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By L. Randall. University of Redlands.

Caltrate Plus 600 200 When pamidronate is given in a single IV infusion con- Citracal caplets + D 315 200 taining 60 or 90 mg buy generic cialis 2.5mg on-line, serum calcium levels decrease Dical-D tablets 117 133 within 2 days purchase 10mg cialis visa, reach their lowest levels in approximately Dical-D Wafers 233 200 7 days discount cialis 5mg with amex, and remain lower for 2 weeks or longer discount 2.5 mg cialis fast delivery. Treat- Os-Cal 250 + D 250 125 Os-Cal 500 + D 500 125 ment can be repeated if hypercalcemia recurs cheap cialis 20 mg without prescription. Zole- Posture-D 600 125 dronate can be given over 15 minutes and effects may last longer than those of pamidronate. They are also con- traindicated in clients with persistent urinary tract infec- often recommended for postmenopausal women with tions and an alkaline urine because calcium phosphate osteoporosis. In general, intake of calcium should not kidney stones are likely to form in such cases. Chronic hypercalcemia requires treatment of the under- vitamin D should not exceed 400 IU daily. These mix- lying disease process and measures to control serum tures are not indicated for maintenance therapy in calcium levels (eg, a high fluid intake and mobilization chronic hypocalcemia. Calcium preparations and digoxin have similar effects istration may help if other measures are ineffective. Serum calcium levels should be measured periodically digitalized client, the risks of digitalis toxicity and car- to monitor effects of therapy. For clients with severely impaired renal function in must be used very cautiously. Oral calcium preparations decrease effects of oral toneal dialysis with a calcium-free solution is effective tetracycline drugs by combining with the antibiotic and safe. For clients receiving a calcium channel blocker (see given at the same time or within 2 to 3 hours of each Chap. Management of Hypercalcemia Prevention of Osteoporosis Clients at risk for hypercalcemia should be monitored for Preventive measures should be implemented for all age early signs and symptoms so treatment can be started before groups to avoid or slow bone loss. In all age groups, preventive efforts include a consis- on the cause and severity. When hypercalcemia is caused by a tumor of para- normal bone development and maintenance. A well-stocked reservoir means that, in later reduce production of PTH. When it is caused by ex- years when bone loss exceeds formation, more bone cessive intake of vitamin D, the vitamin D preparation can be lost before osteoporosis develops. It is age, an adequate calcium intake may slow the devel- treated with interventions that increase calcium excre- opment of osteoporosis and fractures. Although di- tion in the urine and decrease resorption of calcium etary intake is much preferred, a supplement may be from bone into the serum. For severe symptoms or a needed to ensure a daily intake of 1000 to 1500 mg, serum calcium level above 12 mg/dL, the priority is re- especially in adolescent girls, frail elderly, and those hydration. After rehydration, furosemide Vigorous, weight-bearing exercise helps to promote may be given IV to increase renal excretion of calcium and maintain strong bone; inactivity promotes bone and prevent fluid overload. Alendronate (Fosamax) and risedronate (Actonel) are in combination with estrogen and calcium and vitamin approved by the Food and Drug Administration (FDA) D supplements. Treatment of men is similar to that of women except ommended dosage is smaller for prevention than for that testosterone replacement may be needed. Raloxifene (Evista) is approved for prevention of post- treatment measures may be needed, including increased menopausal osteoporosis in women who are unable or dietary and supplemental calcium and possibly vitamin unwilling to take ERT. An adequate intake of vitamin D helps to prevent os- steroid dosage reduction, exercise, and a bisphospho- teoporosis, but supplementation is probably not indi- nate or calcitonin to slow skeletal bone loss. Serum calcitriol can be measured in clients at risk for vitamin D deficiency, including elderly adults and those on Use in Children chronic corticosteroid therapy. Preventive measures are needed for clients on chronic Hypocalcemia is uncommon in children. If hypocalcemia or dietary calcium de- most of the preceding guidelines apply (eg, calcium ficiency develops, principles of using calcium or vitamin D supplements, regular exercise, a bisphosphonate drug). Children should In addition, low doses and nonsystemic routes help be monitored closely for signs and symptoms of adverse ef- prevent osteoporosis and other adverse effects. Hypercalcemia is probably men, corticosteroids decrease testosterone levels by most likely to occur in children with a malignant tumor.

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With minerals for adults generic cialis 5 mg otc, ULs have been estab- mineral–electrolyte imbalances trusted cialis 2.5 mg. Except states discount cialis 20 mg visa, and nonmineral drug preparations are used in excess for magnesium buy cialis 5 mg low cost, which is set for supplements only and ex- states generic cialis 2.5mg with mastercard. Selected individual drugs are described in the follow cludes food and water sources, the stated amounts include sections; routes and dosage ranges are listed in Drugs at a those from both foods and supplements. Glance: Individual Agents Used in Mineral–Electrolyte and The current DRIs were established in 1997, 1998, and Acid–Base Imbalances. Once established, DRIs will be periodically reviewed and updated by the Food and Nutrition Board of the Institute of Medicine Alkalinizing Agent and the National Academy of Science. Sodium bicarbonate has long been used to treat metabolic acidosis, which occurs with severe renal disease, diabetes Macronutrients mellitus, circulatory impairment due to hypotension, shock or fluid volume deficit, and cardiac arrest. The drug dissoci- Some minerals (calcium, phosphorus, sodium, potassium, ates into sodium and bicarbonate ions; the bicarbonate ions magnesium, chlorine, sulfur) are required in relatively large combine with free hydrogen ions to form carbonic acid. This CHAPTER 32 MINERALS AND ELECTROLYTES 471 TABLE 32–1 Minerals and Electrolytes Recommended Daily Intake Characteristics Functions (RDAs or DRIs) Food Sources Sodium Major cation in extracellular Assists in regulating osmotic Approximately 2 g (estimated) Present in most foods. Proteins body fluids (blood, lymph, pressure, water balance, con- contain relatively large tissue fluid) duction of electrical impulses amounts, vegetables and Small amount in intracellular fluid in nerves and muscles, elec- cereals contain moderate to Large amounts in saliva, gastric trolyte and acid–base balance small amounts, fruits contain secretions, bile, pancreatic Influences permeability of cell little or no sodium. Potassium Major cation in intracellular body Within cells, helps to maintain Approximately 40 mEq Present in most foods, includ- fluids osmotic pressure, fluid and ing meat, whole-grain breads Present in all body fluids electrolyte balance, and or cereals, bananas, citrus Eliminated primarily in urine. Nor- acid–base balance fruits, tomatoes, and broccoli mally functioning kidneys ex- In extracellular fluid, functions crete excessive amounts of with sodium and calcium to potassium, but they cannot regulate neuromuscular conserve potassium when in- excitability. The kid- required for conduction of neys excrete 10 mEq or more nerve impulses and contrac- daily in the absence of intake. It is especially enced by acid–base balance important in activity of the and aldosterone secretion. Helps transport glucose into cells and is required for glycogen formation and storage. Re- quired for synthesis of muscle proteins Magnesium A cation occurring primarily in Required for conduction of nerve Adults (DRIs): Males 19–30 y, Present in many foods; diet ad- intracellular fluid impulses and contraction of 400 mg; 31–>70 y, 420 mg; equate in other respects con- Widely distributed in the body, muscle females 19–30 y, 310 mg; tains adequate magnesium. Infants (AIs): 0-6 mo, 30 mg; 7-12 mo, 75 mg Other children (RDAs): 1–3 y, 80 mg; 4–8 y, 130 mg; 9-13 y, 240 mg; 14–18 y, 410 mg (continued) 472 SECTION 5 NUTRIENTS, FLUIDS, AND ELECTROLYTES TABLE 32–1 Minerals and Electrolytes (continued) Recommended Daily Intake Characteristics Functions (RDAs or DRIs) Food Sources Chloride Ionized form of element chlorine Functions with sodium to help 80–110 mEq Most dietary chloride is ingested The main anion of extracellular maintain osmotic pressure and as sodium chloride (NaCl), fluid water balance and foods high in sodium are Almost all chloride is normally Forms hydrochloric acid (HCl) in also high in chloride. Thus, drug ad- drug is not usually recommended now unless the acidosis is ministration may be more harmful than helpful. Even then, stances, treating the underlying cause of the acidosis is safer use must be based on frequent measurements of arterial blood and more effective. For example, in diabetic ketoacidosis, gases and careful titration to avoid inducing alkalosis. In cardiac ar- losis makes the myocardium more sensitive to stimuli and in- rest, interventions to maintain circulation and ventilation are creases the occurrence of dysrhythmias. TABLE 32–2 Sodium Imbalances Causes Pathophysiology Signs and Symptoms Hyponatremia 1. Hypotension and tachycardia uretic drug therapy or when water only is output 3. Headache, dizziness, weakness, lethargy, (eg, excessive sweating) creased glomerular filtration rate, and de- restlessness, confusion, delirium, muscle 2. Excessive losses with vomiting, GI creased ability of kidneys to excrete water tremors, convulsions, ataxia, aphasia suction, diarrhea, excessive water 4. Anorexia, nausea, and vomiting are com- enemas, excessive perspiration, burn (cerebral edema). Leads to impaired neu- mon; abdominal cramps and paralytic wounds, and adrenal insufficiency states rologic and muscular functions. Lethargy, disorientation, hyperactive ciency results from lack of intake or ex- decreases fluid volume in extracellular reflexes, muscle rigidity, tremors and cessive losses (diarrhea, diuretic drugs, fluid and intracellular fluid compartments spasms, irritability, coma, cerebral excessive sweating). Hypotension mon cause of hypernatremia because the creases extracellular fluid volume and 4. Fever, dry skin, and dry mucous thirst mechanism is normally activated, decreases intracellular fluid volume as membranes and water intake is increased. CHAPTER 32 MINERALS AND ELECTROLYTES 473 TABLE 32–3 Potassium Imbalances Causes Pathophysiology Signs and Symptoms Hypokalemia 1. Decreased strength of myocardial con- pressed ST segment; flattened or in- free intravenous fluids for several days.

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With therapeutic heparin purchase cialis 10 mg with visa, observe for an activated partial thromboplastin time of 1 cialis 10 mg cheap. Platelet counts should be done every 2 days during the first week of management and weekly until a maintenance dose is reached discount cialis 20 mg line. With aspirin buy 10 mg cialis, clopidogrel purchase cialis 2.5 mg with mastercard, and other antiplatelet drugs, ob- serve for the absence of thrombotic disorders (eg, myocardial infarction, stroke) g. With cilostazol, observe for ability to walk farther without Improvement may occur within 2 to 4 wk or take as long as 12 wk. It may occur anywhere in the body, spontaneously or in response to minor trauma. With eptifibatide and tirofiban, most major bleeding occurs at the arterial access site for cardiac catheterization. Gastrointestinal (GI) bleeding is fairly common; risks are increased with intubation. Blood in stools may be bright red, tarry (blood that has been digested by GI secretions), or occult (hidden to the naked eye but present with a guaiac test). Genitourinary bleeding also is fairly common; risks are increased with catheterization or instrumentation. Urine may be red (indi- cating fresh bleeding) or brownish or smoky gray (indicating old blood). Or bleeding may be microscopic (red blood cells are visi- ble only on microscopic examination during urinalysis). Surgical wounds, skin lesions, parenteral injection sites, the nose, and gums may be bleeding sites. Other adverse effects: (1) With heparin, tissue irritation at injection sites, tran- These effects are uncommon. They are more likely to occur with sient alopecia, reversible thrombocytopenia, paresthesias, large doses or prolonged administration. With thrombolytic drugs, observe for bleeding with all uses Bleeding is most likely to occur at sites of venipuncture or other and reperfusion dysrhythmias when used for acute myocardial invasive procedures. Drugs that increase risks of bleeding with anticoagulant, These drugs are often used concurrently or sequentially to de- antiplatelet, and thrombolytic agents: crease risks of myocardial infarction or stroke. Drugs that increase effects of heparins: (1) Antiplatelet drugs (eg, aspirin, clopidogrel, others) (2) Warfarin Additive anticoagulant effects and increased risks of bleeding (3) Parenteral penicillins and cephalosporins Some may affect blood coagulation and increase risks of bleeding c. Drugs that decrease effects of heparins: (1) Antihistamines, digoxin, tetracyclines These drugs antagonize the anticoagulant effects of heparin. Drugs that increase effects of warfarin: Mechanisms by which drugs may increase effects of warfarin in- (1) Analgesics (eg, acetaminophen, aspirin and other non- clude inhibiting warfarin metabolism, displacing warfarin from steroidal anti-inflammatory drugs) binding sites on serum albumin, causing antiplatelet effects, in- hibiting bacterial synthesis of vitamin K in the intestinal tract, (2) Androgens and anabolic steroids and others. Drugs that decrease effects of warfarin: (1) Antacids and griseofulvin May decrease GI absorption (2) Carbamazepine, disulfiram, rifampin These drugs activate liver metabolizing enzymes, which acceler- ate the rate of metabolism of warfarin. Drug that may increase or decrease effects of warfarin: (1) Alcohol Alcohol may induce liver enzymes, which decrease effects by ac- celerating the rate of metabolism of the anticoagulant drug. How- ever, with alcohol-induced liver disease (ie, cirrhosis), effects may be increased owing to impaired metabolism of warfarin. Drugs that increase effects of cilostazol: (1) Diltiazem These drugs inhibit the main cytochrome P450 enzyme (CYP3A4) that metabolizes cilostazol. Grapefruit juice also inhibits drug (2) Erythomycin metabolism and should be avoided. When is it appropriate to use vitamin K as an antidote for Nursing Notes: Apply Your Knowledge warfarin? How do antiplatelet drugs differ from heparin and war- Answer: Low-dose subcutaneous heparin is administered pro- farin? How do aminocaproic acid and tranexamic acid stop low-dose heparin therapy. When giving the injection, take care to bleeding induced by thrombolytics? Compare and contrast nursing care needs of clients 1⁄ -inch needle is used. Leave a small air bubble in the syringe to 2 receiving anticoagulant therapy in hospital and home follow the dose and lock the heparin into the subcutaneous space.

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