness and how they will appear to others. Excessive vomiting may lead to problems with dehydration and electrolyte imbalance. Genetics: A hereditary predisposition to eating disorders has been hypothesized on the basis of family histories and an apparent association with other disorders for which the likelihood of genetic influences exist. Neuroendocrine Abnormalities: Some speculation has occurred regarding a primary hypothalamic dysfunction in anorexia nervosa. Studies consistent with this theory have revealed elevated cerebrospinal fluid cortisol levels and a possible impairment of dopaminergic regulation in individuals with anorexia (Halmi, 2008). Neurochemical Influences: Neurochemical influences in bulimia may be associated with the neurotransmitters serotonin and norepinephrine. Some studies have found high levels of endogenous opioids in the spinal fluid of cli- ents with anorexia, promoting the speculation that these chemicals may contribute to denial of hunger (Sadock & Sadock, 2007). Some of these individuals have been shown to gain weight when given naloxone, an opioid antagonist. Psychodynamic Theory: The psychodynamic theory sug- gests that behaviors associated with eating disorders reflect a developmental arrest in the very early years of childhood caused by disturbances in mother-infant interactions. The tasks of trust, autonomy, and separation-individuation go unfulfilled, and the individual remains in the depen- dent position. The problem is compounded when the mother responds to the child’s physical and emotional needs with food. Manifestations include a disturbance in body identity and a distortion in body image. When events occur that threaten the vulner- able ego, feelings emerge of lack of control over one’s body (self). Behaviors associated with food and eating provide feelings of control over one’s life. Family Dynamics: This theory proposes that the issue of control becomes the overriding factor in the family of the individual with an eating disorder. These families often consist of a passive father, a domineering mother, and an overly dependent child. A high value is placed on perfec- tionism in this family, and the child feels he or she must satisfy these standards. Parental criticism promotes an increase in obsessive and perfectionistic behavior on the Eating Disorders ● 221 part of the child, who continues to seek love, approval, and recognition. In adolescence, these distorted eating patterns may represent a rebellion against the parents, viewed by the child as a means of gaining and remaining in control. The symptoms are often triggered by a stressor that the adolescent perceives as a loss of con- trol in some aspect of his or her life. These guidelines, which were released by the National Heart, Lung, and Blood Institute in July 1998, markedly increased the number of Americans considered to be overweight. Obesity is known to contribute to a number of health prob- lems, including hyperlipidemia, diabetes mellitus, osteoarthritis, and increased workload on the heart and lungs. Genetics: Genetics have been implicated in the develop- ment of obesity in that 80% of offspring of two obese parents are obese (Halmi, 2008). This hypothesis has also been supported by studies of twins reared by normal and overweight parents. Physical Factors: Overeating and/or obesity has also been associated with lesions in the appetite and satiety centers of the hypothalamus, hypothyroidism, decreased insulin production in diabetes mellitus, and increased cortisone production in Cushing’s disease. Lifestyle Factors: On a more basic level, obesity can be viewed as the ingestion of a greater number of calories than are expended. Weight gain occurs when caloric in- take exceeds caloric output in terms of basal metabolism and physical activity. Psychoanalytical Theory: This theory suggests that obe- sity is the result of unresolved dependency needs, with the individual being fixed in the oral stage of psychosex- ual development. The symptoms of obesity are viewed as depressive equivalents, attempts to regain “lost” or frus- trated nurturance and care. Common Nursing Diagnoses and Interventions for Anorexia and Bulimia (Interventions are applicable to various health-care settings, such as inpatient and partial hospitalization, community outpatient clinic, home health, and private practice. Possible Etiologies (“related to”) [Refusal to eat] [Ingestion of large amounts of food, followed by self-induced vomiting] [Abuse of laxatives, diuretics, and/or diet pills] [Physical exertion in excess of energy produced through caloric intake] Defining Characteristics (“evidenced by”) [Loss of 15% of expected body weight (anorexia nervosa)] Pale mucous membranes Poor muscle tone Excessive loss of hair [or increased growth of hair on body (lanugo)] [Amenorrhea] [Poor skin turgor] [Electrolyte imbalances] [Hypothermia] [Bradycardia] [Hypotension] [Cardiac irregularities] [Edema] Eating Disorders ● 223 Goals/Objectives Short-term Goal Client will gain lbs per week (amount to be established by client, nurse, and dietitian). Long-term Goal By discharge from treatment, client will exhibit no signs or symptoms of malnutrition. If client is unable or unwilling to maintain adequate oral in- take, physician may order a liquid diet to be administered via nasogastric tube.

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Nurses encounter household measurements when providing home healthcare services and when determining a patient’s fluid intake and output in the hospital setting purchase lanoxin 0.25mg mastercard. Nurses also use pounds when calculating a dose that is based on a patient’s weight 0.25 mg lanoxin visa. Patients should use measuring spoons for medication administration at home and avoid using tableware. Patients are usually more comfortable self-administering medication if the dose is in household measurements. Therefore, a nurse must be able to convert household measure- ments to metric measurements. The nurse must convert that to milliliters (mL) or cubic centimeters (cc) in order to record the intake volume in the patient’s fluid input and output chart. Commonly used conversion factors for household measurement and metric measurement. For example, if the dose is in milligrams and the prescriber’s medication order specifies grams, you’ll need to convert grams to milligrams before calculating the dose. Converting from one metric unit to another metric unit isn’t difficult if you remember these three rules. Determine if the desired measurement is larger or smaller than the given measurement. Remember that gram, liter, and meter are larger units and milligram, milliliter, and millimeter are smaller units. If you are converting from a smaller unit to a larger unit, then you multi- ply by moving the decimal three places to the left. If you are converting from a larger unit to a smaller unit, then you divide by moving the decimal three places to the right. Therefore, you divide by moving the decimal three places to the left, as shown here. Therefore, you multiply by moving the decimal three places to the right, as shown here. This is also the easiest conversion because one milliliter (mL) is equal to 1 cubic centimeter (cc). Always place a zero to the left of the decimal when the quantity is not a whole number. There, you’ll use a teaspoon, tablespoon, or cups mea- sured in ounces to administer medication. When converting from milliliters or cubic centimeters to ounces, divide by 30, as shown here: [Remember 30 cc (30 mL) = 1 oz. For example, the medication prescription is for a 15-mg tablet of Inderal and the hospital has on hand a 15-mg tablet of Inderal. In the real world, the dose specified in the medical prescription may not be available. The hospital might have 10-mg tablets of Inderal and not the 15-mg tablets prescribed. Instead of asking the prescriber to change the medication order, the nurse calculates the proper medication to give the patient based on the medication order and the dose that is on hand. When applying either method, make sure that all the terms are in the same units before calculating the desired dose. For example, the medication order might be in grams and the dose on hand might be in milligrams. The nurse will need to convert the grams to milligrams before calculating the desired dose to give. D × V = A Quantity (Desired dose divided by dose you have H multiplied by vehicle of drug you have equals the amount calculated to be given to the patient) D = desired dose H = dose you have V = vehicle you have (tablets or liquids) A = amount calculated to be given to the patient Ratio and proportion method H V :: D x Means Extremes H is the drug on hand (available) V is the vehicle or drug form (tablet, capsule, liquid) D is the desired dose (as prescribed) x is the unknown amount to give, and :: stands for “as” or “equal to. Example: Give 500 mg of ampicillin sodium by mouth when the dose on hand is in capsules containing 250 mg. For example, use mg following a value in the formula if the value is in milligrams. Parenteral Medications Parenteral medication is a medication that is administered to a patient by an injection or by an intravenous flow. The dose for an injection is calculated using the formula method or the ratio-proportion method that is described previously in this chapter. The nurse must calculate the number of milliliters that should be administered to the patient. The intravenous order directs the nurse to administer a specific vol- ume of fluid to the patient over a specific time period. In order the calculate the drip rate you need to know: • The volume of fluid that is to be infused. This is found in the medication order in milliliters (mL) or cubic centimeters (cc). It is important to remember that although we use milliliters in the following examples, you can substitute cubic centi- meters (cc) for milliliters (mL) if cc is specified in the order.

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PharmacokineticandPha- a-adrenergic receptors and contraction of rat vas rmacodynamic Data Analysis: Concepts and Applica- deferens’ 0.25mg lanoxin free shipping. Interspecies scaling and comparisons Pharmacokinetic/Pharmacodynamic Analysis: in drug development and toxicokinetics purchase 0.25 mg lanoxin. Financial pressures, even for the largest pharma- model ceutical companies, are generally much greater than in the past. The technical response is to max- In former times, it was assumed that developmental imize resources, avoiding any and all redundant drugs proceeded in stepwise fashion from phase I, clinical studies. Phase I was conducted in ‘normal volun- the regulatory authorities and from within the teers’ (although some medical students might pharmaceutical companies themselves. After approval, certain stu- earlier stages of drug development when these dies, to find new indications, address special questions are asked, have driven change in patient subpopulations, for marketing purposes or clinical study design. Increasingly sophisticated to otherwise broaden product labeling might or data are now developed at earlier stages of drug might not be conducted. Strategies such as the overlapping of devel- any generally agreed definitions except, perhaps, opment ‘phases’, as well as the use of early dose- that the studies are run by different teams. None of are (and always have been) sound medical or phar- today’s successful companies actually use such a macological reasons for doing so. It would be unreasonable to study the pharma- cokinetics of relatively toxic agents, at poten- 9. Typically, this information can be gained in Bias is a general consideration in clinical trial patients with diseases potentially responsive to design, regardless of the type of trial being con- these agents. Cytotoxic and antiviral drugs are two of the types of study design considered below. This enemy comes from many quarters doses at which tolerability must be confirmed are (Table 9. The clinical trialist must be sufficiently unknown until the exposure of patients can indi- humble to realize that he or she, himself or herself, cate the doses that may be effective. However, the ability to talk to and understand statisticians is There are some diseases which have neither ani- absolutely essential. Sine qua non: Involve a mal model nor relevant pharmacodynamic or sur- good statistician from the moment a clinical trial rogate end point in normal volunteers. This is one of your best defences against migraine, and normal volunteers cannot report an bias. Nausea, vomiting and gas- tric stasis are common during migraine attacks and may be expected to alter the pharmacoki- 9. Nevertheless, it is quite wrong to assume that these ‘classical’ terms and definitions It does not require a training in advanced statistics still apply to how drugs are developed according to to hold a common sense and accurate approach to modern practice. The classical four-phase strategy creating clinical hypotheses, translate them into the of drug development is far too stereotyped, precise quantities of a measured end point and then 9. This urge comes from natural scientific statistics are presented elsewhere in this book, it is curiosity, as well as a proper ethical concern, common sense that the only way to interpret what because the hazard associated with clinical trials you measure is to define this whole process before is never zero. That bias is the clinical trialist himself/ typically measured before and after drug (or herself. These variables all exhibit years on the fundamentals of end points, their biological variation. Further- familiar, unimodal, symmetrical distributions which more, the relationship between what is measured are supposed to resemble Gaussian (normal), Chi- and its clinical relevance is always debatable: the squared, f, binomial and so on, probability density tendency is to measure something that can be functions. An intrinsic property of biological vari- measured, rather than something that needs valida- ables is that when measured one hundred times, tion as clinically relevant. Good examples include then, on the average and if normally distributed, rheumatological studies: counts of inflamed joints 5% of those measurements will be more than Æ2 before and after therapy may be reported, but do standard deviations from the mean (there are corol- not reveal whether the experimental treatment or laries for the other probability density functions). It is also true the ability to walk (Chaput de Saintonge and Vere, that if you measure one hundred different variables, 1982). The experimental controls included that all 12 patients met the same inclusion criteria (putrid gums, spots on the skin, lassitude 9. All Any general work must include these classic bits of treatments were administered simultaneously (par- history. The trial evidence that either the ancient world or the med- had six groups, with n ¼ 2 patients per group. Sir John Elwes of Marcham Manor (two spoonfuls plus vinegar added to the diet and (Berkshire, now Denman College of the Womens’ used as a gargle), (d) sea water (‘a course’), Institute) was a famous miser. After injuring both (e) citrus fruit (two oranges, plus one lemon legs, Elwes gambled with his apothecary that the when it could be spared) and (f) nutmeg (a ‘big- latter’s treatment of one leg would result in slower ness’). Lind noted, with some disdain, that this last healing than the other leg which would be left treatment was tested only because it was recom- untreated. The famous result wound that took an extra two weeks (Milledge, was that within six days, only 2 of the 12 patients 2004).

All needling parameters will be con- reduce cardiac events in patients with coronary heart sistent with clinical practice quality lanoxin 0.25 mg. The control groups will participate in a cardi- also study varying dwell times after insertion and dif- ology education program trusted 0.25mg lanoxin. They will corre- arterial vasomotor dysfunction (brachial artery reac- late the force required to withdraw the needle with tivity) and the secondary outcome is autonomic ner- the depth of its insertion into muscle and subcuta- vous system imbalances (heart rate variability). The first pilot Autoregulation (Mohan Viswanathan, PhD, phase will develop and validate two sham proce- Children’s Research Institute)—The present project dures to test the efficacy of acupuncture. The acupuncture compared to the sham model devel- study will focus on functional studies and signal oped in the Phase I study. Both in vitro ture points and control points in 80 normal human models of liver cell injury and rat models of liver volunteers. This Efficacy of Acupuncture in the Treatment of three-arm, double-blind clinical efficacy study will Fibromyalgia (Dedra A. The active treatment group will using a selective serotonin reuptake inhibitor, will be receive true acupuncture. These patients will receive needle insertion at (John Allen, PhD, University of Arizona)—This nonchannel, nonpoint locations, or a true placebo. The study is unique in measures of overall health and pain, to determine that treatment effects will be assessed from the per- the optimal duration of treatment and examine the spectives of both western psychiatry and Chinese concordance of allopathic and acupuncture-based medicine. The primary conducted to examine the individual and synergistic goal is to assess the prophylactic effects of omega-3 effects of needle placement and stimulation on the fatty acids in a cohort of bipolar patients with a rel- efficacy of acupuncture as a therapeutic modality in atively high risk of recurrence. The design allows determination of Oxidative Cell Injury in First Episode Psy- dose-effect for the analgesic effect of acupuncture. The clinical design, a placebo-con- manual that standardizes the administration of true trolled, double crossover trial, will also allow for and sham acupuncture that can be used at any assessment of any adverse events associated with study site performing a randomized clinical trial melatonin related to its safety and tolerance. It is (Panax ginseng, Cynanchum wilfordii, Scrophularia hypothesized that patients offered their choice of buergeriana). The Center is state affects the infant’s health, the trial will also studying: assess the effect of treatment on infant well-being. Additional studies are clinical trial); and the biological activities and addressing mechanisms of action, identification of mechanism of action of a Chinese herbal formula active compounds, and characterization of metabo- (whole formula and individual component lism, bioavailability and pharmacokinetics of active herbs)on breast cancer cells in vitro and in vivo, species contained in these botanicals. The Center as well as possible risks and/or benefits for also provides information about botanicals to the women with breast cancer. Olaf College flavonoids; and An Ethnographic Study of Institutional • Assessing the inhibitory effects of soy Review Boards—This Mentored Research Scien- isoflavones compared to genistein on prostate tist Development Award in Research Ethics cancer growth. The proposed study aims Mentored Patient-Oriented Research Career at (1)identifying active antihyperglycemic phytos- Development—Dr. Haskell, PhD, Stanford sive information of interest to healthcare con- University School of Medicine, Cofunded with the sumers and practitioners, and to researchers. The goal of this ment (such as child health, vaccines, and rehabilita- activity is to identify practices worthy of scientific tion and related therapies). Integration of Cancer Center Behavioral and Relaxation Approaches Into the Treat- Chairman,Clinical ment of Chronic Pain and Insomnia, a technology Advisory Board assessment conference held in October 1995,was Health, L. Luke’s Chief, Magnetic Resonance Imaging Medical Center Diagnostic Radiology Department Chicago, Illinois 60612 Warren G. The public-at-large and the broad Office of Cancer Complementary research community also were afforded the oppor- and Alternative Medicine tunity to help shape the final report. Evidence of disease and injury has been dis- The Greek physician Hippocrates advocates natural covered in bodies and organs from as early as remedies and a holistic approach to medical treat- 4000 B. Primitive medicine among peoples including Native Americans, Inuit (Eskimo), and Siberian The Greek physician Asclepiades practices nature tribes emerged through the appointment of healing in Rome. Indians, Mesopotamians, and other peoples prac- ticed herbalism and holistic medicine. Using nat- ural methods including massage, nutrition, 12th century meditation, exercise, and herbal and other thera- The abbess, musician, artist, and healer Hildegard pies, healers focused on balancing a main life force, von Bingen, Germany, writes Physica (The Book of or vital energy, present in the human body to Simples), which describes more than 300 medicinal restore or maintain health. Hildegard believes disease stems from 245 246 The Encyclopedia of Complementary and Alternative Medicine imbalances in the body and called health viriditas, The Swiss physician Barbara von Roll (1502–71) meaning the “green life force of the flesh. The period known as “the age of the Scientific Rev- olution,” in which Aristotle, Galen, and Paracelsus 1322 are still influential, but under the attack that marks The itinerant healer Jacoba Felice de Almania is the beginning of the idea of separation of mind and convicted in Paris of practicing medicine, including body, and that disease exists only on a physical laying on of hands and examining urine, without a level. And Antony van Pre-Columbian cultures in Mesoamerica combine Leeuwenhoek (1632–1723) uses a microscope to magic, religion, and science in a medical system. With each stride in anatomical and physiolog- disease is imbalance of favorable and unfavorable ical science, holistic approaches to medical practice forces. Mayan culture, for example, hemenes, or priests, are members of a respected organized medical society, 1737 and hechiceros are individuals designated to perform The New York physician and obstetrician Elizabeth bleeding, treating wounds, lancing abscesses, and Blackwell writes the Curious Herbal.