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Concerns of child and caregiver; current/ (1) Reinforce pedestrian safety—children recent stressors treatment 1860 neurological purchase indinavir line. Interim health since last visit (include involved in pedestrian-related mo to symptoms 6 days past ovulation discount indinavir 400mg on line r review of systems); for older school-age vehicle accidents children treatment 24 seven buy genuine indinavir, obtain sexual/reproductive his (2) Teach guidelines for bicycle safety; to symptoms checker purchase indinavir in india ry as indicated avoid busy streets 2. Assess parent-child interaction and child child; conduct routine fire drills behavior (4) Teach child to s to p, drop, and roll if b. Height, weight, body mass index, includ clothing catches on fire ing percentiles (5) Teach safety—the danger of matches, c. Vision and hearing screening (refer to (6) Always supervise child when swim screening guidelines this chapter) ming or near any water. Physical examination, including assess (7) Frequently check playground equip ment for scoliosis and Tanner staging ment for stability, loose nuts and f. Parenting strategies Control and Prevention and the Ameri (1) Although the child is maturing, qual can Academy of Pediatrics for updated ity time, attention, and affection recommended childhood and adolescent from parents is important (evidence schedules; inform parents of common side exists supporting “connectedness” effects to parents and/or another adult. Advise parents of any medications pre decision-making scribed, including vitamins and fiuoride, (3) Promote responsibility and account. Nutrition (4) Maintain adequate supervision (1) Nutritional requirements are approxi (5) Discuss methods of discipline; mately 70 cal/kg use positive reinforcement and (2) Most behavioral problems with food appropriate consequences for inap resolved propriate behavior (3) Potential nutritional problems— (6) Establish fair rules obesity, iron deficiency (7) Respect the child’s need for privacy (4) Encourage good nutritional prac (8) Set example by being a good role tices. Good health habits—assist child and use of helmets and protective padding parents to establish early patterns of (2) Seat belt use behavior. Communication—encourage parents to (4) Water safety; swimming assist child in developing good communi (5) Fire prevention safety; home fire drill, cation skills, problem-solving strategies, proper use of appliances and stress management (6) Sunburn prevention g. Drugs, smoking, and alcohol—encourage (7) Prevention of violence in home; lock parent/child discussions up guns, ammunition; teach child h. Sex education—ana to my and physiol firearm safety (avoidance of firearms) ogy, sexual activity, values clarification, (8) Pedestrian safety Child Health Supervision Schedule of Visits with Key Issues 75 k. Lying and cheating (common in school (1) Family communication patterns and age children) relationship with the adolescent (1) School-age children lie to avoid trou (2) Parent’s description of the adoles ble or gain an advantage cent’s strengths and areas needing (2) Appropriate response—confront child improvement; attitudes and behaviors in a positive way, try to understand (3) Discipline practices and response reason for lie, follow through with age (4) Specific concerns and worries about appropriate discipline when needed the adolescent (3) Adults should model honesty 2. Observation of parent-adolescent interac (1) For 6 to 8-year-olds, sports participa tion. Height and weight including percentiles (2) Older school-aged children and teen c. Vision and hearing screening (refer to physical examination screening guidelines this chapter) m. Physical examination—including scoliosis and the parent-child relationship and screen, Tanner stage, and breast exami mutually agree upon a plan with the par nation; pelvic examination if adolescent ent to strengthen needed areas female is sexually active, having irregular n. Subjective information—gather “sensitive” ually active or his to ry of sexual abuse information when alone with the adolescent (4) Pap smear if pelvic examination a. Nutrition—especially appetite; meal performed skipping (5) Liver function tests (if his to ry of drug b. Concerns/worries; current and recent dosage, frequency, course, and potential stressors side effects j. Nutrition appropriate for age review of systems, with special emphasis (1) the adolescent diet should be similar on gathering psychological and sexual/ to an active adult, with extra calories reproductive data during rapid growth periods; prudent k. Continue education regarding use of increased need for calcium, iron, zinc; drugs, alcohol, cigarettes, and caffeine eating disorders; obesity i. Inform parents of major developmental (4) Encourage well-balanced meals and characteristics of adolescents nutritious snacks (1) Increased self-awareness, self (5) Discuss adolescent’s perception of consciousness, and self-appraisal his/her weight (2) Body image concerns (6) Encourage healthy weight loss strate (3) Mood swings and s to rmy behavior gies if indicated. Safety—same as school age child, plus: which to judge own values, but still (1) Emphasize the possible consequences needing family to provide acceptance of drinking and use of drugs while and feeling of self-worth driving (6) Interest in opposite sex (2) Discourage being a passenger when j. Parenting strategies with adolescents the driver has been drinking or using (1) Fairness in rules and reasonable limit drugs setting (3) Discuss typical high-risk situations (2) Allow decision making and how to avoid them; role play (3) Respect adolescent’s privacy healthy behaviors to use in high-risk (4) Expect periods of estrangement (be situations available; adolescent needs support (4) Encourage safe swimming and diving ive family) practices (5) Praise achievements at home, (5) Discuss proper use of safe sports school, extracurricular activities equipment and maintenance (6) Bolster self-esteem (6) Instruct adolescent in proper training (7) Supervision as needed and warm-up exercises for sports and (8) Encourage independence, new physical activities experiences, after-school activities, (7) Educate regarding safe and proper use including part-time job of firearms and other potentially dan (9) Promote family communication gerous objects such as firecrackers (10) Serve as role model—practice good (8) Discuss use and misuse of over-the health habits. Developmental Issues to imitate their behavior (1) Discuss dating and peer pressure (11) Recognize signs of probable sub (2) Encourage open communication with stance abuse—drop in school parents, peers, and school personnel performance, personality change, (3) Teach stress reduction techniques and mood swings, sleepiness or fatigue, coping skills depression (4) Educate regarding healthy outlets for k. Emphasize positive qualities of the anger adolescent and the parent-adolescent (5) Discuss plans for the future—further relationship and mutually agree upon a education, work, recreation, hobbies, plan to strengthen needed areas marriage, parenthood l. Refer parents to resources that can assist myths, and proper skin care them in building their teen’s assets as well f. Discuss issues related to sexuality— as with their parenting skills decision making; mature relationships; n. The anterior fontanel usually closes by: a physical examination would be most benefi cial with which of the following age groupsfi Diffuse edema of the soft tissue of the scalp which usually crosses suture lines in the 5. Providing reassurance of “normalcy” during the newborn is: course of an examination would be most impor tant for: a. An infant should no longer have a head lag when pulled from the supine to sitting position 6. Allergic rhinitis best at the lower left sternal border that changes with positioning is suggestive of a: 15. A white instead of red refiex upon eye exami nation of a 1-year-old child would suggest: a. An eye that deviates in when covered but returns to midline when uncovered is an: a. Which of the following would usually not be considered a sign of a pituitary tumor in an 18. A hypernasal voice and snoring in a child is sug nation test for a dislocated hipfi Physiological splitting of the second heart should be examined in a child complaining of sound during inspiration in a child: knee painfi Which of the following is the most important his to ry-taking question for a sports evaluationfi Fruits, cereal, meats, and vegetables feeding is well established they can expect baby d. Children 2 years of age and older who have a parent with a to tal cholesterol level of 43. Appropriate anticipa to ry guidance for the 240 mg/dL or greater parents of an 8-year-old girl should not include: b. Overweight children with a family his to ry nerisms and restless activity of premature cardiovascular disease b. Retrieved June 29, 2009, from She reports her newborn wants to nurse for 30. A 15-year-old who has just started Bright futures: Guidelines for health supervision of in menarche fants, children and adolescents. Fetal exposure to to xic substances includ Birth head size: 32–38 cm (average 34 cm) ing alcohol, medications. Fetal exposure to radiation in first and/or 4–6 months: 1 cm/month 3 cm second trimesters 6–12 months: 0. Delayed developmental miles to nes, neurologi cal problems, mental retardation • Etiology/Incidence (2. Primary: Caused by a variety of genetic/ chromosomal disorders • Differential Diagnosis 2. Benign macrocephaly—familial or catch-up sutures growth in thriving premature infant 2. Pathological macrocephaly narrowed temporal diameter and occipital fiattening (familial microcephaly) • Physical Findings 3. Transillumination of skull may reveal chronic • Diagnostic Tests/Findings subdural effusions, hydrocephaly, or large cys 1. Test infant serum and urine for amino and increased intracranial pressure organic acids 5. Most disorders are untreatable; accurate diag prognosis, guide to management, and genetic nosis is essential for appropriate genetic and counseling family counseling 3. Management is supportive; especially necessary placement in a program that will maxi 4. Skull x-rays can provide indirect information mize development since many are mentally such as changes seen with increased intracra retarded nial pressure, primary skeletal dysplasias, or calcifications Macrocephaly • Management/Treatment • Definition: Head circumference greater than 2 to 1. Surgical correction; closure of sutures of some disorders such as shunt placement with hydro • Etiology/Incidence cephalus or tumor resection 1. Intracranial lesions—neoplasms, subdural effusions • Definition: Increased production, impaired c. Increase in brain size (megalencephaly)— ventricles and ventricular enlargement seen in neurofibroma to sis 2. Normal head growth with large heads: Familial • Etiology/Incidence macrocephaly (benign) 1.
Valvuloplasty Recall the definitions of the terms in italics in the following statements symptoms non hodgkins lymphoma discount 400 mg indinavir mastercard. Then symptoms 9 weeks pregnancy buy indinavir 400 mg otc, apply your knowledge and determine whether each statement is true (T) or false (F) symptoms 3 weeks into pregnancy buy 400mg indinavir with mastercard. Systemic vascular resistance is the amount of pressure exerted by the systemic vascular bed symptoms vaginal cancer purchase indinavir without a prescription. In fetal circulation, oxygenated blood from the placenta flows from the right atrium in to the left atrium through the. After birth, the fetal shunt between the pulmonary artery and the aorta, which is called the, closes. After birth, pulmonary vascular resistance because the systemic arterial pressure. The point of maximal impulse at the seventh intercostal space indicates cardiomegaly. Cardiac catheterization can be an interventional as well as a diagnostic procedure. Chapter 22 the Child with a Cardiovascular Alteration Physiologic Consequences of Congenital Heart Disease 42. In Eisenmenger syndrome, an acyanotic defect with left- to -right shunting becomes a cyanotic defect with right- to -left shunting. Classic signs of are decreased pulses and blood pressure in the lower extremities. Cyanotic Lesions with Increased or Decreased Pulmonary Blood Flow Match each defect with its description. Total anomalous pulmonary venous return Infective Endocarditis, Rheumatic Fever, and Kawasaki Disease Answer as either true (T) or false (F). Children with congenital heart disease have an increased risk for development of infective endocarditis. Endocarditis prophylaxis generally consists of an antibiotic taken orally 1 hour before invasive procedures. Antibiotic prophylaxis with penicillin for at least 5 years is part of the management of rheumatic fever without cardiac complications. Kawasaki disease is associated with untreated or partially treated strep to coccal infections. Manifestations of rheumatic fever include arthritis, carditis, chorea, heart murmur, and painless, red skin lesions. Normal blood pressure for a child is defined as a sys to lic or dias to lic blood pressure less than the 90th percentile for age and sex. Nonpharmacologic therapies for primary hypertension are usually not effective in children and adolescents. Which type of cardiomyopathy is a major cause of sudden cardiac death in adolescentsfi Drugs used to decrease ventricular hypercontractility and outflow tract obstruction are and blockers. In children, borderline levels for low-density lipoprotein cholesterol are mg/dL, and a high level is greater than mg/dL. One student will act as the nurse and another student will be a parent, who has just learned that his or her child has a cardiac defect and will require surgery. The parent can describe which of the nurse’s interventions were effective and which could be improved. Try to discover what the health care team did that was helpful for the family during the child’s hospitalization. Design a plan that teaches a 12-year-old child what to expect during catheterization. His blood pressure is at the 95th percentile for his age and sex, but a review of his chart reveals that his blood pressure has been slightly below the 90th percentile on previous visits. On the basis of these findings, what questions would you ask Michael and his parentsfi The physician makes the diagnosis of essential hypertension and decides to initiate nonpharmacologic therapy. How would you assess the family’s need for information about the following treatmentsfi What key features of these treatments would you stress when you present the informationfi Which nursing interventions would be appropriate to include in the child’s plan of carefi Administering low-dose aspirin two times per day 143 Copyright © 2013, 2007, 2002 by Saunders, an imprint of Elsevier Inc. Children with hypertension who are receiving loop diuretics are at risk for imbalances of: a. A to ddler is hospitalized with congestive heart failure and is receiving digoxin and furosemide. An infant with a left- to -right shunt is admitted to the hospital in congestive heart failure. While doing a newborn assessment, the nurse finds the infant’s blood pressure in the arms is much higher than in the legs. Parents of a to ddler with tetralogy of Fallot explain that because they do not want the child to become overexerted, they confine the child in a playpen or crib to limit mobility. While taking routine vital signs, the nurse notices the infant is having a hypercyanotic episode. Parents of children with congenital heart problems often feel a loss of control when the child is hospitalized. The father of a child with a congenital heart defect asks the nurse why his daughter has to take penicillin before she gets her teeth cleaned by the dentist. The nurse is preparing an in-service about rheumatic fever for a group of pediatric nurses. Rheumatic fever is diagnosed by using the Jones criteria in the presence of at least two major characteristics or one major and two minor manifestations. Rheumatic fever manifests in 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic strep to coccal infection of the upper respira to ry tract. Rheumatic fever is a prevalent condition that is epidemic in the southwest regions of the United States. Rheumatic fever occurs once in a lifetime but can have significant long-term cardiac involvement. Rheumatic fever has clinical manifestations including arthritis, carditis, and chorea. Rheumatic fever is treated with a 10-day course of oral penicillin, anti-inflamma to ry agents, and bed rest. The nurse is teaching a parent of a 3-year-old who had heart surgery 5 days ago about care after discharge. Profound central cyanosis 145 Copyright © 2013, 2007, 2002 by Saunders, an imprint of Elsevier Inc. Binding of a metallic ion with a structure that results in inactivation of the ion 7. Polycythemia: 146 Chapter 23 the Child with a Hema to logic Alteration Copyright © 2013, 2007, 2002 by Saunders, an imprint of Elsevier Inc. Match each complication of sickle cell disease with its clinical manifestation 20. Priapism 147 Copyright © 2013, 2007, 2002 by Saunders, an imprint of Elsevier Inc. In hemophilia A, the missing blood clotting component is; in hemophilia B, the missing component is. Prolonged and excessive bleeding and menorrhagia are signs of von Willebrand disease. Medications used to treat aplastic anemia include steroids, cyclosporin, antithymocyte/anti-lymphocyte globulin, and. When both parents have the trait, what are the chances that: (1) A child will have neither the trait nor the diseasefi When one parent has the disease and the other has the trait, what are the chances that: (1) A child will have neither the trait nor the diseasefi When neither parent has the disease but one has the trait, what are the chances that: (1) A child will have neither the trait nor the diseasefi When the mother is a carrier and the father does not have hemophilia, what are the chances that: (1) A daughter will have the diseasefi
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Allergym ayoccur to treatment 1st degree burn trusted 400mg indinavir itchiness/hives symptoms migraine purchase 400 mg indinavir mastercard,are nottypically indicative ofa true IgE-m ediated eitherthe beta-lactam ring (in w hich case apatientisallergic to medicine 1975 safe 400 mg indinavir allbeta-lactam s)or to symptoms 5dp5dt buy indinavir amex the unique side chain (in w hich case the allergyisonly to specificagents). Afterencountering a specificantigen,IgE antibodiescan triggeran im m une response. When possible,referpatientsw ith uncertain penicillin allergy for fi "True"IgE-m ediated allergy:potentiallylife-threatening reaction;also know n asa type-1 im m ediate hypersensitivityreaction. Skin testing isespecially helpfulw hen the allergy his to ry fi Graded challenge:som e variation in approaches,bu to ften a sm alldose ofa potentialallergen. When the risk oftrue penicillin allergy islow,a graded challenge th fi Desensitization:sim ilar to the graded challenge,butata slow erpace. A sam ple pro to colforan oral using a cephalosporin w ith a dissim ilarside-chain isappropriate. Table 1:Fac to rsthatdecrease the likelihood ofa true allergy 10,000 In a given group of10,000 patients: 5 Skin testisnegative:thisprovidesa 97-99% certainty thatthe patientisnotallergic. Tim ing:ifreaction occurred afterdays to w eeksoftaking antibiotic,itisunlikely to be IgE-m ediated. M anagem en to fPenicillin Allergy Aftera reaction to penicillin,can a beta-lactam be prescribed in the futurefi The answ errequiresaccurate differentiation betw een three typesofbeta-lactam adverse reactions. Penicillin Adverse Event SeriousPenicillin Adverse Event True IgE-M ediated Penicillin Allergy. Stevens-Johnson syndrom e,interstitial Atm inim um,presentsasan itchy rash orhives. M ore severe sym p to m sinclude itchy,occursin fi10% ofpatientstaking penicillin,usually nephritis,hem olyticanem ia,serum sickness*. These reactionscan be life-threatening and 12 9-11 after2-5 daysoftherapy,and m ay lastseveralw eeks. These reactionsusually occur>72hrsafterbeta usually occur<1hraftertaking a beta-lactam dose. Ifthe skin testresultis IgE-m ediated,and so a cephalosporin ordifferent an alternative agent. Stevens-Johnson syndrom e,interstitialnephritis,hem olyticanem ia,serum sickness)are contraindications to anybeta-lactam; reactionslisted. G enerally,these occur fi Ifallergy islikely IgE-m ediated,skin test(ifpossible)using a cephalosporin w ith a differentside chain than the cephalosporin thatpreviously reacted. Ifno after7-10 daysoftherapyand relate to 12-15 reaction,give a graded challenge;ifreaction,orifskin testing notavailable,use an alternative agent(ordesensitization). Sym p to m s 2017 include urticarialvasculitis,renal -Skin testsin Saskatchew an are available via referral(currently <6 m onth w aiting list). Evidence suggeststhatcarbapenem shave a ~1% cross-reactivity w ith penicillins,and are appropriate in 16 desensitization are contraindicated. Com m on A dverse Events O verallN N H = 8-12 Yeastinfection N N H = 23 fi In a m eta-analysis(10 trials,2450 patients)com paring antibiotics to placebo foracute rhinosinusitis,com m on adverse events(such asnausea,vom iting, 2,5 diarrhea,orabdom inalpain)occurred in 27% ofpatientson antibioticsversus15% on placebo (N N H = 8-12). The antibioticsused in thism eta-analysis 3,4,5 included penicillins,m acrolides,and tetracyclines. A llergic Reactions N N H from 20 (rash,hives) to 10,000 (anaphylaxis) 7,8 Allergic reactionscan occurw ith any antibiotic;penicillin in particularisw ellstudied. About5-10% ofpatientsw illself-reporta penicillin allergy; how everthe 9 vastm ajority ofthese reactionsare delayed reactions,occurring days to w eeksafterinitiating therapy,and do nottypically indicate a true allergy. Serious A dverse Events N N H from 300 to 30,000 Rare butseriousadverse eventsare associated w ith allantibiotics. Large,long-term random ized controlled trialsare uncom m on,and so itisdifficult to puta precise estim ate on how prevalentthese eventsare. Although thisisthought to be unlikely,there isa sm allbutrealrisk & a backup birth controlm ethod isalw aysrecom m ended. Every course ofantibiotic islikely to resultin som e em erging resistance w hich could affectthe next choice ofantibiotic regim en forthatindividual,especially ifw ithin 3 m onthsofthe previousantibiotic. Forexam ple,strainsofStrep to coccuspneum oniae resistant to levofloxacin w ere docum ented in the sam e year 21 22 levofloxacin w asintroduced to the m arket. Rare,butw orrisom e,reportsofbacteria resistant to every available antim icrobialcan be found in the literature. Q uotes from the team fi:H arm sspeak louderw hen there islittle orno benefit to offsetthem! In concentration-dependentkilling,an antim icrobialism ore effective ata higherdose. Classificationsare notabsolute -forexam ple,agentsm ay be bacteriostaticin m ostsituationsbutbactericidalathigh concentrations,orbacteriostaticagainstsom e organism sand bactericidalagains to thers. Anaerobiccoverage can be im portantin situationssuch asaspiration pneum onia,intra-abdom inalinfections,and diabeticfootulcers. Antim icrobialsw ith good activity include m etronidazole,clindam ycin,am ox-clav,and m oxifloxacin. Asa result,they cannotbe view ed undera gram stain and are naturally resistant to allbeta-lactam s. Antim icrobialsw ith good activity include m acrolides,fluoroquinolones,and tetracyclines. Com m on beta-lactam ase producersinclude H aem ophilus influenzae,Neisseria gonorrhoeae,M oraxella catarrhalis,Escherichia coli,Proteus,Klebsiella,and Bacteroidesfragilis. H ow ever, to day Staph aureusisreliably resistant to penicillin,am oxicillin,and am picillin through beta-lactam ase production. In response,beta-lactam ase-resistantantibioticsw ere invented,like m ethicillin,cloxacillin,and oxacillin. Am oxicillin fi Considerw atchfulw aiting in acute otitism edia forsuitable children (see page 78). M ax: 1000-4000m g/day $40 risk 2-4/1000 vsbaseline riskof1-2/1000 fi Excellentbioavailability. M ax: 3000m g/day Cephalosporins:Binds to penicillin binding proteinson bacterialcellw alls,inhibiting cellw allbiosynthesis. G onorrhea resistance to cefixim e ~ 2% in Canada (com bine cefixim e w ith am acrolide due to resistance + to add chlam ydiacoverage). Riskofallergy cross-sensitivitybetw een cephalosporinsand penicillinsislow -see AntibioticOverview page. Enterobacter; Peds: 8m g/kg po q24h $29 20m g/m Lsusp straw berryfi Neisseria;Proteus;E. Stearate:250m g po q6h $20 Erythrom cyin Es to late 50m g/m Lsusp fifi fi H asbeen used to increase G Im otilitye. Non-es to late: fi Es to late form ulation:contraindicated in pregnancy (fi hepa to to xicity),butbestin kidsasm ostacid stable. Situp aftertaking foratleast30 m inutes,and take w ith a fullglassofw ater, to reduce riskofpillslodging in the esophagusand causing ulceration. Pg 13 OralAntibiotics(continued) Treatw ith adequate dose & appropriate duration © w w w. M ayhave lessabsorption via jejunos to m ytube since fluroquinolonesare likelyabsorbed in the duodenum. Note:ifPseudom onassuspected in seriousinfection,m ayuse com bination therapyem pirically. Neisseria;H aem ophilus; Peds: 20-30m g/kg/day po divided q12h $29 P1P2,3 L 250,500,750m g tab fi fi M oraxella;Pasteurella;m anyatypicals. Sulfam ethoxazole & trim ethoprim inhibitsuccessive stepsin folicacid pathw ay,& thusare synergisticin com bination. Coverage:Staphylococci; Peds: 10-30m g/kg/day po divided q6h $34 150,300m g cap Strep to cocci;m anyoralanaerobes. Peds: 15-30-50m g/kg/day po divided q8h $12 250m g tab fi Usefulin:intra-abdom inalinfections;C. See Online Extrasfi forinstructionson com pounding fi H eavilyconcentratesin urine (>100xserum levelifhealthykidneys). Adult:600m g po q12h $802 fi Usefulin:m ulti-drug resistantinfections(including pneum onia,skin and softtissue,etc. Coverage:The onlyoraluse isfortreatm en to fClostridium difficile colitis(drug of Peds: 40m g/kg/day po divided q6h $234 125,250m g cap fi fi choice ifsevere infection,orifsecond recurrence ofC. M:Essentiallyno oralabsorption (used po for 2010 localeffectin bow el);how ever,dialysispatientsm ayrequire a random vancom ycin levelif to xicitysuspected. 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This was not a good prac of botulism occurs when the preformed to medicine synonym generic 400mg indinavir xin tice because the drug should be used only by is ingested in contaminated food and causes patients exposed to symptoms 5dp5dt fet purchase cheap indinavir on line the disease and because illness within 6 hours to medications post mi buy 400 mg indinavir free shipping 2 weeks treatment for scabies proven 400 mg indinavir. Symp to ms s to rage conditions and validation of expira include double vision, blurred vision, droop tion dates cannot be ensured. Botulism is not communicable from one It may be necessary to use antigens in vivo as person to the next. Typically, these are injected Pneumonic plague occurs when Yersinia intradermally and the site inspected for pestis infects the lung. A of this illness include fever, headache, weak positive reaction is determined by the extent ness, and cough with a bloody or watery of induration (in millimeters) and degree of sputum. This disease progresses over 2 to reaction, from slight induration to vesicula 4 days and may cause septic shock. There is no vaccine against this were removed from the market as a result of disease. The vaccine will go the vaccine will be ordered to arrive at to about 10,000 patients. What will you your facility, shipped overnight from recommend to the organizing committee the manufacturer with sufficient dry ice to ensure that the vaccine arrives intact, to keep it frozen, the week before it is to stable, and activefi On Monday of the week of the vaccinations, Objective infOrmatiOn the vaccines will be packaged in sufficient the vaccine is a lyophilized vaccine that dry ice and shipped overnight to arrive must be s to red in a freezer until it is recon at each of the 10 sites the next morning stituted with sterile water for injection (Tuesday). Prior to recon cinations can be scheduled for Wednesday stitution, it must remain in frozen, and if through Friday of that week; this will allowed to reach room temperature prior minimize s to rage and potential handling to reconstitution, it must be discarded problems of the vaccine. One of the more recent delayed hypersensitivity skin test antigens in vivo diagnostic biologics, Candida albicans and a glycerin negative control for percuta skin test antigen, is useful in the assessment neous administration. Chapter 16 • BiologiCs 603 pharmaceutics clinical case study A: the patient is reacting to the immu Vaccines are antigenic substances admin nization Pediarix, a combination of istered for prophylactic purposes to diphtheria and tetanus to xoids and achieve active immunity. They may Diphtheria is an acute to xin-mediated also be a to xoid, a bacterial to xin that is infectious disease caused by to xigenic modified and de to xified by use of mod strains of Corynebacterium diphtheriae. The Tetanus is a condition of neuromuscu end result of the processing is considered lar dysfunction as a result of a potent non to xic, although the antigenic prop exo to xin released from Clostridium tet erties remain. Pertussis, or whooping cough, is vaccinated, and immunization schedules a respira to ry tract condition caused have been developed for both groups. Hepatitis B For example, the pediatric immunization is a condition that affects the liver. List vaccination resources: Health care monovalent and polyvalent biological providers can refer patients and caregiv products. Define and explain the term “cold chain” ing the benefits versus risks of a child re as it relates to the s to rage, handling, and ceiving a thimerosal-containing vaccine. Describe the different methods of induc ods for creating each type of biological ing immunity via bacterial vaccines. Compare and contrast the different types information provided for immunizations of oncological vaccinations. Safety-related regula to ry actions for biologicals A vaccine decreases the incidence of otitis media approved in the United States and the European in 6 to 30-month old children in day care. Mercury concentrations and metabolism in (Accessed Oc to ber 12, 2013) infants receiving vaccines containing thimerosal: A 16. Biological Products; Bacterial Vaccines and 12, 2013) Related Biological Products; Implementation 17. Clinical vaccines-and-related-biological-products responses to undiluted and diluted smallpox implementation-of-efficacy. List drugs that are typically administered by each of these drug delivery methods 3. Explain the advantages/disadvantages of using one of these drug delivery methods over oral administration 4. Describe the use of the various pharmaceutical adjuvants, which are employed in the formulation of these dosage forms 5. Differentiate between the various types of contact lens products and appro priate care products, which are employed for each 6. Explain how patients can misuse/abuse these products intentionally or unintentionally Pharmaceutical dosage forms and drug both systemic drug use and to pical treat delivery systems applied to pically to the ments may be employed. An eye that does not blink can accom general considerations of solutions and sus modate a maximum of about 30 fiL of fluid, pensions presented in Chapters 13 and 14 by but, when blinked, can retain only about describing additional requirements of these 10 fiL (2). Because the capacity of the eye to dosage forms when designed specifically for retain liquid and semisolid preparations is ophthalmic, nasal, or otic use. Larger volumes of liquid prepa Pharmaceutical preparations are applied to p rations may be used to flush or bathe the eye. A single drop of an ophthalmic or infectious conjunctivitis or inflammation; solution or suspension measures about 50 elevated intraocular pressure and glaucoma; fiL (based on 20 drops/mL), so much of an and dry eye due to inadequate production administered drop may be lost. In treating certain volume to administer, based on eye capacity, ophthalmic conditions, such as glaucoma, is 5 to 10 fiL (1). Microliter-dosing medication 606 Chapter 17 • SpeCial SolutionS and SuSpenSionS 607 droppers are not generally available for per and fungal keratitis are amphotericin B, sonal use; consequently, loss of instilled natamycin, and flucy to sine. The average dropper inflammation of the eye, as allergic conjunc delivers about 25 to 50 fiL/drop. Among the to pical anti-inflamma to ry Because of the dynamics of the lacrimal steroidal agents are fluorometholone, system, the retention time of an ophthalmic prednisolone, and dexamethasone salts. For example, following administration of • Antiviral agents: Used against viral infec pilocarpine ophthalmic solution, the solu tions, as that caused by herpes simplex virus. Several other types of agents are used in the treatment of pharmacOlOgic categOries Of glaucoma, including carbonic anhydrase Ophthalmic Drugs inhibi to rs, such as acetazolamide (oral); beta-blockers, such as timolol; alpha the major categories of drugs applied to pi adrenergic agents, such as apraclonidine cally to the eye are as follows: hydrochloride; sympathomimetics, such • Anesthetics: Topical anesthetics, such as as dipivefrin hydrochloride; and an ester tetracaine, cocaine, and proparacaine, prodrug analog of prostaglandin F2a. Mydriatics having a long • Antibiotic and antimicrobial agents: Used duration of action are termed cycloplegics. Among the agents used are atropine, scopolamine, homatropine, to pically are azithromycin, gentamicin cyclopen to late, phenylephrine, hydroxy sulfate, sodium sulfacetamide, ciprofloxa amphetamine, and tropicamide. They are intended to soothe, refresh, and remove redness due to minor eye irritation. Among the vasoconstric to rs used to pically are naphazoline, oxymetazo line, and tetrahydrozoline hydrochlorides. Antihistamines, such as emedastine difu marate, ke to tifen fumarate, and olopata dine hydrochloride, are included in some products to provide relief of itching due to pollen, ragweed, and animal dander. The prepara vation, iso to nicity, buffering, viscosity, ocular tion of a sterile solution by passage through a syringe bioavailability, and packaging. These erable to sterilize ophthalmics in their final preservative-free preparations are packaged containers by au to claving at 121°C (250°F) in single-use containers. As an alternative, bacterial filters may bility, chemical and physical compatibility be used. Although bacterial filters work with with other formulation and packaging com a high degree of efficiency, they are not as ponents, and effectiveness at the concentra reliable as the au to clave. Among the antimicrobial final product testing is used to validate the preservatives used in ophthalmic solutions absence of microbes, sterility may be ensured and suspensions and their effective concen by either method. To maintain sterility during use, antimi crobial preservatives generally are included in ophthalmic formulations; an exception is Figure 17. A chemical that is vatives have limitations; for example, chlo highly ionized will contribute a greater num robutanol cannot be au to claved because it ber of particles to the solution than will be the decomposes to hydrochloric acid even in same amount of a poorly ionized substance. This degradation renders a the effect is that a solution with a greater product susceptible to microbial growth and number of particles, whether they are mol could alter its pH and thereby affect the sta ecules or ions, has higher osmotic pressure bility and/or physiologic activity of the ther than does a solution having fewer particles. Body fluids, including blood and tears, In concentrations to lerated by the eye, have an osmotic pressure corresponding to all of the aforementioned preservative that of a 0. However, preservative mix term iso to nic, meaning equal to ne, is com tures of benzalkonium chloride (0. The latter agent, the osmotic pressure of two liquids that may which is commonly employed as a chelating or may not be physiologic fluids. In the blood filled membrane is placed in a solution of a stream, a hyper to nic injection can cause cre higher solute concentration than its own, nation (shrinking) of blood cells; in the eye, the solvent, which has free passage in either the solution can draw water to ward the direction, passes in to the more concentrated site of the to pical application. Conversely, a solution until equilibrium is established on hypo to nic solution may induce hemolysis of both sides of the membrane and an equal con red blood cells or passage of water from the centration of solute exists on the two sides. In practice, the iso to nicity limits of an the concentration of a solution with ophthalmic solution in terms of sodium respect to osmotic pressure is concerned with chloride or its osmotic equivalent may range the number of particles of solute in solution. This disso the calculations necessary to prepare iso ciation fac to r, commonly symbolized by the osmotic solutions may be made in terms of letter i, must be included in the proportion data relating to the colligative properties of when we seek to determine the strength of solutions (9). Like osmotic pressure, the other an iso-osmotic solution of sodium chloride colligative properties of solutions, namely, (molecular weight, 58. Since osmotic Quantities of two substances that are to nicic equiva pressure depends on the number of particles, lents are proportional to the molecular weights of substances that dissociate have an effect that each multiplied by the i value of the other.