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DTaP (diphtheria and tetanus toxoids buy discount clomiphene 50mg line, acellular per- should have influenza vaccine annually cheap 50 mg clomiphene free shipping. Middle-aged adults tussis vaccine) at 2 months buy 100 mg clomiphene, 4 months, 6 months, 15 to should maintain immunizations against tetanus; high-risk 18 months, and 4 to 6 years of age. Haemophilus influenzae type b vaccine (Hib) at 2, 4, 6, should receive hepatitis B once (if not previously taken) and and 12 to 15 months of age. If Pedvax- HIB or ComVax is given at 2 and 4 months of age, a dose at 6 months is not needed. DTaP/Hib combination Use in Older Adults products should not be used for primary immunization at 2, 4, or 6 months but can be used as boosters after Annual influenza vaccine and one-time administration of any Hib vaccine. Inactivated poliovirus vaccine (IPV) injection at 2 and 4 months of age, at 6 to 18 months, and at 4 to 6 years of age. Oral polio vaccine (OPV) is no longer recom- mended for use in the United States. These vaccines are given later than DTaP and IPV because sufficient antibodies may not be produced Jim and Sue bring in their newborn for a well-child examination. Pneumococcal 7-valent conjugate vaccine (Prevnar) to further explain that they read an article outlining several cases that involved serious complications (deaths and lifelong disabil- all children at 2 to 23 months of age and pneumococcal ities) after infant immunizations. Varicella at 12 to 18 months and again at approximately • How you feel as a health care provider when people select not 12 years of age. For children with chronic illnesses such as asthma, heart • How you can help these parents make an informed decision. CHAPTER 43 IMMUNIZING AGENTS 653 for healthy older adults and those with chronic respiratory, immune globulin or varicella-zoster immune globulin may be cardiovascular, and other diseases. Compared to healthy, immunocompetent individuals, the an- tibody response to immunization is usually adequate but re- Use in Cancer duced in immunosuppressed persons. Also, with hepatitis For patients with active malignant disease, live vaccines B vaccine, antibody concentrations should be measured and should not be given. Although killed vaccines and toxoids booster doses given if antibody concentrations fall. When possible, patients should receive (MMR, varicella, yellow fever) should generally not be given needed immunizations 2 weeks before or 3 months after im- to people with HIV infection, other immune diseases, or im- munosuppressive radiation or chemotherapy treatments. In addition, patients who have not received HIV infection should receive inactivated vaccines. If an im- chemotherapy for 3 to 4 weeks may have an adequate anti- munosuppressed person is exposed to measles or varicella, body response to influenza vaccine. NURSING Immunizing Agents ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Read the package insert, and check the expiration date on Concentration, dosage, and administration of biologic products all biologic products (eg, vaccines, toxoids, and human im- often vary with the products. Also, use reconstituted prod- ucts within designated time limits because they are usually stable for only a few hours. The vastus lateralis is the largest skeletal muscle mass in the infant and the preferred site for all intramuscular (IM) injections. With measles, mumps, rubella (MMR) vaccine, use only The reconstituted preparation is stable for approximately 8 h. If not the diluent provided by the manufacturer, and administer the used within 8 h, discard the solution. Give hepatitis B vaccine IM in the anterolateral thigh of in- Higher blood levels of protective antibodies are produced when the fants and young children and in the deltoid of older children vaccine is given in the thigh or deltoid than when it is given in the and adults. Although the IM route is preferred, the drug can be buttocks, probably because of injection into fatty tissue rather than given SC in people at high risk of bleeding from IM injections gluteal muscles. Give IM human immune serum globulin with an 18- to To promote absorption and minimize tissue irritation and other ad- 20-gauge needle, preferably in gluteal muscles. If the dose is verse reactions 5 mL or more, divide it and inject it into two or more IM sites. Aspirate carefully before IM or SC injection of any immu- To avoid inadvertent IV administration and greatly increased risks nizing agent.

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However order clomiphene 100 mg online, creams or ointments may be used for dry generic clomiphene 50 mg with amex, crusted le- sions clomiphene 100 mg generic, and powders may be used for drying effects. Rosacea • Topical vaginal medications may be applied as douche Mild skin cleansers (eg, Cetaphil), oral tetracycline, and top- solutions, vaginal tablets, or vaginal creams used with ical metronidazole are commonly used; oral isotretinoin and an applicator. These medications • Anorectal medications may be applied as ointments, prevent or treat acneiform lesions; they have little to no effect creams, foams, and rectal suppositories. Few guidelines have been developed for Principles of topical drug therapy are generally the same as drug therapy of these disorders. In addition, topical corticosteroids should children, have more permeable skin and are more likely to ab- be used with caution on thinned or atrophic skin. In addition, absorption is in- creased in the presence of broken or damaged skin. Home Care With topical corticosteroids, suppression of the HPA axis (see Chap. When a home care nurse is involved, responsibili- paired adrenal function may include delayed growth and ties may include assessing clients, other members of the house- low plasma cortisol levels. Signs of intracranial hyper- hold, and the home environment for risks of skin disorders; tension may include headaches and swelling of the optic teaching preventive or treatment measures; assisting with treat- nerve (papilledema) on ophthalmoscopic examination. Because children are at high risk for development of sys- Nursing Notes: Apply Your Knowledge temic adverse effects with topical corticosteroids, these drugs should be used only if clearly indicated, in the smallest effec- tive dose, for the shortest effective time, and usually without You are making a home visit to young parents of a 6-month-old occlusive dressings. The teenage mother is home alone with the baby when you be used initially in infants and in intertriginous areas of older visit. She states that the baby has had a severe diaper rash for the last 2 weeks. If a more potent drug is required for severe dermati- ment data do you need to collect? What general principles should tis, the child should be examined often and the strength of the you include in your teaching about diaper rash? NURSING Dermatologic Drugs ACTIONS NURSING ACTIONS RATIONALE/EXPLANATION 1. Use the correct preparation for the intended use (ie, derma- Preparations may differ in drug contents and concentrations. For topical application to skin lesions: (1) Wash the skin, and pat it dry. To avoid bacterial cross-contamination between clients (5) Wash hands before and after application. Wash hands before to avoid exposing the client to infection; wash hands afterward to avoid transferring the drug to your own face or eyes and causing adverse reactions. Observe for therapeutic effects Therapeutic effects depend on the medication being used and the disorder being treated. With dermatologic conditions, observe for healing of skin With acne and rosacea, improvement may require 6 to 12 wk of lesions. With vaginal disorders, observe for decreased vaginal dis- charge and pruritus. Observe for adverse effects Incidence of adverse effects is low with topical agents. Local ef- fects may occur with most topical agents but may be more likely a. Local irritation or inflammation—burning on application, with antiseptics, local anesthetics, and antimicrobials. Allergic and irritant reactions to preservatives, fragrances, and other ingredients may prevent healing or worsen dermatitis. In ad- dition, children are at higher risk because they may absorb pro- portionally larger amounts and be more sensitive to systemic toxicity.

Each woman should be analysed as though she had received the intervention to which she had DATA COLLECTION been randomised generic clomiphene 25 mg online. This minimises any bias due Data in a trial are usually collected from sources to non-random removal of participants from such as case notes generic clomiphene 25 mg mastercard, local clinic databases and the trial discount 50 mg clomiphene mastercard. Occasionally interviews usually phase I and II drug trials, where strict may be used to explore areas which are not capa- rules of exclusion for protocol violation apply. General practitioners, local and national point of view to perform as separate analysis databases may also be accessed to obtain clini- by treatment received. This should be clearly cal information such as retreatment rates or seri- described as such and should be used to assess ous complications about patients who are lost to the primary outcome. To avoid recruitment bias, it is important to target all eligible women and record all refusals. It may be helpful to obtain some baseline Presenting Results clinical details about them in order to explore Analysis should follow the original plan set out any major differences between participants and in the protocol and the CONSORT recommen- non-participants, which could affect the external dations should be observed. Trial Co-Ordination Results of subgroup analyses should be treated Following informed consent, it is important to with caution and used mainly as hypothesis- obtain baseline information by filling in datasheets generating exercises in most modest-sized trials. Subse- There should be a conscious attempt to limit quent data collection should occur at the pre- discussion to the results generated by the trial specified times and an efficient system of timely and avoid speculation. Clinicians need to be gen- (in order to prevent twin pregnancies) it may be uinely uncertain about the best treatment. In such appropriate to stop if the pregnancy rate in the a clinical situation, there should be no conflict single embryo group becomes unacceptably low. The important issue is that participants are also CONCLUSION in personal equipoise and give informed consent. Despite awareness of its importance, there is Clinical trials in gynaecology have lagged behind evidence that some doctors do not seem to take those in other disciplines in terms of overall informed consent as seriously as they should. There are few large This may well be because participants seem to multi-centre trials, particularly surgical trials. The be less willing to be randomised, when they are clinical population is heterogeneous and interven- given more preliminary data, and made aware of tions under scrutiny diverse. In such as those for infertility and unwanted fer- many trials, a significant number of participants tility target women (and their partners) who have emerge from consultations expecting to benefit specific reproductive health needs but are oth- personally by their participation. Trialists in this field need the Human Fertilisation and Embryology Author- to design more pragmatic trials with clinically ity (HFEA) in the United Kingdom. In gynaecology data pertaining to licensed treatments (including these should be quality of life and satisfaction; donor insemination, IVF and ICSI) are confi- in infertility, live birth rates per couple/woman. Further- REFERENCES more, trials involving manipulation of gametes and embryos need separate approval from the 1. HFEA in addition to approval from the local Blinding and exclusions after allocation in ran- ethics committee. Out HJ, Schnabel PG, Rombout F, Geurts TB, Bosschaert MA, Coelingh Bennink HJ. A bioe- independent data monitoring committee should quivalence study of two urinary follicle stimulat- be available to review the results of an interim ing hormone preparations: Follegon and Metrodin. El-Refaey H, Rajasekar D, Abdalla M, Calder L, marked superiority or toxicity of one arm of Templeton A. Induction of abortion with Mifepri- stone (RU 486) and oral or vaginal Misoprostol. A evaluating the use of prophylactic antibiotics randomised trial of hysterectomy versus endome- during hysteroscopic surgery where the control trial ablation for the treatment of dysfunctional GYNAECOLOGY AND INFERTILITY 355 bleeding: clinical psychological and economic out- intra-cytoplasmic sperm injection (ICSI) in non- come at four years. Br J Obstet Gynaecol (1997) 104: endometrium for heavy menstrual loss: clinical 1332–5. Ashok PW, Kidd A, Flett GM, Fitzmaurice A, fertility and male subfertility: a randomised trial Graham W, Templeton A. Lancet (2000) 355: son of medical abortion and surgical vacuum aspi- 13–18. Fertil scopic management in women consulting a gynae- Steril (1996) 65(5): 939–45.

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Guide- approximately one half purchase clomiphene 25 mg on line, and replacement therapy may lines for treating hypercalcemia in children are essentially the be needed buy clomiphene 50 mg lowest price. Safety order clomiphene 50mg visa, effectiveness, and dosages of etidronate, pamidronate, and zoledronate have not been established. Management of Osteoporosis Once bone loss is evident (from diagnostic tests of bone Use in Older Adults density or occurrence of fractures), several interventions may help slow further skeletal bone loss or prevent frac- Hypocalcemia is uncommon because calcium moves from tures. Most drugs used to treat osteoporosis decrease the bone to blood to maintain normal serum levels. However, rate of bone breakdown and thus slow the rate of bone loss; calcium deficiency commonly occurs because of long-term di- a newer drug, teriparatide (Forteo), actually increases bone etary deficiencies of calcium and vitamin D, impaired absorp- formation. As with prevention, those diagnosed with osteoporosis and impaired liver or kidney metabolism of vitamin D to its ac- need adequate calcium and vitamin D (at least the rec- tive form. These and other factors lead to demineralization and ommended dietary allowance), whether obtained from weakening of bone (osteoporosis) and an increased risk of frac- the diet or from supplements. Postmenopausal women are at high risk for development vitamin D are sometimes used to treat clients with se- of osteoporosis. If such doses are used, caution men, it occurs less often, at a later age, and to a lesser extent should be exercised because excessive amounts of vita- min D can cause hypercalcemia and hypercalciuria. Numerous studies indicate that regular physical activity helps to reduce bone loss How Can You Avoid This Medication Error? Women who smoke should be encouraged to stop be- taking alendronate (Fosamax), 10 mg ac breakfast for her severe cause smoking has effects similar to those of menopause osteoporosis. Wenzel before breakfast to ad- (estrogen deficiency and accelerated bone loss). Alendronate (Fosamax), 10 mg daily or 70 mg weekly, ing, I think I will just skip breakfast and sleep a little longer this and risedronate (Actonel), 5 mg daily, are Food and morning. She does so with a sip of water Drug Administration (FDA) approved for treatment of and sends you on your way. The drugs can 378 SECTION 4 DRUGS AFFECTING THE ENDOCRINE SYSTEM than in older women. Both men and women who take corti- Pamidronate and zoledronate are nephrotoxic and renal func- costeroids are at risk of developing osteoporosis. In general, apparently does not require dosage adjustment in renal all older adults need to continue their dietary intake of dairy impairment. Older adults with osteoporosis or risk factors for developing osteoporo- sis may need calcium supplements, and a bisphosphonate or Use in Hepatic Impairment calcitonin to prevent or treat the disorder. With hypercalcemia, treatment usually requires large If vitamin D therapy is needed for a client with impaired liver amounts of IV 0. They should be moni- The bisphosphanates are not metabolized in the liver and tored closely for signs of fluid overload, congestive heart fail- are unlikely to affect liver function. Use in Renal Impairment Home Care Clients with renal impairment or failure often have disor- dered calcium and bone metabolism. The calcium re- The home care nurse has an excellent opportunity to promote duces blood levels of phosphate by reducing its absorption health and prevent illness related to calcium and bone dis- from foods. All members of a household should be assessed in re- produce calcium phosphate, which is insoluble and excreted lation to calcium and vitamin D intake because an adequate in feces. If vitamin D therapy is needed to treat osteomalacia amount of these nutrients is needed throughout life. Children, associated with renal impairment, calcitriol (Rocaltrol) or di- adolescent girls, and older women often have inadequate in- hydrotachysterol (Hytakerol) is preferred. Calcitriol is the ac- takes, with risks of having or developing osteoporosis. Teaching or other assistance may also be None of the bisphosphonate drugs is recommended for use needed by clients who are receiving medications to prevent in severe renal impairment (eg, serum creatinine > 5 mg/dL or treat osteoporosis.

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