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Zero-order controlled release offers the advantage of improved control over drug plasma levels: the peaks and troughs of conventional therapy are avoided and constant plasma levels are attained purchase cafergot 100mg on-line pain treatment for dogs with cancer. The risk of side- effects is minimized since possible toxic peak drug plasma levels are never obtained and the total amount of drug administered is lower than with frequent repeated dosing cheap cafergot 100 mg overnight delivery pain medication for arthritis in dogs. There is also a reduction in symptom breakthrough which can occur if plasma concentrations drop too low purchase cafergot 100 mg cape fear pain treatment center. Furthermore order cafergot 100 mg with visa pain treatment for arthritis on the hip, patient compliance is also improved as a result of the reduction in the number and frequency of doses required to maintain therapeutic efficacy. For example, the problem of dosing through the night is eliminated since the drug is slowly released in vivo. A wide variety of drug delivery systems have been developed to achieve zero-order controlled release and are discussed further in the relevant chapters. Situations in which changing levels of response may be required include: Circadian rhythms Biological processes are frequently associated with rhythms of a predictable period. Some of these rhythms have periods of less than a second, others are ultradian (a period ranging from a few minutes to a 31 Figure 1. The intensity of the disease state and associated symptomatology may vary over a 24 h period. For example, in hypertension, blood pressure is lower during the night and increases early in the morning, therefore optimal therapy should facilitate maximum drug levels in the morning. Approximately 80% of insulin-dependent diabetics experience the dawn phenomenon, a rapid rise in serum glucose levels in the dawn hours. At this time interval, the insulin dose should be increased to meet the biological need. Variation in the pharmacokinetics of a drug may also occur (chronopharmacokinetics) which is directly related to the time of day that the drug is administered. The responsiveness of the biological systems (chronopharmacodynamics) may also vary depending on the time of day that the drug is administered, thereby possibly resulting in altered efficacy and/or altered intensity of side-effects. This in turn has created huge challenges, but also exciting opportunities for drug delivery. The goal is to tailor drug input to match these complex, newly defined time courses. There are already some examples of chronotherapeutics in the literature, including the timed administration of theophylline and corticosteroids to asthmatics, treatment of hypertension and, increasingly, the administration of cytotoxic drugs. However, this is still a new, and as yet, poorly understood area of study with much progress to be made. Fluctuating metabolic needs Insulin causes a decrease in blood glucose concentrations. Physiologically, insulin delivery is modulated on a minute-to-minute basis as the hormone is secreted into the portal circulation and requirements vary widely and critically with nutrient delivery, physical activity and metabolic stress. Ideally, an insulin 32 delivery system should be instantaneously responsive to these fluctuating metabolic needs. A variety of other drugs such as calcitonin and growth hormone also demand complex release requirements. Pulsatile release Many endogenous peptides and proteins are released in a pulsatile fashion and subject to complex feedback control mechanisms, consequentially, drug timing plays a crucial role in determining the observed effect. The precise molecular site of action of this process is unclear, but it is thought to involve an initial loss of receptors, followed by an uncoupling of receptors from their effector systems. Chronic administration is used clinically in the treatment of sex- hormone responsive tumors such as prostate and breast cancer. Again, the challenge for drug delivery is to match drug input with the desired therapeutic outcome. Research is currently concentrated in two main areas: • peptides and proteins; • nucleic acid therapies. These new biotherapeutics are discussed briefly below, with particular reference to the problems associated with their successful drug delivery and targeting. However, significant 33 advances in recent years in the fields of biotechnology and molecular biology have led to the availability of large quantities of pure, potent and highly specific peptide and protein drugs, often with modified or “super- agonist” properties, for a wide variety of therapeutic and diagnostic indications (Box 1. However, there exists a large number of barriers to their successful delivery: In vitro stability barriers Peptides and proteins possess an inherent instability due to the chemical reactivity of certain amino acids. This results in degradation reactions such as transpeptidation, side-chain hydrolysis, diketopiperazine formation, disulphide exchange, oxidation and racemization. Stability is affected by environmental factors, including pH, organic acids, ionic strength, metal ions, detergents, temperature, pressure, interfaces and agitation. Exopeptidases cleave at N- and C- termini and endopeptidases cleave at an internal peptide bond example, susceptibility of proteins to thermal inactivation can seriously limit the range of methods that can be used in their sterilization, as well as in the fabrication of their delivery systems. Freezing concentrates the protein, buffer salts, other electrolytes and may dramatically shift pH. Peptide and protein instability in vitro is manifested by the tendency of such molecules to undergo self- association in solution, resulting in the formation of multimers and, in the extreme, aggregation and precipitation. For example, insulin at pH 7 exists predominantly as hexameric aggregates, which are too large to be absorbed. Proteins tend to undergo denaturation in vitro, the rates of interfacial denaturation are strongly dependent on the specific protein and on such solution properties as temperature, pH and salt concentration. For example, human growth hormone undergoes only limited, and fully reversible, denaturation between pH 1. Various approaches have been attempted to prevent loss of protein by adsorption to glass and plastic, including treating surfaces with proteins such as bovine serum albumin, fibrinogen and ovalbumin, or modifying the solvent by adding surfactants or glycerol. Potential peptide and protein drugs are subject to degradation by numerous enzymes or enzyme systems throughout the body. Small peptides are relatively resistant to the action of endopeptidases but their activity is significant for large peptides. By considering these features, the enormous difficulties associated with overcoming the enzymatic barrier to peptide and protein delivery should be apparent. Degradation usually occurs at the site of administration and is possible in every anatomical site en route to the target receptor. Furthermore, protecting a single bond on a peptide or protein drug from a particular type of enzyme is insufficient to confer protection on the entire drug from enzymatic hydrolysis—other enzymes may attack the protected bond and the other unprotected bonds on the drug are still vulnerable. Several methods of modifying peptide structure to improve metabolic stability have been investigated, including: • substitution of an unnatural amino acid in the primary structure; • introduction of conformational constraints; • reversal of the direction of the peptide backbone; • acylation or alkylation of the N-terminus; • reduction of the carboxy-terminus; formation of an amide. However, even extensive modifications of peptide structure can only afford relative, rather than absolute, protection from enzyme attack. In the gastrointestinal tract, the enzymatic barrier is probably the most significant obstacle to the successful oral delivery of peptides and proteins, as demonstrated by the following observations: • The rate of hydrolysis of peptides is inversely related to the amount transported across the intestine. Luminal activity from the pancreatic proteases trypsin, chymotrypsin, elastase and carboxypeptidase A is mainly directed against large dietary proteins. The main enzymatic activity against small bioactive peptides is derived from the brush border of the enterocyte. Intracellular degradation is most specific against di-peptides and occurs mainly in lysosomes, but also in other intracellular organelles. In comparison to the oral route, much less is known about the nature of the enzymatic barrier to therapeutic peptides and proteins in alternative routes such as the buccal, nasal, pulmonary, dermal and 36 vaginal routes. As a first step in characterizing the proteolytic barrier, the proteolytic activity in various mucosal tissues can be determined by incubating a peptide or protein in epithelial tissue homogenates. However, care should be exercised in interpreting studies of this kind as peptides are often exposed to a wide range enzymes, including both extra- and intracellular enzymes, present in a homogenate of epithelial tissue. The actions of intracellular enzymes will not be significant if the peptide is absorbed by the paracellular route, never coming into contact with the inside of the cell. Studies on characterizing the enzymatic barrier at each delivery site have investigated the pattern of cleavage of enkephalins, substance P, insulin and proinsulin, and have demonstrated the presence of both exo- and endo-peptidases in the various epithelial tissues. What distinguishes one route from another is probably the relative proportion of these proteases, as well as their subcellular distribution. Absorption barriers Absorption barriers to peptides and proteins arise from the enzymatic barrier described above and also from the physical barrier properties of the epithelium, arising from the hydrophobic membranes and tight intercellular junctions.

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The uptake of particles by macrophages is a fairly rapid process but the subsequent clearance of particle-laden macrophages only occurs over days or weeks 100mg cafergot free shipping pain treatment center dr mckellar. Absorption is clearly important for systemically-acting drugs since it is one element of the events leading to delivery of drug to its site of action cheap 100mg cafergot otc pain treatment sciatica. Absorption is equally important for locally-acting drugs since for these compounds it represents removal of drug from its site of action cafergot 100mg fast delivery shingles pain treatment natural. Metabolism of drugs is also an important consideration since it may lead to drug inactivation or the production of active or toxic metabolites cheap cafergot 100 mg without prescription pain treatment for bulging disc. These same features also offer great potential for the delivery of systemically-acting compounds. The surface area of the airways is approximately 140 m, slightly larger than that of the small intestine. More importantly, however, a well-2 designed aerosol system can rapidly deliver drug to a high proportion of this surface area, whereas an orally delivered drug will have its access to the small intestine delayed by gastric emptying. In some parts of the alveolar region the airways to blood pathlength is less than 0. This property facilitates very rapid transfer of gases, vapors and other small molecules. Drug absorption from this region is usually more rapid than from any other epithelial route of delivery. This rich blood supply which promotes rapid gaseous exchange is also beneficial for systemic drug delivery. Drugs absorbed from the lung pass directly to the heart avoiding first-pass metabolism in the liver, although some drugs will be subject to first-pass metabolism during absorption in the lung. These regional differences play an important role in the absorption of drugs into the systemic circulation, which is likely to occur more efficiently from the A region. Thus delivery systems designed for systemically-acting drugs should target the A region. Bronchodilator drugs act upon the smooth muscle of conducting airways and we might expect that a more central deposition of these drugs would give a greater pharmacodynamic response. Targeting locally-acting anti-inflammatory drugs is complex since there is dispute as to whether inflammation in the central airways is less or more important than that in peripheral airways. The situation is further complicated by possible redistribution of drugs within the lung, which seems likely to occur after deposition. The epithelial permeability towards hydrophilic solutes is at least 10-fold lower than that of the endothelium. The epithelium of the lung is much more permeable than that of other mucosal routes. For example, less than 3% of an oral dose of sodium cromoglycate reaches the circulation whereas more than 70% is absorbed from the lung into the bloodstream after inhalation. In the A region the tight junction gap between type-I alveolar cells is reported as 1 nm. Consequently the permeability of the paracellular route is much greater than seen with other membranes. Large molecules up to 150 kDa are reported to be absorbed to a small extent into the bloodstream after pulmonary administration. Permeability then decreases during the first few weeks of life and then shows no further age-related changes. An increase in permeability of the alveolar membrane is seen in a number of pulmonary disease states including adult respiratory distress syndrome and fibrosis. Increased permeability will be seen in association with inflammatory reactions, where there is an influx of polymorphs and other cells into the airways. Inhalation of toxicants, such as smoke and industrial dusts, is associated with increased permeability. Hyperinflation of the lung by vigorous exercise or repeatedly performing lung function tests may also lead to increased membrane permeability, possibly resulting from a disturbance of the intercellular junctions. Lipid-soluble drugs are usually absorbed transcellularly, since they partition into the lipid membranes of the epithelial cells and then diffuse through the cells, down a concentration gradient according to Fick’s Law (see Section 1. Lung absorption rate constants correlate with the lipid/buffer distribution coefficients for a number of compounds. Highly lipophilic drugs show very rapid absorption, for example morphine shows peak blood levels within 5 minutes after inhalation. Compounds which are poorly lipid-soluble may be absorbed via the paracellular route, the drug absorption rate being inversely related to their molecular size. The absorption of these hydrophilic drugs will generally be slower than that of lipophilic drugs but will still occur more rapidly than from other mucosal routes including intestinal, rectal, nasal and buccal (see Chapters 6, 7 and 9). Large molecular weight drugs may be absorbed by the process of transcytosis, in which the macromolecule is carried in vesicles from one side of a cell to the other (see Section 1. Transcytotic mechanisms occur in type-I cells for albumin and pulmonary delivered macromolecules may be transported by similar routes. The role of these mechanisms in the absorption of drugs into the bloodstream has not been quantified and for some drugs, more than one route of absorption exists. Absorption from the gastrointestinal tract may also occur, either because of direct swallowing of a portion of the inhaled dose, or because of secondary swallowing following mucociliary clearance. Many isozymes of the cytochrome P-450 family have been identified in the respiratory tract with the highest concentrations of these occurring in the nasal and smaller airways with lower levels in the trachea and main bronchi. Their distribution tends to be more widespread and their activities much higher than is seen with the P-450 systems. Locally-acting inhaled drugs may be inactivated by these enzyme systems, for example isoprenaline and rimiterol are metabolized by catechol-O-methyl transferase. The inhaled steroid beclomethasone dipropionate is hydrolysed by esterases, firstly to an active metabolite, beclomethasone monopropionate, and then to an inactive metabolite, beclomethasone. Inhaled drugs intended for systemic action are likely to be subjected to some first-pass metabolism during their absorption from the lung. The extent of this pre-systemic first-pass metabolism in the lung has not been fully quantified for many drugs but is estimated to be far less than that seen in the gastrointestinal tract and liver after oral dosing (see Section 6. A brief overview of both the advantages and disadvantages of pulmonary drug delivery is given below. Local administration is also associated with some disadvantages for these drugs: • oropharyngeal deposition may give local side-effects; • patients may have difficulty using the delivery devices correctly. The disadvantages of the lungs for delivery of systemically-acting drugs include: • The lungs are not readily accessible surfaces for drug delivery. Complex delivery devices are required to target drugs to the airways and these devices may be inefficient. Dexterity is also required, which may be lacking in the very young and elderly populations. For the systemic delivery of drugs with a narrow therapeutic index, such variations may be unacceptable. Efficient drug delivery of slowly absorbed drugs must overcome the ability of the lung to remove drug particles by mucociliary transport. In order to deliver drugs to the lung, a therapeutic aerosol must be generated for inhalation. An aerosol can be considered as a colloidal, relatively stable two- phase system, consisting of finely divided condensed matter in a gaseous continuum. Atomization is the process by which an aerosol is produced and can be electrically, pneumatically or mechanically powered. The mechanism, advantages, disadvantages and the potential strategies for improvement of the devices used for aerosol generation are summarized in Table 10. Selection of appropriate salts and pH adjustment will usually permit the desired concentration to be achieved. If this is 263 not feasible, then the use of co-solvents such as ethanol and/or propylene glycol can be considered. However, such solvents change both the surface tension and viscosity of the solvent system which in turn influence aerosol output and droplet size.

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This very moment should be viewed as even more precious than other moments buy 100 mg cafergot with visa pain medication for dogs after being neutered, as when you think of it that way buy cafergot 100 mg without a prescription laser treatment for shingles pain, it gives you a break from your regularly scheduled programming of much scarier or upsetting thoughts generic 100 mg cafergot otc pain buttocks treatment. To emphasize the preciousness of this moment and the fact that you have the ability to enjoy it buy discount cafergot 100 mg on line pain medication for dogs with hip problems, think of other people who are less fortunate than you. This could be personal friends, family, or even acquaintances that have suffered emotional or physical challenges. You might briefly reflect on the tragedies that the homeless people in your city suffer, or the people of the world who face civil war and natural disasters such as earthquakes or flooding. Let go of these more depressing thoughts and realize that where you are right now, in this moment, is truly not so bad. If you’re not aware of what’s happening in the present moment, there’s no way you can practice mindfulness. This helps you to be more interested and aware of what you’re doing and to better concentrate on it. For example, you may say to yourself something like, “Now eating,” “Now walking,” “Now washing my hands” etc. Mindfulness in Action: Being Present in the Moment • 127 • Maintain concentration One of the problems that people who are first practicing mindfulness report is that they have not developed the attribute of sustained concentration in order to really pay attention to whatever they’re doing. Try to consciously maintain your concentration on what you’re doing and guess what? Whatever you can do in your life to be more mindful is a step in the right direction. You can create greater interest in any given moment by asking yourself, “What’s new or special about this experience? Rather than just looking at a bunch of trees and thinking, “a forest,” slow down, take the time and interest, to look more closely at the trees that make up the forest. There’s a tremendous beauty in the parts that make up the whole and then in the whole itself, once all the parts are reintegrated. For example, when eating your food, be grateful for nature reflected in the sun, earth, rain, and seeds that allowed the food to grow. Appreciate that you may be physically well enough that you have an appetite, you can feed yourself, you can swallow your food and you can digest your food to whatever degree is possible for you. Mika reminds herself regularly how grateful she is to have a life here in Canada and a job where she can provide for her family. Look for a reason to be thankful and encourage this attitude of gratitude whenever you can. There’s a tremendous delight to be found in enjoying a moment from a joyful, curious, spontaneous, child-like perspective. If you’re walking in the forest and suddenly want to walk balancing on top of a log, do it. Quiet your mind and come to your experiences from a place of relative mental silence. When you bring your attention to something of interest, use this as an opportunity to initially take a deep breath in and out. This will help you to calm your body and mind, so that you may be more relaxed in the moment and can then really take in something that interests you, fully and completely. Mindfulness in Action: Being Present in the Moment • 129 • Be more open Be present from an openness of heart and mind. My patient Larry looks like a pretty scary guy when you first meet him, but when he smiles, it changes his whole appearance and people react to him in a totally different way. Research has found that the physical act of smiling, even when you don’t feel like it very much, will lift your spirit. Remind Yourself to Be Mindful You may approach each day with the best of intentions, but you’ll find that even though you know that mindfulness is really good for you, you’ll still forget to be mindful. Ask them to send a suggestion about what you could be particularly mindful of that day. Your friends or family can be a wonderful source of support and encouragement as you incorporate mindfulness into your life. Before you speak or move, you have a moment before the words or action, when you already have in mind the intention to perform the activity. By constantly bringing your attention to this moment you will develop your practice of mindfulness. As you know, the act of observing, deepening, and lengthening the breath is the best technique for stress relief. It’s easier to be mindful when a strong thought, emotion or physical sensation is present. However, often you’ll be in a mental and/or emotional state without necessarily being conscious of it. This state might just be in the background of your activities without calling for your attention. The body can often be the indirect clue to what you are unconsciously experiencing. It can be helpful during your day to stop and just scan the body and feel if there’s any tension anywhere. I am not even aware of this underlying tension until I consciously bring my awareness to my body. Recognizing the tension, I can rest with mindfulness in the mental and physical sensations using a focus on my breathing to support the relaxation and acceptance of what’s present. Practice First and foremost in the practice of mindfulness, fully experience whatever you’re doing. Here are a couple of exercises that help you to really focus on your activity in a mindful fashion. Eating Mindfully I’ll use eating as an example of how you can be truly present to the activity you’re engaged in. Try to become fully present to the act of eating from the beginning to the end of the meal. Are you eating because you’re hungry, because you’re angry, or sad and 132 • Mindfulness Medication you’re using food as a way to soothe yourself, or because it’s just dinnertime and yet you’re not hungry? Watch how your mind chooses the particular food on the plate, how much it chooses and how it tells your hand to collect the food on the fork, or spoon. Observe the process of how you bring the food to your mouth, the saliva that starts to accumulate in your mouth and how you swallow the food. Do you want to pick up another morsel of food before you have even finished the first bite? Try to put the fork or spoon down after you put the food in your mouth and simply observe the sensations that arise. If the answer that pops up is, “Because I felt like it,” don’t let your inquiry stop there. Is it because you’re truly hungry, or do you feel that you need to take as much food as you can to fill some other need? By slowing down and observing this process, you will have been truly present to the experience of eating. Not only will you enjoy your sensations that much more, but you’ll begin to see how your mind operates and makes the choices it does without really consulting you. Showering Mindfully The next time you take a shower, I’d like you to do it mindfully as well. Again, try to be present to the actual sensations of the event, but also carefully observe how your mind makes its decisions. When you take a shower, observe how your mind has created a ritual about this event.

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The Rancho Los Amigos Level of Cognitive Function is a scale frequently used to assess cognitive function and evaluate ongoing recovery from head injury purchase cafergot 100mg on line pain treatment after root canal. Progress through the levels of cognitive function can vary widely for individual patients discount cafergot 100 mg without prescription pain medication for dogs spayed. To allow the patient longer times of uninterrupted sleep and rest cafergot 100 mg on line pain treatment toothache, the nurse can group nursing care activities so that the patient is disturbed less frequently discount 100 mg cafergot with mastercard pain treatment center university of rochester. Back rubs and other measures to increase comfort can assist in promoting sleep and rest. Supporting Family Coping Having a loved one sustain a serious head injury can produce a great deal of prolonged stress in the family. Such changes are associated with disruption in family cohesion, loss of leisure pursuits, and loss of work capacity, as well as social isolation of the caretaker. The family may experience marital disruptions, anger, grief, guilt, and denial in recurring cycles (Hsueh-Fen & Stuifbergen, 2004). To promote effective coping, the nurse can ask the family how the patient is different now, what has been lost, and what is most difficult about coping with this situation. Helpful interventions include providing family members with accurate and honest information and encouraging them to continue to set well-defined short-term goals. Support groups help the family members share problems, develop insight, gain information, network, and gain assistance in maintaining realistic expectations and hope. The Brain Injury Association (see Resources) serves as a clearinghouse for information and resources for patients with head injuries and their families, including specific information on coma, rehabilitation, behavioral consequences of head injury, and family issues. This organization can provide names of facilities and professionals who work with patients with head injuries and can assist families in organizing local support groups. Many patients with severe head injury die of their injuries, and many of those who survive experience long-term disabilities that prevent them from resuming their previous roles and functions. During the most acute phase of injury, family members need support and facts from the health care team. Many patients with severe head injuries that result in brain death are young and otherwise healthy and are therefore considered for organ donation. Family members of patients with such injuries need support during this extremely stressful time and assistance in making decisions to end life support and permit donation of organs. Bereavement counselors and members of the organ procurement team are often very helpful to family members in making decisions about organ donation and in helping them cope with stress. Any decrease in this pressure can impair cerebral perfusion and cause brain hypoxia and ischemia, leading to permanent damage. Impaired Oxygenation and Ventilation Impaired oxygen and ventilation may require mechanical ventilatory support. The patient must be monitored for a patent airway, altered breathing patterns, and hypoxemia and pneumonia. Interventions may include endotracheal intubation, mechanical ventilation, and positive end-expiratory pressure. Impaired Fluid, Electrolyte, and Nutritional Balance Fluid, electrolyte, and nutritional imbalances are common in the patient with a head injury. Undernutrition is also a common problem in response to the increased metabolic needs associated with severe head injury. If the patient cannot eat, enteral feedings or parenteral nutrition may be initiated within 48 hours after the injury to provide adequate calories and nutrients (Bader et al. Nutritional support in the form of early feeding after head injury is associated with better survival outcomes and decreased disability (Yanagawa, Bunn, Roberts, et al. Post-traumatic Seizures Patients with head injury are at an increased risk for post-traumatic seizures. Post- traumatic seizures are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury) (Somjen, 2004). Seizure prophylaxis is the practice of administering antiseizure medications to patients with head injury to prevent seizures. However, many antiseizure medications impair cognitive performance and can prolong the duration of rehabilitation. Therefore, it is important to weigh the overall benefit of these medications against their side effects. Research evidence supports the use of prophylactic antiseizure agents to prevent immediate and early seizures after head injury, but not for prevention of late seizures (Somjen, 2004). The nurse must assess the patient carefully for the development of post-traumatic seizures. Risk factors that increase the likelihood of seizures are brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more, and age older than 65 years (Somjen, 2004). The nurse explains to the patient and family, verbally and in writing, how to monitor for complications that merit contacting the neurosurgeon. If the patient is at risk for late posttraumatic seizures, antiseizure medications may be prescribed at discharge. The patient and family require instruction about the side effects of these medications and the importance of continuing to take them as prescribed. Continuing Care Rehabilitation of the patient with a head injury begins at the time of injury and continues into the home and community. Depending on the degree of brain damage, the patient may be referred to a rehabilitation setting that specializes in cognitive restructuring after brain injury (Ashley, 2004). The patient is encouraged to continue the rehabilitation program after discharge, because improvement in status may continue 3 or more years after injury. Changes in the patient with a head injury and the effects of long-term rehabilitation on the family and their coping abilities need frequent assessment. Teaching points to address with the family of the patient who is about to return home are described in Chart 63-6. Depending on his or her status, the patient is encouraged to return to normal activities gradually. During the acute and rehabilitation phases of care, the focus of teaching is on obvious needs, issues, and deficits. The nurse needs to remind the patient and family of the need for continuing health promotion and screening practices after these initial phases. Patients who have not been involved in these practices in the past are educated about their importance and are referred to appropriate health care providers. The patient is monitored closely for any changes in motor or sensory function and for symptoms of progressive neurologic damage. Edema of the spinal cord may occur with any severe cord injury and may further compromise spinal cord function. These findings usually are recorded on a flow sheet so that changes in the baseline neurologic status can be monitored closely and accurately. The patient should have both eyes closed so that the examination reveals true findings, not what the patient hopes to feel. The patient is also assessed for spinal shock, a complete loss of all reflex, motor, sensory, and autonomic activity below the level of the lesion that causes bladder paralysis and distention. The lower abdomen is palpated for signs of urinary retention and overdistention of the bladder. Further assessment is made for gastric dilation and ileus caused by an atonic bowel, a result of autonomic disruption. Temperature is monitored, because the patient may have periods of hyperthermia as a result of alteration in temperature control due to autonomic disruption. Nursing Interventions Promoting Adequate Breathing and Airway Clearance Possible impending respiratory failure is detected by observing the patient, measuring vital capacity, monitoring oxygen saturation through pulse oximetry, and monitoring 418 arterial blood gas values. Early and vigorous attention to clearing bronchial and pharyngeal secretions can prevent retention of secretions and atelectasis. Suctioning may be indicated, but caution must be used, because this procedure can stimulate the vagus nerve, producing bradycardia, which can result in cardiac arrest. If the patient cannot cough effectively because of decreased inspiratory volume and inability to generate sufficient expiratory pressure, chest physical therapy and assisted coughing may be indicated.

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