Patient Care Plan: Med/Surg clinical Trina Skinner

Orange no. 2

A.K.D. 88 yr old female

Rm. 4015-3

Code status: DNR

Allergies: Codeine, Sulpha drugs

Physician: Hospitalist

Level of care: Total care; WHISPA lift transfer

Diet: small portions, minced; high calorie, high protein; Provide strawberry Ensure BID. Set up & assist with feeding as necessary

Reason for admission: Cerebral Vascular Accident (CVA); ruled out occult hip fracture

Diagnoses/Medical History:

Cerebral Vascular Accident

Definition: A cerebral vascular accident is another name for a stroke. It is damage to the brain caused by a disruption of the blood supply to a part of the brain. This disruption of blood supply can be caused by a blood clot, or by a ruptured artery.

The symptoms of a cerebral vascular accident depend on which part of the brain is affected. Common symptoms may include paralysis of a part of the body, loss of all or part of the vision, or loss of the ability to speak or to understand speech.

Major Risk Factors associated with Cerebral Vascular Accident

Many factors can increase your risk of a stroke. A number of these factors can also increase your chances of having a heart attack. Stroke risk factors include:

Potentially treatable risk factors

High blood pressure — risk of stroke begins to increase at blood pressure readings higher than 120/80 millimeters of mercury (mm Hg). Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors.

Cigarette smoking or exposure to secondhand smoke.

High cholesterol — a total cholesterol level above 200 milligrams per deciliter (mg/dL), or 5.2 millimoles per liter (mmol/L).

Diabetes. Being overweight or obese. Physical inactivity. Obstructive sleep apnea (a sleep disorder in which the oxygen level intermittently drops

during the night). Cardiovascular disease, including heart failure, heart defects, heart infection or

abnormal heart rhythm. Use of some birth control pills or hormone therapies that include estrogen. Heavy or binge drinking. Use of illicit drugs such as cocaine and methamphetamines.

Other risk factors

Personal or family history of stroke, heart attack or TIA. Being age 55 or older. Race — African-Americans have higher risk of stroke than people of other races. Gender — Men have a higher risk of stroke than women. Women are usually older

when they have strokes, and they are more likely to die of strokes than men.

Causal Factors

A stroke occurs when the blood supply to your brain is interrupted or reduced. This deprives your brain of oxygen and nutrients, which can cause your brain cells to die. A stroke may be caused by a blocked artery (ischemic stroke) or a leaking or burst blood vessel (hemorrhagic stroke). Some people may experience a temporary disruption of blood flow through their brain (transient ischemic attack).

Ischemic strokeAbout 85 percent of strokes are ischemic strokes. Ischemic strokes occur when the arteries to your brain become narrowed or blocked, causing severely reduced blood flow (ischemia). The most common ischemic strokes include:

Thrombotic stroke. A thrombotic stroke occurs when a blood clot (thrombus) forms in one of the arteries that supply blood to your brain. A clot often may be caused by fatty deposits (plaque) that build up in arteries and cause reduced blood flow (atherosclerosis) or other artery conditions.

Embolic stroke. An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of blood clot is called an embolus.

Hemorrhagic strokeHemorrhagic stroke occurs when a blood vessel in your brain leaks or ruptures. Brain hemorrhages can result from many conditions that affect your blood vessels, including uncontrolled high blood pressure (hypertension) and weak spots in your blood vessel walls (aneurysms). A less common cause of hemorrhage is the rupture of an arteriovenous malformation (AVM) — an abnormal tangle of thin-walled blood vessels, present at birth. The types of hemorrhagic stroke include:

Intracerebral hemorrhage. In an intracerebral hemorrhage, a blood vessel in the brain bursts and spills into the surrounding brain tissue, damaging brain cells. Brain cells beyond the leak are deprived of blood and damaged. High blood pressure, trauma, vascular malformations, use of blood-thinning medications and other conditions may cause intracerebral hemorrhage.

Subarachnoid hemorrhage. In a subarachnoid hemorrhage, an artery on or near the surface of your brain bursts and spills into the space between the surface of your brain and your skull. This bleeding is often signaled by a sudden, severe headache. A subarachnoid hemorrhage is commonly caused by the rupture of an aneurysm, a small sack-shaped or berry-shaped outpouching on an artery in the brain. After the hemorrhage, the blood vessels in your brain may widen and narrow erratically (vasospasm), causing brain cell damage by further limiting blood flow to parts of your brain.

Signs & Symptoms

Note when your signs and symptoms begin, because the length of time they have been present may guide your treatment decisions.

Trouble with walking. You may stumble or experience sudden dizziness, loss of balance or loss of coordination.

Trouble with speaking and understanding. You may experience confusion. You may slur your words or have difficulty understanding speech.

Paralysis or numbness of the face, arm or leg. You may develop sudden numbness, weakness or paralysis in your face, arm or leg, especially on one side of your body. Try to raise both your arms over your head at the same time. If one arm begins to fall, you may be having a stroke. Similarly, one side of your mouth may droop when you try to smile.

Trouble with seeing in one or both eyes. You may suddenly have blurred or blackened vision in one or both eyes, or you may see double.

Headache. A sudden, severe headache, which may be accompanied by vomiting, dizziness or altered consciousness, may indicate you're having a stroke.

When to see a doctor:

Seek immediate medical attention if you notice any signs or symptoms of a stroke, even if they seem to fluctuate or disappear. Call 911 or your local emergency number right away. Every minute counts. Don't wait to see if symptoms go away. The longer a stroke goes untreated, the greater the potential for brain damage and disability. To maximize the effectiveness of evaluation and treatment, you'll need to be treated at a hospital within three hours after your first symptoms appeared. If you're with someone you suspect is having a stroke, watch the person carefully while waiting for emergency assistance.

Exams/Tests

To determine the most appropriate treatment for your stroke, your emergency team needs to evaluate the type of stroke you're having and the areas of your brain affected by the stroke. They also need to rule out other possible causes of your symptoms, such as a brain tumor or a drug reaction. Your doctor may use several tests to determine your risk of stroke, including:

Physical examination. Your doctor will ask you or a family member what symptoms you've been having, when they started and what you were doing when they began. Your doctor then will evaluate whether these symptoms are still present. Your doctor will want to know what medications you take and whether you have experienced any head injuries. You'll be asked about your personal and family history of heart disease, TIA or stroke. Your doctor will check your blood pressure and use a stethoscope to listen to your heart and to listen for a whooshing sound (bruit) over your neck (carotid) arteries, which may indicate atherosclerosis. Your doctor may also use an ophthalmoscope to check for signs of tiny cholesterol crystals or clots in the blood vessels at the back of your eyes.

Blood tests. You may have several blood tests, which give your care team important information such as how fast your blood clots, whether your blood sugar is abnormally high or low, whether critical blood chemicals are out of balance, or whether you may have an infection. Your blood's clotting time and levels of sugar and key chemicals must be managed as part of your stroke care. Infections also must be treated.

Computerized tomography (CT) scan. Brain imaging plays a key role in determining if you're having a stroke and what type of stroke you may be experiencing. A CT scan uses a series of X-rays to create a detailed image of your brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. Doctors may inject a dye into your blood vessels to view your blood vessels in your neck and brain in greater detail (computerized tomography angiography).

Magnetic resonance imaging (MRI). An MRI uses powerful radio waves and magnets to create a detailed view of your brain. An MRI can detect brain tissue damaged by an ischemic stroke and brain hemorrhages. Sometimes your doctor may inject a dye into a blood vessel to view the arteries and veins and highlight blood flow (magnetic resonance angiography, or magnetic resonance venography).

Carotid ultrasound. In this test, sound waves create detailed images of the inside of the carotid arteries in your neck. This test shows buildup of fatty deposits (plaques) and blood flow in your carotid arteries.

Cerebral angiogram. In this test, your doctor inserts a thin, flexible tube (catheter) through a small incision, usually in your groin, and guides it through your major arteries and into your carotid or vertebral artery. Then your doctor injects a dye into your blood vessels to make them visible under X-ray imaging. This procedure gives a detailed view of arteries in your brain and neck.

Echocardiogram. An echocardiogram uses sound waves to create detailed images of your heart. An echocardiogram can find a source of clots in your heart that may have traveled from your heart to your brain and caused your stroke. You sometimes may have a transesophageal echocardiogram. In this test, your doctor inserts a flexible tube with a small device (transducer) attached in your throat and down into your esophagus — the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, a transesophageal echocardiogram can create clear, detailed ultrasound images of your heart and any blood clots.

Treatment Options

Emergency treatment for stroke depends on whether you're having an ischemic stroke blocking an artery — the most common kind — or a hemorrhagic stroke involving bleeding into the brain.

Ischemic strokeTo treat an ischemic stroke, doctors must quickly restore blood flow to your brain.

Emergency treatment with medications. Therapy with clot-busting drugs (thrombolytics) must start within 4.5 hours if they are given into the vein — and the sooner, the better. Quick treatment not only improves your chances of survival but also may reduce the complications from your stroke. You may be given:

Aspirin. Aspirin, an anti-thrombotic drug, is an immediate treatment after an ischemic stroke to reduce the likelihood of having another stroke. Aspirin prevents blood clots from forming. In the emergency room, you may be given a dose of aspirin. The dose may vary, but if you already take a daily aspirin for its blood-thinning effect, you may want to make a note of that on an emergency medical card so doctors will know if you've already taken some aspirin.

Other blood-thinning drugs, such as heparin, also may be given, but this drug isn't proven to be beneficial in the emergency setting so it's used infrequently. Clopidogrel (Plavix), warfarin (Coumadin), or aspirin in combination with extended release dipyridamole (Aggrenox) may also be used, but these aren't usually used in the emergency room setting.

Intravenous injection of tissue plasminogen activator (TPA). Some people who are having an ischemic stroke can benefit from an injection of a recombinant tissue plasminogen activator (TPA), also called alteplase, usually given through a vein in the arm. This potent clot-busting drug needs to be given within 4.5 hours after stroke symptoms begin if it's given into the vein. This drug restores blood flow by dissolving the blood clot causing your stroke, and it may help people who have had strokes recover more fully. Your doctor will consider certain risks, such as potential bleeding in the brain, to determine if TPA is the most appropriate treatment for you.

Emergency procedures. Doctors sometimes treat ischemic strokes with procedures that must be performed as soon as possible.

Medications delivered directly to the brain. Doctors may insert a long, thin tube (catheter) through an artery in your groin and thread it to your brain, and then release TPA directly into the area where the stroke is occurring. The time window for this treatment is somewhat longer than for intravenous TPA but still limited.

Mechanical clot removal. Doctors may use a catheter to maneuver a tiny device into your brain to physically grab and remove the clot.

Other procedures. To decrease your risk of having another stroke or TIA, your doctor may recommend a procedure to open up an artery that's moderately to severely narrowed by plaque. Doctors sometimes recommend these procedures to prevent a stroke. Options may include:

Carotid endarterectomy. In a carotid endarterectomy, a surgeon removes fatty deposits (plaques) from your carotid arteries that run along each side of your neck to your brain. In this procedure, your surgeon makes an incision along the front of your neck, opens your carotid artery, and removes fatty deposits (plaques) that block the carotid artery. Your surgeon then repairs the artery with stitches or a patch made with a vein or artificial material (graft). The procedure may reduce your risk of ischemic stroke. However, a carotid endarterectomy also involves risks, especially for people with heart disease or other medical conditions.

Angioplasty and stents. In an angioplasty, a surgeon inserts a catheter with a mesh tube (stent) and balloon on the tip into an artery in your groin and guides it to the blocked carotid artery in your neck. Your surgeon inflates the balloon in the narrowed artery and inserts a mesh tube (stent) into the opening to keep your artery from becoming narrowed after the procedure.

Hemorrhagic strokeEmergency treatment of hemorrhagic stroke focuses on controlling your bleeding and reducing pressure in your brain. Surgery also may be used to help reduce future risk.

Emergency measures. If you take warfarin (Coumadin) or anti-platelet drugs such as clopidogrel (Plavix) to prevent blood clots, you may be given drugs or transfusions of blood products to

counteract their effects. You may also be given drugs to lower pressure in your brain (intracranial pressure), lower your blood pressure or prevent seizures. People having a hemorrhagic stroke can't be given clot-busters such as aspirin and TPA, because these drugs may worsen bleeding.

Once the bleeding in your brain stops, treatment usually involves bed rest and supportive medical care while your body absorbs the blood. Healing is similar to what happens while a bad bruise goes away. If the area of bleeding is large, surgery may be used in certain cases to remove the blood and relieve pressure on the brain.

Surgical blood vessel repair. Surgery may be used to repair certain blood vessel abnormalities associated with hemorrhagic strokes. Your doctor may recommend one of these procedures after a stroke or if you're at high risk of a spontaneous aneurysm or arteriovenous malformation (AVM) rupture:

Surgical clipping. A surgeon places a tiny clamp at the base of the aneurysm, to stop blood flow to it. This can keep the aneurysm from bursting, or it can prevent re-bleeding of an aneurysm that has recently hemorrhaged.

Coiling (endovascular embolization). In this procedure, a surgeon inserts a catheter into an artery in your groin and guides it to your brain using X-ray imaging. Your surgeon then guides tiny detachable coils into the aneurysm (aneurysm coiling). The coils fill the aneurysm, which blocks blood flow into the aneurysm and causes the blood to clot.

Surgical AVM removal. Surgeons may remove a smaller AVM if it's located in an accessible area of your brain, to eliminate the risk of rupture and lower the risk of hemorrhagic stroke. However, it's not always possible to remove an AVM if it's too large or if it's located deep within your brain.

Stroke recovery and rehabilitationFollowing emergency treatment, stroke care focuses on helping you regain your strength, recover as much function as possible and return to independent living. The impact of your stroke depends on the area of the brain involved and the amount of tissue damaged. If your stroke affected the right side of your brain, your movement and sensation on the left side of your body may be affected. If your stroke damaged the brain tissue on the left side of your brain, your movement and sensation on the right side of your body may be affected. Brain damage to the left side of your brain may cause speech and language disorders. In addition, if you've had a stroke, you may have problems with breathing, swallowing, balancing and vision.

Most stroke survivors receive treatment in a rehabilitation program. Your doctor will recommend the most rigorous therapy program you can handle based on your age, overall health and your degree of disability from your stroke. Your doctor will take into consideration your lifestyle, interests and priorities, and availability of family members or other caregivers.

Your rehabilitation program may begin before you leave the hospital. It may continue in a rehabilitation unit of the same hospital, another rehabilitation unit or skilled nursing facility, an outpatient unit, or your home.

Every person's stroke recovery is different. Depending on your condition, your treatment team may include:

Doctor trained in brain conditions (neurologist) Rehabilitation doctor (physiatrist) Nurse Dietitian Physical therapist Occupational therapist Recreational therapist Speech therapist Social worker Case manager Psychologist or psychiatrist Chaplain

Atrial Fibrillation (A-Fib)

Atrial fibrillation is an irregular and often rapid heart rate that commonly causes poor blood flow to the body. During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms include heart palpitations, shortness of breath and weakness.

Episodes of atrial fibrillation can come and go, or you may have chronic atrial fibrillation. Although atrial fibrillation itself usually isn't life-threatening, it is a serious medical condition that sometimes requires emergency treatment. It can lead to complications. Treatments for atrial fibrillation may include medications and other interventions to try to alter the heart's electrical system.

Major Risk Factors associated with A-Fib

Risk factors for atrial fibrillation include:

Age. The older you are, the greater your risk of developing atrial fibrillation. Heart disease. Anyone with heart disease, including valve problems and a history of

heart attack and heart surgery, has an increased risk of atrial fibrillation. High blood pressure. Having high blood pressure, especially if it's not well controlled

with lifestyle changes or medications, can increase your risk of atrial fibrillation. Other chronic conditions. People with thyroid problems, sleep apnea and other medical

problems have an increased risk of atrial fibrillation.

Drinking alcohol. For some people, drinking alcohol can trigger an episode of atrial fibrillation. Binge drinking — having five drinks in two hours for men, or four drinks for women — may put you at higher risk.

Family history. An increased risk of atrial fibrillation runs in some families.

Causal Factors

Your heart consists of four chambers — two upper chambers (atria) and two lower chambers (ventricles). Within the upper right chamber of your heart (right atrium) is a group of cells called the sinus node. This is your heart's natural pacemaker. The sinus node produces the impulse that normally starts each heartbeat.

Normally, the impulse travels first through the atria and then through a connecting pathway between the upper and lower chambers of your heart called the atrioventricular (AV) node. As the signal passes through the atria, they contract, pumping blood from your atria into the ventricles below. As the signal passes through the AV node to the ventricles, the ventricles contract, pumping blood out to your body.

In atrial fibrillation, the upper chambers of your heart (atria) experience chaotic electrical signals. As a result, they quiver. The AV node — the electrical connection between the atria and the ventricles — is overloaded with impulses trying to get through to the ventricles. The ventricles also beat rapidly, but not as rapidly as the atria. The reason is that the AV node is like a highway on-ramp — only so many vehicles can get on at one time.

The result is a fast and irregular heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute. The normal range for a heart rate is 60 to 100 beats a minute.

Possible causes of atrial fibrillationAbnormalities or damage to the heart's structure are the most common cause of atrial fibrillation. Possible causes of atrial fibrillation include:

High blood pressure Heart attacks Abnormal heart valves Heart defects you're born with (congenital) An overactive thyroid gland or other metabolic imbalance Exposure to stimulants, such as medications, caffeine or tobacco, or to alcohol Sick sinus syndrome — functioning of the heart's natural pacemaker Emphysema or other lung diseases Previous heart surgery Viral infections Stress due to pneumonia, surgery or other illnesses Sleep apnea

However, some people who have atrial fibrillation don't have any heart defects or damage, a condition called lone atrial fibrillation. In lone atrial fibrillation, the cause is often unclear, and serious complications are rare.

Atrial flutterAtrial flutter is similar to atrial fibrillation, but the rhythm in your atria is more organized and less chaotic than the abnormal patterns common with atrial fibrillation. Sometimes you may have atrial flutter that develops into atrial fibrillation and vice versa. The symptoms, causes and risk factors of atrial flutter are similar to those of atrial fibrillation. For example, strokes are also a concern in someone with atrial flutter. As with atrial fibrillation, atrial flutter is usually not life-threatening when it's properly treated.

Signs & Symptoms

A heart in atrial fibrillation doesn't beat efficiently. It may not be able to pump enough blood out to your body with each heartbeat.

Some people with atrial fibrillation have no symptoms and are unaware of their condition until it's discovered during a physical examination. Those who do have atrial fibrillation symptoms may experience:

Palpitations, which are sensations of a racing, uncomfortable, irregular heartbeat or a flopping in your chest

Decreased blood pressure Weakness Lightheadedness Confusion Shortness of breath Chest pain

Atrial fibrillation may be:

Occasional. In this case it's called paroxysmal (par-ok-SIZ-mul) atrial fibrillation. You may have symptoms that come and go, lasting for a few minutes to hours and then stopping on their own.

Chronic. With chronic atrial fibrillation, your heart rhythm is always abnormal.

When to see a doctorIf you have any symptoms of atrial fibrillation, make an appointment with your doctor. Your doctor should be able to tell you if your symptoms are caused by atrial fibrillation or another heart arrhythmia.

If you have chest pain, seek emergency medical assistance immediately. Chest pain could signal that you're having a heart attack.

Exams/Tests

To diagnose atrial fibrillation, your doctor may do tests that involve the following:

Electrocardiogram (ECG). In this noninvasive test, patches with wires (electrodes) are attached to your skin to measure electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed.

Holter monitor. This is a portable machine that records all of your heartbeats. You wear the monitor under your clothing. It records information about the electrical activity of your heart as you go about your normal activities for a day or two. You can press a button if you feel symptoms, so your doctor can know what heart rhythm was present at that moment.

Event recorder. This device is similar to a Holter monitor except that not all of your heartbeats are recorded. There are two recorder types: One uses a phone to transmit signals from the recorder while you're experiencing symptoms. The other type is worn all the time (except while showering) for as long as a month. Event recorders are especially useful in diagnosing rhythm disturbances that occur at unpredictable times.

Echocardiogram. In this noninvasive test, sound waves are used to produce a video image of your heart. Sound waves are directed at your heart from a wand-like device (transducer) that's held on your chest. The sound waves that bounce off your heart are reflected through your chest wall and processed electronically to provide video images of your heart in motion, to detect underlying structural heart disease.

Blood tests. These help your doctor rule out thyroid problems or other substances in your blood that may lead to atrial fibrillation.

Chest X-ray. X-ray images help your doctor see the condition of your lungs and heart. Your doctor can also use an X-ray to diagnose conditions other than atrial fibrillation that may explain your signs and symptoms.

Treatment Options

In some people, a specific event or an underlying condition, such as a thyroid disorder, may trigger atrial fibrillation. If the condition that triggered your atrial fibrillation can be treated, you might not have any more heart rhythm problems — or at least not for quite some time. If your symptoms are bothersome or if this is your first episode of atrial fibrillation, your doctor may attempt to reset the rhythm.

The treatment option best for you will depend on how long you've had atrial fibrillation, how bothersome your symptoms are and the underlying cause of your atrial fibrillation. Generally, the goals of treating atrial fibrillation are to:

Reset the rhythm or control the rate Prevent blood clots

The strategy you and your doctor choose depends on many factors, including whether you have other problems with your heart and if you're able to take medications that can control your heart rhythm. In some cases, you may need a more invasive treatment, such as surgery or medical procedures using catheters.

Resetting your heart's rhythmIdeally, to treat atrial fibrillation, the heart rate and rhythm are reset to normal. To correct your condition, doctors may be able to reset your heart to its regular rhythm (sinus rhythm) using a procedure called cardioversion, depending on the underlying cause of atrial fibrillation and how long you've had it. Cardioversion can be done in two ways:

Cardioversion with drugs. This form of cardioversion uses medications called anti-arrhythmics to help restore normal sinus rhythm. Depending on your heart condition, your doctor may recommend trying intravenous or oral medications to return your heart to normal rhythm. This is often done in the hospital with continuous monitoring of your heart rate. If your heart rhythm returns to normal, your doctor often will prescribe the same anti-arrhythmic or a similar one to try to prevent more spells of atrial fibrillation.

Electrical cardioversion. In this brief procedure, an electrical shock is delivered to your heart through paddles or patches placed on your chest. The shock stops your heart's electrical activity momentarily. When your heart begins again, the hope is that it resumes its normal rhythm. The procedure is performed during sedation, so you shouldn't feel the electric shock.

Before cardioversion, you may be given a blood-thinning medication, such as warfarin (Coumadin), for several weeks to reduce the risk of blood clots and stroke. Unless the episode of atrial fibrillation lasted less than 24 hours, you'll need to take warfarin for at least four to six weeks after cardioversion to prevent a blood clot from forming even after your heart is back in normal rhythm. Warfarin is a powerful medication that can have dangerous side effects if not taken exactly as directed by your doctor. If you have any concerns about taking warfarin, talk to your doctor.

Or, instead of taking warfarin, you may have a test called transesophageal echocardiography — which can tell your doctor if you have any heart blood clots — just before cardioversion. In transesophageal echocardiography, a tube is passed down your esophagus and detailed ultrasound images are made of your heart. You'll be sedated during the test.

Maintaining a normal heart rhythmAfter electrical cardioversion, anti-arrhythmic medications often are prescribed to help prevent future episodes of atrial fibrillation. Commonly used medications include:

Amiodarone (Cordarone, Pacerone) Dronedarone (Multaq) Propafenone (Rythmol)

Sotalol (Betapace) Dofetilide (Tikosyn) Flecainide (Tambocor)

Although these drugs can help maintain a normal heart rhythm in many people, they can cause side effects, including:

Nausea Dizziness Fatigue

Rarely, they may cause ventricular arrhythmias — life-threatening rhythm disturbances originating in the heart's lower chambers. These medications may be needed indefinitely. Even with medications, the chance of another episode of atrial fibrillation is high.

Heart rate controlSometimes atrial fibrillation can't be converted to a normal heart rhythm. Then the goal is to slow the heart rate to between 60 and 100 beats a minute (rate control). Heart rate control can be achieved two ways:

Medications. Doctors have prescribed the medication digoxin (Lanoxin). It can control heart rate at rest, but not as well during activity. Most people require additional or alternative medications, such as calcium channel blockers or beta blockers. Other blood pressure lowering medications, such as angiotensin-converting enzyme (ACE) inhibitors, also are sometimes used to lower blood pressure and reduce the risk of atrial fibrillation complications.

Atrioventricular (AV) node ablation. If medications don't work, or you have side effects, AV node ablation may be another option. The procedure involves applying radiofrequency energy to the pathway connecting the upper and lower chambers of your heart (AV node) through a long, thin tube (catheter) to destroy this small area of tissue.

The procedure prevents the atria from sending electrical impulses to the ventricles. The atria continue to fibrillate, though, and anticoagulant medication is still required. A pacemaker is then implanted to establish a normal rhythm. After AV node ablation, you'll need to continue to take blood-thinning medications to reduce the risk of stroke, because your heart rhythm is still atrial fibrillation.

Other surgical and catheter proceduresSometimes medications or cardioversion to control atrial fibrillation doesn't work. In those cases, your doctor may recommend a procedure to destroy the area of heart tissue that's causing the erratic electrical signals and restore your heart to a normal rhythm. These options can include:

Radiofrequency catheter ablation. In many people who have atrial fibrillation and an otherwise normal heart, atrial fibrillation is caused by rapidly discharging triggers, or "hot spots." These hot spots are like abnormal pacemaker cells that fire so rapidly that the upper chambers of your heart quiver instead of beating efficiently.

Radiofrequency energy is directed to these hot spots through a catheter inserted in an artery near your groin and threaded up to your heart. This catheter is used to destroy these hot spots, scarring the tissue so the erratic electrical signals are normalized. This corrects the arrhythmia without the need for medications or implantable devices. In some cases, other types of catheters that can freeze the heart tissue (cryotherapy) are used.

Surgical maze procedure. The maze procedure is done during an open-heart surgery. Using a scalpel, doctors create several precise incisions in the upper chambers of your heart to create a pattern of scar tissue. Because scar tissue doesn't carry electricity, it interferes with stray electrical impulses that cause atrial fibrillation. Radiofrequency or cryotherapy also can be used to create the scars, and there are several variations of the surgical maze technique. The procedure has a high success rate, but because it usually requires open-heart surgery, it's generally reserved for people who don't respond to other treatments or when it can be done during other necessary heart surgery, such as coronary artery bypass surgery or heart valve repair. Some people need a pacemaker implanted after the procedure.

Preventing blood clotsMost people who have atrial fibrillation or who are undergoing certain treatments for atrial fibrillation are at especially high risk of blood clots that can lead to stroke. The risk is even higher if other heart disease is present along with atrial fibrillation. Your doctor may prescribe blood-thinning medications (anticoagulants) such as:

Warfarin (Coumadin). If you're prescribed warfarin, carefully follow your doctor's instructions on taking it. Warfarin is a powerful medication that can have dangerous side effects. You'll need to have regular blood tests to monitor warfarin's effects.

Dabigatran (Pradaxa). Another option for preventing blood clots is dabigatran. Dabigatran is as effective as warfarin at preventing blood clots that can lead to strokes, and doesn't require blood tests to make sure you're getting the proper dose. You shouldn't take dabigatran if you have a mechanical heart valve due to an increased risk of stroke or heart attack. Talk to your doctor about taking dabigatran as an alternative to warfarin if you're concerned about your risk of stroke.

Rivaroxaban (Xarelto). Rivaroxaban is another anticoagulant medication that's as effective as warfarin for preventing strokes. Rivaroxaban is a once-daily medication. Like any other anticoagulant, follow your doctor's dosing instructions carefully and don't stop taking rivaroxaban without talking to your doctor first.

You may need to take medications to prevent blood clots in addition to medications designed to treat your irregular heartbeat. Many people have spells of atrial fibrillation and don't even know it — so you may need lifelong anticoagulants even after your rhythm has been restored to normal.

Bowel Resection

A bowel resection is a surgical procedure in which a part of the large or small intestine is removed. It may be performed due to cancer, necrosis, enteritis, diverticular disease, or a block in the intestine due to scar tissue. Other reasons to perform bowel resection include ulcerative colitis, traumatic injuries, precancerous polyps, and familial polyposis

Transient Ischemic Attacks (TIA’s)

A transient ischemic attack (TIA) is like a stroke, producing similar symptoms, but usually lasting only a few minutes and causing no permanent damage. Often called a mini stroke, a transient ischemic attack may be a warning. About 1 in 3 people who have a transient ischemic attack eventually has a stroke, with about half occurring within a year after the transient ischemic attack.

A transient ischemic attack can serve as both a warning and an opportunity — a warning of an impending stroke and an opportunity to take steps to prevent it.

Major Risk Factors associated with TIA’s

Risk factors you can't changeYou can't change the following risk factors for transient ischemic attack and stroke. But knowing you're at risk can motivate you to change your lifestyle to reduce other risks.

Family history. Your risk may be greater if one of your family members has had a TIA or a stroke.

Age. Your risk increases as you get older, especially after age 55. Gender. Men have a slightly higher likelihood of TIA and stroke, but more than half of

deaths from stroke occur in women. Sickle cell disease. Also called sickle cell anemia, stroke is a frequent complication of

this inherited disorder. Sickle-shaped blood cells carry less oxygen and also tend to get stuck in artery walls, hampering blood flow to the brain.

Race. Blacks are at greater risk of dying of a stroke, partly because of the higher prevalence of high blood pressure and diabetes among blacks.

Risk factors you can take steps to control You can control or treat a number of risk factors, including:

High blood pressure. Risk of stroke begins to increase at blood pressure readings higher than 115/75 millimeters of mercury (mm Hg). Your doctor will help you decide on a target blood pressure based on your age, whether you have diabetes and other factors.

Cardiovascular disease. This includes heart failure, a heart defect, a heart infection or an abnormal heart rhythm.

Carotid artery disease. The blood vessels in your neck that lead to your brain become clogged.

Peripheral artery disease (PAD). The blood vessels that carry blood to your arms and legs become clogged.

Cigarette smoking. Smoking increases your risk of blood clots, raises your blood pressure and contributes to the development of cholesterol-containing fatty deposits in your arteries (atherosclerosis).

Physical inactivity. Engaging in 30 minutes of moderate intensity exercise most days helps reduce risk.

Diabetes. Diabetes increases the severity of atherosclerosis — narrowing of the arteries due to accumulation of fatty deposits — and the speed with which it develops.

Poor nutrition. Eating too much fat and salt, in particular, increases your risk of TIA and stroke.

High cholesterol. Eating less cholesterol and fat, especially saturated fat and trans fats, may reduce the plaques in your arteries. If you can't control your cholesterol through dietary changes alone, your doctor may prescribe a statin or another type of cholesterol-lowering medication.

High levels of homocysteine. Elevated levels of this amino acid in your blood can cause your arteries to thicken and scar, which makes them more susceptible to clots.

Excess weight. A body mass index of 25 or higher and a waist circumference greater than 35 inches in women or 40 inches in men increase risk.

Heavy drinking. If you drink alcohol, limit yourself to no more than two drinks daily if you're a man and one drink daily if you're a woman.

Use of illicit drugs. Avoid cocaine and other drugs. Use of birth control pills. If you use any hormone therapy, talk to your doctor about

how the hormones may affect your risk of TIA and stroke.

Causal Factors

A transient ischemic attack has the same origins as that of an ischemic stroke, the most common type of stroke. In an ischemic stroke, a clot blocks the blood supply to part of your brain. In a transient ischemic attack, unlike a stroke, the blockage is brief, and there is no permanent damage.

The underlying cause of a TIA often is a buildup of cholesterol-containing fatty deposits called plaques (atherosclerosis) in an artery or one of its branches that supplies oxygen and nutrients to your brain. Plaques can decrease the blood flow through an artery or lead to the development of a clot. Other causes include a blood clot moving to your brain from another part of your body, most commonly from your heart.

A transient ischemic attack has the same origins as that of an ischemic stroke, the most common type of stroke. In an ischemic stroke, a clot blocks the blood supply to part of your brain. In a transient ischemic attack, unlike a stroke, the blockage is brief, and there is no permanent damage.

The underlying cause of a TIA often is a buildup of cholesterol-containing fatty deposits called plaques (atherosclerosis) in an artery or one of its branches that supplies oxygen and nutrients to your brain. Plaques can decrease the blood flow through an artery or lead to the development of a clot. Other causes include a blood clot moving to your brain from another part of your body, most commonly from your heart.

Signs & Symptoms

Transient ischemic attacks usually last a few minutes. Most signs and symptoms disappear within an hour. The signs and symptoms of TIA resemble those found early in a stroke and may include:

Sudden weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body

Slurred or garbled speech or difficulty understanding others Sudden blindness in one or both eyes or double vision Dizziness, loss of balance or coordination

You may have more than one TIA, and the recurrent signs and symptoms may be similar or different depending on which area of the brain is involved. If signs and symptoms last longer than 24 hours or cause lasting brain damage, it's considered a stroke.

When to see a doctorSeek immediate medical attention if you suspect you've had a transient ischemic attack. Prompt evaluation and identification of potentially treatable conditions may help you prevent a stroke.

Exams/Tests

Because a transient ischemic attack is short-lived, your doctor may diagnose a TIA based just on the medical history of the event rather than on anything found during a general physical and neurological examination. To help determine the cause of your TIA and to assess your risk of stroke, your doctor may rely on the following:

Physical examination and tests. Your doctor may check for risk factors of stroke, including high blood pressure, high cholesterol levels, diabetes and high levels of the amino acid homocysteine. Your doctor may also use a stethoscope to listen for a whooshing sound (bruit) over your arteries that may indicate atherosclerosis. Or your doctor may observe cholesterol fragments (emboli) in the tiny blood vessels of your retina, at the back of your eye, during an eye examination using an ophthalmoscope.

Carotid ultrasonography. A wand-like device (transducer) sends high-frequency sound waves into your neck. After the sound waves pass through your tissue and back, your doctor can analyze images on a screen to look for narrowing or clotting in the carotid arteries.

Computerized tomography (CT) scanning. CT scanning of your head uses X-ray beams to assemble a composite, 3-D look at your brain.

Computerized tomography angiography (CTA) scanning. Scanning of the head may also be used to noninvasively evaluate the arteries in your neck and brain. CTA scanning uses X-rays, similar to a standard CT scan of the head, but may also involve injection of a contrast material into a blood vessel.

Magnetic resonance imaging (MRI). This procedure, which uses a strong magnetic field, can generate a composite, 3-D view of your brain.

Magnetic resonance angiography (MRA). This is a method of evaluating the arteries in your neck and brain. It uses a strong magnetic field, similar to MRI.

Echocardiography. Your doctor may choose to perform a transthoracic echocardiogram (TTE) or transesophageal echocardiogram (TEE). A TTE involves moving an instrument called a transducer across your chest. The transducer emits sound waves that echo off of different parts of your heart, creating an ultrasound image. During a TEE, a flexible probe with a transducer built into it is placed in your esophagus — the tube that connects the back of your mouth to your stomach. Because your esophagus is directly behind your heart, clearer, detailed ultrasound images can be created. This allows a better view of some things, such as blood clots, that might not be seen clearly in a traditional echocardiography exam.

Arteriography. This procedure gives a view of arteries in your brain not normally seen in X-ray imaging. A radiologist inserts a thin, flexible tube (catheter) through a small incision, usually in your groin. The catheter is manipulated through your major arteries and into your carotid or vertebral artery. Then, the radiologist injects a dye through the catheter to provide X-ray images of the arteries in your brain.

Blood tests. Your doctor may request a blood screen to check for abnormalities in certain areas — such as your blood glucose level, serum cholesterol and homocysteine count — that may indicate an underlying problem.

Treatment Options

Once your doctor has determined the cause of your transient ischemic attack, the goal of treatment is to correct the abnormality and prevent a stroke. Depending on the cause of your TIA, your doctor may prescribe medication to reduce the tendency for blood to clot or may recommend surgery or a balloon procedure (angioplasty).

MedicationsDoctors use several medications to decrease the likelihood of a stroke after a transient ischemic attack. The medication selected depends on the location, cause, severity and type of TIA. Two frequently prescribed types of drugs are:

Anti-platelet drugs. These medications make your platelets, one of the circulating blood cell types, less likely to stick together. When blood vessels are injured, sticky platelets begin to form clots, a process completed by clotting proteins in blood plasma. The most frequently used anti-platelet medication is aspirin. Aspirin is also the least expensive treatment with the fewest potential side effects. An alternative to aspirin is the anti-platelet drug clopidogrel (Plavix). Your doctor may consider prescribing Aggrenox, a combination of low-dose aspirin and the anti-platelet drug dipyridamole, to reduce blood clotting. The way dipyridamole works is slightly different from aspirin.

Anticoagulants. These drugs include heparin and warfarin (Coumadin). They affect clotting-system proteins instead of platelet function. Heparin is used short term and warfarin over a longer term. These drugs require careful monitoring. If atrial fibrillation is present, your doctor may prescribe another type of anticoagulant, dabigatran (Pradaxa).

SurgeryIf you have a moderately or severely narrowed neck (carotid) artery, your doctor may suggest carotid endarterectomy (end-ahr-tur-EK-tuh-me). This preventive surgery clears carotid arteries of fatty deposits (atherosclerotic plaques) before another TIA or stroke can occur. An incision is made to open the artery, the plaques are removed, and the artery is closed.

AngioplastyIn selected cases, a procedure called carotid angioplasty, or stenting, is an option. This procedure involves using a balloon-like device to open a clogged artery and placing a small wire tube (stent) into the artery to keep it open.

Hypothyroidism

HTN- Hypertension

Hypertension (HTN) or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevated.[1] This requires the heart to work harder than normal to circulate blood through the blood vessels. Blood pressure is summarized by two measurements, systolic and diastolic, which depend on whether the heart muscle is contracting (systole) or relaxed between beats (diastole).

Normal blood pressure at rest is within the range of 100-140mmHg systolic (top reading) and 60-90mmHg diastolic (bottom reading). High blood pressure is said to be present if it is persistently at or above 140/90 mmHg.

Major Risk Factors associated with Hypertension

Stroke, myocardial infarction (heart attacks), heart failure, aneurysms of the arteries (e.g. aortic aneurysm), peripheral arterial disease and is a cause of chronic kidney disease.

Causal Factors

There are two types of high blood pressure.

Primary (essential) hypertensionFor most adults, there's no identifiable cause of high blood pressure. This type of high blood pressure, called essential hypertension or primary hypertension, tends to develop gradually over many years.

Secondary hypertensionSome people have high blood pressure caused by an underlying condition. This type of high blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood pressure than does primary hypertension. Various conditions and medications can lead to secondary hypertension, including:

Kidney problems Adrenal gland tumors Certain defects in blood vessels you're born with (congenital) Certain medications, such as birth control pills, cold remedies, decongestants, over-the-

counter pain relievers and some prescription drugs Illegal drugs, such as cocaine and amphetamines

Signs & Symptoms

High blood pressure usually causes no symptoms and high blood pressure often is labeled "the silent killer." People who have high blood pressure typically don't know it until their blood pressure is measured.

Sometimes people with markedly elevated blood pressure may develop:

headache ,

dizziness ,

blurred vision,

nausea and vomiting , and

chest pain and shortness of breath.

Exams/Tests

High Blood Pressure Diagnosis

Blood pressure is measured with a blood pressure cuff (sphygmomanometer). This may be done using a stethoscope and a cuff and gauge or by an automatic machine. It is a routine part of the physical examination and one of the vital signs often recorded for a patient visit. Other vital signs include pulse rate, respiratory rate (breathing rate), temperature, and weight.

When discussing blood pressure issues, the health care practitioner may ask questions about past medical history, family history, and medication use, including prescriptions, over-the-counter medications, herbal remedies, and food additives. Other questions may include lifestyle habits, including activity levels, smoking, alcohol consumption, and illegal drug use.

Physical examination may include listening to the heart and lungs, feeling for pulse in the wrist and ankles, and feeling and listening to the abdomen looking for signs of an enlarged aorta. Eye examination with an ophthalmoscope may be helpful by looking at the small blood vessels on the retina in the back of the eyeball.

Normal Blood Pressure

o Systolic less than 120 mm Hg; diastolic less than 80 mm Hg

Prehypertension

o Systolic 120-139 or diastolic 80-89 mm Hg

High Blood Pressure

o Stage 1: Systolic 140-159; diastolic 90-99 mm Hg

o Stage 2: Systolic more than 160; diastolic more than 100 mm Hg

Blood tests may be considered to assess risk factors for heart disease and stroke as well as looking for complications of hypertension. These include complete blood count (CBC), electrolytes, BUN (blood urea nitrogen), and creatinine and GFR (glomerular filtration rate) to measure kidney function. A fasting lipid profile will measure cholesterol and triglyceride levels in the blood. If appropriate, blood tests may be considered to look for an underlying cause of high blood pressure including abnormal thyroid or adrenal gland function.

Ultrasound of the kidneys, CT scan of the abdomen, or both may be done to assess damage or enlargement of the kidneys and adrenal glands.

Other studies may be considered depending upon the individual patient's needs

Electrocardiogram (ECG) may help evaluate heart rate and rhythm. It is a screening test to help assess heart muscle thickness. If hypertension is long-standing, the heart muscle has to hypertrophy, or get larger, to push blood against the increased pressure within the arteries of the body.

Echocardiogram is an ultrasound examination of the heart It is used to evaluate the anatomy and the function of the heart. A cardiologist is required to interpret this test and can evaluate the heart muscle and determine how thick it is, whether it moves appropriately, and how efficiently it can push blood out to the rest of the body. The echocardiogram can also assess heart valves, looking for narrowing (stenosis) and leaking (insufficiency or regurgitation). A chest X-ray may be used as a screening test to look for heart size, the shape of the aorta, and to assess the lungs

Doppler ultrasound is used to check blood flow through arteries at pulse points in your arms, legs, hands, and feet. This is an accurate way to detect peripheral vascular disease, which can be associated with high blood pressure. It also can measure blood flow in the arteries to both kidneys and sometimes depicts narrowings that can lead to high blood pressure in a minority of patients.

Treatment Options

Blood pressure control is a lifelong challenge. Hypertension can progress through the years, and treatments that worked earlier in life may need to be adjusted over time. Blood pressure control may involve a stepwise approach beginning with diet, weight loss, and lifestyle changes and eventually adding medications as required. In some situations, medications may be recommended immediately. As with many diseases, the health care practitioner and patient work together as a team to find the treatment plan that will work for that specific individual.

Osteoporosis

Osteoporosis causes bones to become weak and brittle — so brittle that a fall or even mild stresses like bending over or coughing can cause a fracture. Osteoporosis-related fractures most commonly occur in the hip, wrist or spine.

Bone is living tissue, which is constantly being absorbed and replaced. Osteoporosis occurs when the creation of new bone doesn't keep up with the removal of old bone.

Osteoporosis affects men and women of all races. But white and Asian women — especially those who are past menopause — are at highest risk. Medications, dietary supplements and weight-bearing exercise can help strengthen your bones.

Major Risk Factors associated with Osteoporosis

A number of factors can increase the likelihood that you'll develop osteoporosis — including your age, race, lifestyle choices, and medical conditions and treatments.

Unchangeable risksSome risk factors for osteoporosis are out of your control, including:

Your sex. Women are much more likely to develop osteoporosis than are men. Age. The older you get, the greater your risk of osteoporosis. Race. You're at greatest risk of osteoporosis if you're white or of Asian descent. Family history. Having a parent or sibling with osteoporosis puts you at greater risk,

especially if you also have a family history of fractures. Frame size. Men and women who have small body frames tend to have a higher risk

because they may have less bone mass to draw from as they age.

Hormone levelsOsteoporosis is more common in people who have too much or too little of certain hormones in their bodies. Examples include:

Sex hormones. The reduction of estrogen levels at menopause is one of the strongest risk factors for developing osteoporosis. Women may also experience a drop in estrogen during certain cancer treatments. Men experience a gradual reduction in testosterone levels as they age. And some treatments for prostate cancer reduce testosterone levels in men. Lowered sex hormone levels tend to weaken bone.

Thyroid problems. Too much thyroid hormone can cause bone loss. This can occur if your thyroid is overactive or if you take too much thyroid hormone medication to treat an underactive thyroid.

Other glands. Osteoporosis has also been associated with overactive parathyroid and adrenal glands.

Dietary factorsOsteoporosis is more likely to occur in people who have:

Low calcium intake. A lifelong lack of calcium plays a major role in the development of osteoporosis. Low calcium intake contributes to diminished bone density, early bone loss and an increased risk of fractures.

Eating disorders. People who have anorexia are at higher risk of osteoporosis. Low food intake can reduce the amount of calcium ingested. In women, anorexia can stop menstruation, which also weakens bone.

Weight-loss surgery. A reduction in the size of your stomach or a bypass of part of the intestine limits the amount of surface area available to absorb nutrients, including calcium.

Steroids and other medicationsLong-term use of corticosteroid medications, such as prednisone and cortisone, interferes with the bone-rebuilding process. Osteoporosis has also been associated with medications used to combat or prevent:

Seizures Depression Gastric reflux Cancer Transplant rejection

Lifestyle choicesSome bad habits can increase your risk of osteoporosis. Examples include:

Sedentary lifestyle. People who spend a lot of time sitting have a higher risk of osteoporosis than do their more-active counterparts. Any weight-bearing exercise is beneficial for your bones, but walking, running, jumping, dancing and weightlifting seem particularly helpful for creating healthy bones.

Excessive alcohol consumption. Regular consumption of more than two alcoholic drinks a day increases your risk of osteoporosis, possibly because alcohol can interfere with the body's ability to absorb calcium.

Tobacco use. The exact role tobacco plays in osteoporosis isn't clearly understood, but researchers do know that tobacco use contributes to weak bones.

Causal Factors

Your bones are in a constant state of renewal — new bone is made and old bone is broken down. When you're young, your body makes new bone faster than it breaks down old bone and your bone mass increases. Most people reach their peak bone mass by their early 20s. As people age, bone mass is lost faster than it's created.

How likely you are to develop osteoporosis depends partly on how much bone mass you attained in your youth. The higher your peak bone mass, the more bone you have "in the bank" and the less likely you are to develop osteoporosis as you age.

Signs & Symptoms

In the early stages of bone loss, you usually have no pain or other symptoms. But once bones have been weakened by osteoporosis, you may have osteoporosis signs and symptoms that include:

Back pain, caused by a fractured or collapsed vertebra Loss of height over time A stooped posture A bone fracture that occurs much more easily than expected

When to see a doctorYou may want to talk to your doctor about osteoporosis if you've:

Gone through early menopause Experienced a loss of height Had a bone break much more easily than expected Taken corticosteroids for a lengthy period of time Got a family history of osteoporosis

Exams/Tests

The most common test to measure bone density is dual energy X-ray absorptiometry (DXA). This procedure is quick, simple and gives accurate results. It painlessly measures the density of bones in your spine, hip and wrist — the areas most likely to be affected by osteoporosis.

Treatment Options

BisphosphonatesFor both men and women, the most widely prescribed osteoporosis medications are bisphosphonates. Examples include:

Alendronate (Fosamax) Risedronate (Actonel, Atelvia) Ibandronate (Boniva) Zoledronic acid (Reclast, Zometa)

Side effects include nausea, abdominal pain, difficulty swallowing, and the risk of an inflamed esophagus or esophageal ulcers. Injected forms of bisphosphonates don't cause stomach upset. And it may be easier to schedule a quarterly or yearly injection than to remember to take a weekly or monthly pill.

Long-term bisphosphonate therapy has been linked to a rare problem in which the upper thighbone cracks, but doesn't usually break completely. Bisphosphonates also have the potential to affect the jawbone. Osteonecrosis of the jaw is a rare condition occurring after a tooth extraction in which a section of jawbone dies and deteriorates.

Hormone-related therapyEstrogen, especially when started soon after menopause, can help maintain bone density. However, estrogen therapy can increase a woman's risk of blood clots, endometrial cancer, breast cancer and possibly heart disease.

Raloxifene (Evista) mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. Taking this drug may also reduce the risk of some types of breast cancer. Hot flashes are a common side effect. Raloxifene also may increase your risk of blood clots.

In men, osteoporosis may be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy can help increase bone density.

Less common osteoporosis medicationsIf you can't tolerate the more common treatments for osteoporosis — or if they don't work well enough — your doctor might suggest trying:

Teriparatide (Forteo). This powerful drug uses parathyroid hormone to stimulate new bone growth. It's given by injection under the skin. Long-term effects are still being studied, so therapy is recommended for two years or less.

Denosumab (Prolia, Xgeva). Compared to bisphosphonates, denosumab produces similar or better results while targeting a different step in the bone remodeling process. Denosumab is delivered via a shot under the skin every six months. The most common side effects are back and muscle pain.

Calcitonin, salmon (Fortical, Miacalcin). A substance produced by the thyroid gland, calcitonin reduces bone resorption and may slow bone loss. It's usually administered as a nasal spray and may cause nasal irritation in some people. It is the least effective of the available therapies.

Medications

Metoprolol

Class: Antianginals, antihypertensives (Therapeutic); Beta blockers (Pharmacologic)

Dose/Route: (Lopressor) 50 mg PO QAM 0900 hrs ; (Betaloc) 25 mg. PO QPM 1700 hrs

Indications: Hypertension, angina pectoris, prevention of MI (Myocardial Infarction), management of stable , symptomatic (class II or III) Ischemic , hypertensive, or cardiomyopathic origin

Unlabeled use: Ventricular arrhythmias/tachycardia, tremors,

Action: Blocks stimulation of beta (myocardial)-adrenergic receptors; decreases blood pressure, decreases heart rate

Interactions:

Drug-Drug: General anesthesia, IV phenytoin, and Virapamil may cause increased myocardial depression. Increased brachycardia may occur with Digoxin. Increased hypotension may occur with other antihypertensives, acute ingestion of alcohol, or nitrates.

Adverse reactions/Side effects:

CNS: fatigue, weakness, anxiety,depression, dizziness, drowsiness, insomnia, memory loss, MCS (mental status changes), nervousness, nightmares. EENT: blurred vision. RESP.: bronchospasm, wheezing. GI: constipation, diarrhea, dry mouth, flatulence, drug-induced hepatitis. CV: bradycardia, pulmonary edema, heartburn. Concurrent administration of thyroid preparations decreases effectiveness.

Levothyroxine (Synthroid)

Class: hormones (Therapeutic), thyroid preparations (Pharmacologic)

Dose/Route: 50 mcg (0.05 mg) P0 QD 0900 hrs

Indications: Thyroid supplementation in hypothyroidism. Treatment of suppression of wuthyroid goiters and thyroid cancer

Adverse reactions/Side effects: Usually only seen when excessive doses cause iatrogenic hyperthyroidism. CNS: nervousness, headache, insomnia, irritability. CV: angina pectoris, arrhythmias, hypotension, tachycardia. GI: cramps, diarrhea, vomiting, levothyroxine tablets, choking, gagging, dysphagia. Derm: hair loss (in children), sweating. Endo: hyperthyroidism, menstrual irregularities. Metab: heat intolerance, weight loss. MS: accelerated bone maturation in children.

Interactions:

Drug-Drug: Bile acid sequestrants and orlistat decrease absorption of orally administered thyroid preperations. May increase effects of warfarin. May increase requirement for insulin or oral hypoglycemic agents in diabetics. Concurrent estrogen therapy may increase thyroid replacement requirements. Increased cardiovascular effects with adrenergics (sympathomimetics).

Drug-Food: Foods or supplements containing calcium, iron, magnesium, or zinc may bind levothyroxine and prevent complete absorption.

Atrovastatin (Lipitor)

Class:

Dose/Route: 40 mg PO QD, 0900 hrs

Indications: High cholesterol

Adverse reactions/Side effects:

Felodipine ER (extended release)

Class: Antianginals, antihypertensives (Therapeutic), Calcium channel blockers (Pharmacologic)

Dose/Route: 10 mg. PO QD, 0900 hrs

Indications: Management of hypertension, angina pectoris, and vasospastic (Prinzmetal’s) angina

Interactions:

Drug-Drug: Additive hypotension may occur when used concurrently with fentanyl, other antihypertensives, nitrates, acute ingestion of alcohol, or quinidine

Adverse reactions/Side effects

CNS: headache, abnormal dreams, anxiety, confusion, dizziness, drowsiness, nervousness, psychiatric disturbances, weakness. EENT: blurred vision, disturbed equilibrium, tinnitus. Resp.: cough, dyspnea. CV: arrhythmias, CHF, peripheral edema, chest pain, tachycardia. GI: anorexia, dry mouth, constipation. GU: dysuria, nocturia, polyuria.

Tramacet (Acetaminophen /Tramadol)

Class: Acetaminophen- antipyretic, non-opioid analgesic, Tramadol- Analgesics (centrally acting)

Dose/Route: 1 tab: 325 mg. Acetaminophen/37.5 mg. Tramadol PO TID: 0900, 1700, 2100 hrs

Indications:

Acetaminophen: Mild pain, fever

Tramadol: Moderate to moderately severe pain

Interactions:

Drug-Drug:

Acetaminophen: Chronic high-dose acetaminophen (>2 g./day) may increase risk of bleeding with warfarin. Hepatotoxicity is additive with other hepatotoxic substances, including ETOH. NSAIDS increase the risk of adverse adrenal effects (avoid chronic concurrent use).

Tramadol: Increased risk of CNS depression when used concurrently with other CNS depressants. Increased risk seizures with high doses of penecillins, cephalosporins, phenothiazines, opioid analgesics, or antidepressants.

Adverse reactions/Side effects:

Acetaminophen: GI: hepatic failure, hepatotoxicity (overdose). GU: renal failure. Hemat: neutropenia, pancytopenia, leucopenia. Derm: rash, urticaria

Tramadol: CNS: seizures, dizziness, headache, somnolence, anxiety, CNS stimulation, confusion, malaise. EENT: visual disturbances. CV: vasodilation. Derm: sweating. Neuro: hypertonia.

Citalopram (Celexa)

Class: Antidepressants (Therapeutic), Selective serotonin reuptake inhibitors (SSRIs).

Dose/Route: 20 mg. PO QD, 0900

Indications: Depression

Interactions:

Drug-Drug: MAO inhibitors

Adverse reactions/Side effects: CNS: neuroleptic malignant syndrome, suicidal thoughts, apathy, confusion, drowsiness, insomnia, weakness, agitation, amnesia, anxiety, decreased libido, dizziness, fatigue, impaired concentration, increased depression, migraine headache

Baclofen (Lioseral)

Class: Antispasticity agents, skeletal muscle relaxants (centrally acting).

Dose/Route: 10 mg. PO QD, QHS 2100 hrs

Indications: PO: Treatment of reversible spasticity due to multiple sclerosis or spinal cord lesions. IT: Treatment of severe spasticity originating in the spinal cord. Unlabeled use: Management of pain in trigeminal neuralgia.

Interactions:

Drug-Drug: Increased CNS depression with other CNS depressants

Drug-Natural Products: Concomitant use of kava-kava, valerian, or chamomile can increase CNS depression.

Adverse reactions/Side effects: CNS: seizures, dizziness, drowsiness, fatigue, depression. EENT: tinnitus, nasal congestion. CV: edema, hypotension. GI: Nausea. Derm: pruritis, rash. Metab.: hyperglycemia, weight gain. Neuro: ataxia

Ferrous fumerate (33% elemental iron) Palafer

Class: Antianemics (Therapeutic), Iron supplements (Pharmacologic).

Dose/Route: 300 mg. PO QHS, 2100 hrs

Indications: prevention/treatment of iron-deficiency anemia

Interactions:

Drug-Drug: Oral iron supplmenents decrease absorption of tetracyclines, bisphosphonates, fluoroquinolones, levothyroxine.

Drug-Food: Iron absorption is decreased 33-50% by concurrent administration of food.

Adverse reactions/Side effects: PO, GI: constipation, dark stools, diarrhea, epigastric pain.

Lab Values

Neutrophils: 6.59 (high)

Lymphocytes: 0.87 (low)

Monocytes: 0.81 (high)

INR: 5.8 (high)

Sodium: 132 (low)

Chloride: 96 (low)

Urea level: 11.5 (high)

Nursing Diagnoses (NANDA):

*Tissue perfusion, ineffective, renal, risk for: at risk for a decrease in blood circulation to the kidney that may compromise health

Disuse syndrome, risk for: at risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity

Nursing Interventions:

Assess vital signs bid; with careful attention to BP & HR; follow drug protocol for cardiac meds

Encourage patient to mobilize and perform ROM exercise as tolerated- adjust for right side weakness

Instruct client to avoid intake of gas-forming foods (e.g. beans, cauliflower, cabbage, onions), carbonated beverages, and large meals in order to prevent gastric distention and additional pressure on the diaphragm

Assess level, nature, and location of pain, i.e. what is the nature/level of pain/sensation on the side affected by the CVA?

Report & document pertinent information to appropriate member of health care team, in relation to affects of recently suffered CVA

Note evidence of hemi -paralysis/weakness on side affected by CVA

Provide support for stroke affected side and assess physiological changes frequently

Perform regular strength tests in order to assess loss of function on side affected by CVA (i.e. have patient grip my hand or attempt to raise legs/arms

Follow bowel care protocol as directed (Physician’s order)

Elevate right heel (and other bony prominences) in order to prevent skin breakdown/ development of decibutis ulcers

Monitor intake/output- (careful attention to insufficient intake)

References

Mayo Clinic. 2011. Retrieved from http://www.mayoclinic.com/health/osteoporosis/DS00128/DSECTION=treatments-and-drugs

NANDA. (2012). Nanda nursing diagnosis. Retrieved from http://www.fchs.ac.ae/fchs/uploads/Files/Semester%201%20-%202011-2012/NANDA%20group%20list.pdf