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By: John Walter Krakauer, M.A., M.D.

  • Director, the Center for the Study of Motor Learning and Brain Repair
  • Professor of Neurology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/9121870/john-krakauer

Low-dose aspirin is also indicated in extreme thrombocytosis if ristocetin cofactor activity is! In high-risk patients antibiotics zoloft buy generic doxycycline 200mg online, platelet-normalizing therapy with hydroxyurea is indicated antimicrobial keyboards doxycycline 100mg on line. Interferon-a or busulfan is used when poorly tolerant antibiotic overuse 100mg doxycycline with amex, or resistant to kaspersky anti-virus discount 200mg doxycycline fast delivery hydroxyurea. Platelet count should be normalized before surgery, particularly splenectomy, to minimize complications and avoid rebound thrombocytosis. Venous and arterial thromboembolic events are treated in accordance with national guidelines and institutional policy. Patients with extreme thrombocytosis and hemor rhage should be treated to lower the platelet count with medical therapy or thrombocytapheresis. Although the therapeutic mecha nisms are not well defined, rapid cytoreduction is believed to ameliorate prothrombotic factors associated with the dysfunctional platelets. Elective thrombocytapheresis should also be considered for cytoreduction of patients at increased risk of major hemorrhage when hydroxyurea is contraindicated, such as in pregnancy or in situations when the onset of action of hydroxyurea cytoreduction is too slow, such as the requirement for emergent surgery. Platelet-lowering agents must be given to prevent rapid reaccumulation of circulating platelets whenever possible. Although anecdotal case reports have described a potential benefit of thrombocytapheresis with secondary thrombocytosis, rationale is unde fined and efficacy unproven. Anticoagulant ratio of whole blood: anticoagulant should be 1:6–12; heparin should be avoided to prevent ex vivo platelet clumping. Goal for prophylaxis of high-risk patients who are pregnant, undergoing surgery, or postsplenectomy should be determined on case-by-case basis (considering the patient’s history of thrombosis or bleeding at a specific platelet count). Without an informative clinical history, platelet count of 600 3 109/L may be sufficient. Can vera, plateletapheresis, thrombocytapheresis, apheresis, myeloproli cer 2006;107:361–370. Asian J Transfus Sci 2015;9: with vascular complications in essential thrombocythemia: analysis 85–86. Am J Hematol nectomy reactive thrombocytosis in idiopathic thrombocytopenic 2014;89:306–309. J Clin Apher 2013; proliferative neoplasms: trends and subgroup risk profiles in the 28:321–324. Acquired von Willebrand’s themia: 2015 update on diagnosis, risk-stratification and man disease in myelofibrosis and essential thrombocythemia. Because these genetic mutations are not all directly impactful on the complement cascade, therapy with ecu lizumab may not be beneficial. Further experience is needed to determine whether plasma can be a source for therapeutic intervention, although intuitively, plasma should contain the deficient coagulation factors absent or decreased in affected patients. These six patients were treated for eight separate epi sodes, with remission achieved in seven episodes (88%) (five complete and two partial remissions). Comprehensive genetic analysis of complement and A, Ozen S, Topaloglu R, Besbas N, Ashraf S, Du Y, Liang C, coagulation genes in atypical hemolytic uremic syndrome. J Am Chen P, Lu D, Vadnagara K, Arbuckle S, Lewis D, Wakeland Soc Nephrol 2014;25:55–64. Lemaire M, Fremeaux-Bacchi V, Schaefer F, Choi M, Tang mic syndrome in a patient with thrombomodulin mutation. Incomplete forms with mild or no typical hematologic features account for $20% of cases. The primary event in the pathogenesis appears to be endothelial injury leading to formation of platelet-fibrin hyaline microthrombi which occlude arterioles and capillaries. Infection, pregnancy, or drugs may trigger clinical disease in the presence of these mutations. A history of recurrent infections from Streptococcus or other encapsulated microorganisms such as Neisseria meningitidis or Haemophilus influenza should suggest a familial etiology. Disease may present with an insidious onset at any age but many cases present in first few months of life. In familial disease, lack of functional complement factors results in excessive activation of alternate complement pathway causing glomerular injury. Kidney transplantation may be considered but risks recurrence of the disease process in the allograft; graft loss are common. The avaibl ability of eculizumab may also reduce the need for kidney transplantation. Nester C, Stewart Z, Myers D, Jetton J, Nair R, Reed A, Thomas C, Smith R, Brophy P. References of the identified articles were searched Engl J Med 2009; 361:1676–1687. Terminal comple botic thrombocytopenic purpura and hemolytic uremic syn ment inhibitor eculizumab in atypical hemolytic-uremic syn drome. However, 9 (clopidogrel, cyclosporine, estrogen/progesterone, gemcitabine, interferon, mitomycin, quinine, tacrolimus, and ticlopidine) accounted for 76% of reports. An example is quinine-dependent antibodies directed at platelet glycoproteins, granulo cytes, lymphocytes, and endothelial cells. Current management/treatment Initial management involves immediate discontinuation of suspected drug, or reduction of dose when discontinuation is not a medical option. Supportive care and other interventions reported for specific drugs include: Gemcitabine-dialysis, antihypertensives, corticosteroids, rituximab; Quinine corticosteroids, antiplatelet agents; Bevacizumab-steroids, cyclophosphamide; Cyclosporine/Tacrolimus/Sirolimus—use alternative immunosuppression. Pathogenesis is thought to be multifactorial including autoimmunity, drug dependent antibodies, and endothelial toxicity. This drug toxicity appears to occur by two different mechanistic pathways, characterized primarily by time of onset before versus after 2 weeks of thienopyridine administration. Clin Nephrol 2009; terms thrombotic microangiopathy or hemolytic uremic syndrome or 71:130–139. Is therapeutic plasma exchange and the respective drug: gemcitabine, quinine, cyclospo exchange indicated for patients with gemcitabine-induced hemo rine, tacrolimus, ticlopidine, clopidogrel, thienopyridine, sirolimus, lytic uremic syndrome Rapid and complete resolution of chemotherapy-induced thrombotic thrombocytopenic purpura/ 1. Cancer Drug-induced thrombotic microangiopathy: a systematic review Chemother Pharmacol 2010;65:1001–1004. Semin Thromb Hemost 2012;38:839–844 ways for thienopyridine-associated thrombotic thrombocytopenic 14. Pelle G, Shweke N, Van Huyen J-P, Tricot L, Hessaline S, hemolytic uremic syndrome in a patient with metastatic pancre Fremeaux-Bacchi V, Hiesse C, Delahoussse M. Cancer Chemother Pharma kidney toxicity of intraocular administration of vascular endo col 2009;64:177–181. Garc a-Mart n P, Alarcon-Payer C, Lopez-Fernandez E, Pang Z, Wang L, Liu D, Wang Q, Gao C. Transplan safety of sirolimus-based graft-versus-host disease prophylaxis tation-associated thrombotic microangiopathy in patients treated in patients undergoing allogeneic hematopoietic stem cell trans with sirolimus and cyclosporine as salvage therapy for graft plantation: a meta-analysis of randomized controlled trials. The incidence varies based on the diagnostic criteria and transplant-associated risk factors. Abnormalities the identified articles were searched for additional cases and trials. Posttransplant thrombotic microangiopathy: sensitivity of pro associated thrombotic microangiopathy: real progress or are we still posed new diagnostic criteria. Small vessels, big trouble graft-versus-host disease after allogeneic hematopoietic stem cell in the kidneys and beyond: hematopoietic stem cell transplantation transplantation. Oran B, Donato M, Aleman A, Hosing C, Korbling M, Detry microangiopathy in hematopoietic stem-cell transplantation. Christidou F, Athanasiadou A, Kalogiannidis P, Natse T, Bamichas G, tacrolimus following allogeneic stem cell transplantation: risk Salum R, Sakellari I, Anagnostopoulos A, Fassas A, Sombolos K. Biol Blood Marrow Trans Therapeutic plasma exchange in patients with grade 2-3 hematopoietic plant 2007;13:469–477. Peffault de Latour R, Xhaard A, Fremeaux-Bacchi V, Coppo P, pura: a ten-year experience. Transplantation-associated in a patient with posttransplant thrombotic microangiopathy. Posttransplantation thrombotic thrombocyto nostic criteria for hematopoietic stem cell transplant-associated penic purpura: a single-center experience and a contemporary microangiopathy: results of a consensus process by an International review. Plasmapheresisrefractory following pediatric hematopoietic stem cell transplantation. Biol conditioning: close association with transplant-associated microan Blood Marrow Transplant 2014;20:518–525.

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Obtain patient educa tion information from the Crohn’s and Colitis Foundation of America antibiotics for acne in adults buy line doxycycline. Recommend use of medication reminders (containers that separate pills according to bacterial conjunctivitis buy doxycycline 100 mg with mastercard day U and time) antibiotic resistance questionnaire discount 200 mg doxycycline free shipping. Advise patient to different antibiotics for sinus infection doxycycline 200 mg fast delivery limit tasks that impose strain on the lower abdominal muscles and to sleep close to bathroom because of frequent diarrhea. Encourage patient to keep a record Unconscious Patient 639 of foods that irritate bowel and to eliminate them from diet. Evaluation Expected Patient Outcomes • Reports decrease in frequency of diarrheal stools • Experiences less pain • Maintains uid volume balance • Attains optimal nutrition • Avoids fatigue • Experiences less anxiety • Copes successfully with diagnosis • Maintains skin integrity • Acquires an understanding of the disease process • Recovers without complications For more information, see Chapter 38 in Smeltzer, S. Coma is a clinical state—an unarous able unresponsive condition—in which the patient is unaware of self or the environment for prolonged periods (days to U months, or even years). Akinetic mutism is a state of unre sponsiveness to the environment in which the patient makes no voluntary movement. A persistent vegetative state is one in which the unresponsive patient resumes sleep–wake cycles after coma but is devoid of cognitive or affective mental func tion. Locked-in syndrome results from a lesion affecting the pons and results in paralysis and the inability to speak, but vertical eye movements and lid elevation remain intact and 640 Unconscious Patient are used to indicate responsiveness. The causes of uncon sciousness may be neurologic (head injury, stroke), toxicologic (drug overdose, alcohol intoxication), or metabolic (hepatic or renal failure, diabetic ketoacidosis). Medical Management the rst priority is a patent and secure airway (intubation or tracheostomy). Then circulatory status (carotid pulse, heart rate and impulse, blood pressure) is assessed and adequate oxy genation maintained. Diagnosis Nursing Diagnoses • Ineffective airway clearance related to inability to clear respiratory secretions • Risk for uid volume de cit related to inability to ingest uids • Impaired oral mucous membranes related to mouth breathing, absence of pharyngeal re ex, and inability to ingest uids • Risk for impaired skin integrity related to immobility or restlessness • Impaired tissue integrity of cornea related to diminished or absent corneal re ex • Ineffective thermoregulation related to damage to hypothalamic center • Impaired urinary elimination (incontinence or retention) related to impairment in neurologic sensing and control • Bowel incontinence related to impairment in neurologic sensing and control and also related to changes in nutri tional delivery methods • Disturbed sensory perception related to neurologic impairment • Interrupted family processes related to health crisis Collaborative Problems/Potential Complications • Respiratory distress or failure • Pneumonia U • Aspiration • Pressure ulcer • Deep vein thrombosis • Contractures Planning and Goals Goals of care during the unconscious period may include main tenance of a clear airway, protection from injury, attainment of uid volume balance, achievement of intact oral mucous 642 Unconscious Patient membranes, maintenance of normal skin integrity, absence of corneal irritation, attainment of effective thermoregulation, effective urinary elimination, bowel continence, accurate perception of environmental stimuli, maintenance of intact family or support system, and absence of complications. Nursing Interventions Maintaining the Airway • Establish an adequate airway, and ensure ventilation. Protecting the Patient • Provide padded side rails for protection; keep two rails in the raised position during the day and three at night. Therefore, physical restraints should be avoided if possible; a written prescription must be obtained if their use is essential for the patient’s well-being. Unconscious Patient 643 Maintaining Fluid Balance and Managing Nutritional Needs • Assess for hydration status: Examine tissue turgor and mucous membranes, assess intake and output trends, and analyze laboratory data. Providing Mouth Care • Inspect mouth for dryness, in ammation, and crusting; cleanse and rinse carefully to remove secretions and crusts and keep membranes moist; apply petrolatum to lips. Maintaining Skin and Joint Integrity • Follow a regular schedule of turning and repositioning to prevent breakdown and necrosis of the skin, and to provide kinesthetic, proprioceptive, and vestibular stimulation. Preserving Corneal Integrity • Cleanse eyes with cotton balls moistened with sterile normal saline to remove debris and discharge. Maintaining Body Temperature • Adjust environment to promote normal body temperature. Preventing Urinary Retention • Palpate or scan bladder at intervals to detect urinary retention. U Promoting Bowel Function • Evaluate abdominal distention by listening for bowel sounds and measuring abdominal girth. Unconscious Patient 645 Promoting Sensory Stimulation • Provide continuing sensory stimulation (eg, auditory, visual, olfactory, gustatory, tactile, and kinesthetic activities) to help patient overcome profound sensory deprivation. Meeting the Family’s Needs • Reinforce and clarify information about patient’s condition to permit family members to mobilize their own adaptive capacities. Monitoring and Managing Potential Complications • Monitor vital signs and respiratory function for signs of respiratory failure or distress. Evaluation Expected Patient Outcomes • Maintains clear airway and demonstrates appropriate breath sounds • Experiences no injuries • Attains or maintains adequate uid balance • Attains or maintains healthy oral mucous membranes • Maintains normal skin integrity • Has no corneal irritation • Attains or maintains thermoregulation • Has no urinary retention • Has no diarrhea or fecal impaction • Receives appropriate sensory stimulation • Has family members who cope with crisis • Avoids other complications For more information, see Chapter 61 in Smeltzer, S. Stones U are formed in the urinary tract when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric acid increases. Factors that favor formation of stones include infection, urinary stasis, and periods of immo bility, all of which slow renal drainage and alter calcium metab olism. The problem occurs predominantly in the third to fth decades and affects men more often than women. Urolithiasis 647 Clinical Manifestations Manifestations depend on the presence of obstruction, infec tion, and edema. Medical Management Basic goals are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present. Stone Removal Procedures • Ureteroscopy: stones fragmented with use of laser, electro hydraulic lithotripsy, or ultrasound and then removed. Urolithiasis 649 • Assess for associated symptoms, including nausea, vomit ing, diarrhea, and abdominal distention. Diagnosis Nursing Diagnoses • Acute pain related to in ammation, obstruction, and abra sion of the urinary tract • De cient knowledge regarding prevention of recurrence of renal stones Collaborative Problems/Potential Complications • Infection and urosepsis (from urinary tract infection and pyelonephritis) • Obstruction of the urinary tract by a stone or edema, with subsequent acute renal failure Planning and Goals Major goals may include relief of pain and discomfort, pre vention of recurrence of renal stones, and absence of com plications. U • Assess the patient’s ability to monitor urinary pH and interpret the results during follow-up visits. U V Vein Disorders: Venous Thrombosis, Thrombophlebitis, Phlebothrombosis, and Deep Vein Thrombosis Although the vein disorders described here do not necessar ily present an identical pathology, for clinical purposes these terms are often used interchangeably. The exact cause of venous thrombosis remains unclear, although three factors (Virchow’s triad) are believed to play a signi cant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. Thrombophlebitis is an in ammation of the walls of the veins, often accompanied by the formation of a clot. When a clot develops initially in the veins as a result of stasis or hyper coagulability, but without in ammation, the process is referred to as phlebothrombosis. Venous thrombosis can occur in any vein but is most fre quent in the veins of the lower extremities than the upper extremities. Damage to the lining of blood vessels creates a site for clot formation, and increased blood coagulability occurs in patients who abruptly stop taking anticoagulant medications and also occurs with oral contraceptive use and several blood dyscrasias. The danger associated with venous thrombosis is that parts of a clot can become detached and produce an embolic occlusion of the pulmonary blood vessels. Risk Factors • History of varicose veins, hypercoagulation, neoplastic dis ease, cardiovascular disease, or recent major surgery or injury • Obesity • Advanced age • Oral contraceptive use 653 654 Vein Disorders Clinical Manifestations • Signs and symptoms are nonspeci c. Assessment and Diagnostic Methods • History revealing risk factors such as varicose veins or neo plastic disease. Prevention Prevention is dependent on identifying risk factors for throm bus and on educating the patient about appropriate interven tions. V Medical Management Objectives of management are to prevent the thrombus from growing and fragmenting, resolve the current thrombus, and prevent recurrence. Early signs include decreasing platelet count, the need for increasing doses of heparin to maintain the therapeutic level, and thromboembolic or hemorrhagic complications (appearance of skin necrosis, skin discoloration, purpura, and blistering). If thrombocy topenia does occur, perform platelet aggregation studies, dis continue heparin, and rapidly initiate alternate anticoagu lant therapy. Providing Comfort • Elevate affected extremity and apply warm, moist packs to reduce discomfort. Teach the family member who is to assist the patient to apply the stockings so that they do not cause undue pressure on any part of the feet or legs. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the oor in the morning. Positioning the Body and Encouraging Exercise • Elevate feet and lower legs periodically above heart level when on bed rest. Teaching Patients Self-Care • Teaching the patient how to apply graduated compression stockings and explain the importance of elevating the legs and exercising adequately. Appendix C Key Health Care Abbreviations and Acronyms Note: these are examples and may differ slightly from facility to facility. See Activated vitamin D fatigue, 177 Calcium antagonists, 333 psychological support, 177–178 Calcium channel blockers, 581, 584 medical management, 177 Calcium intake and osteoporosis, 475 risk factors, 175 Calcium stones, 64 Bronchopneumonia, 551 Calculous cholecystitis, 225 Buerger’s disease, 106–107 Campath. See Bronchogenic surgical management, 214 carcinoma Catheterization, 91 cholangiocellular, 172 cardiac, 63, 67, 209, 348, 439, 580 of colon, 152 intermittent self, 445, 447 of esophagus, 159 intermittent sterile, 222 hepatocellular, 171–172, 362 pulmonary artery, 23 in ltrating ductal, 138 Catheter obstruction in prostate cancer, in ammatory, 139 189 renal. See Haloperidol decanoate Helicobacter pylori Haloperidol decanoate, 372 and chronic gastritis, 313 Hand trauma management, 309–310 and peptic ulcer, 501 Hashimoto’s thyroiditis.

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