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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Adrienne Ruth Barnosky, DO
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A pH sensor enteral tube is available which does not require fluid aspirate to obtain pH values; it can be useful in distinguishing gastric from small bowel placement of the tube medications given for uti clozaril 100 mg lowest price. The pH method is less helpful with continuous feedings symptoms walking pneumonia generic clozaril 100mg overnight delivery, because tube feedings have a pH value of 6 medicine quest order 100mg clozaril free shipping. Studies suggest that aspiration may be performed more easily with polyurethane tubes and tubes with a size 10 Fr diameter symptoms 3 weeks into pregnancy cheap clozaril 50 mg online. If step 2 is ineffective, insufflate another 20 mL of air and replace the large syringe with a smaller one (12 mL); attempt to aspirate. The prepared area is covered with a strip of hypoallergenic tape or Op-site; the tube is then placed over the tape and secured with a second piece of tape. This keeps the tube from dislodging when the patient moves but still allows it to pass into the intestine. Instead of tape, a feeding tube attachment device (Hollister) can be used to secure the tube. This device adheres to the nose and uses an adjustable clip to hold the tube in place. After the nasoenteric tube has progressed into the intestine (after approximately 24 hours), the tube may be taped in place. The nurse measures the exposed tube length every shift and compares it with the original measurement. An increase in the length of exposed tube may indicate dislodgement, or a leaking or ruptured balloon if the tube has a balloon. Pleural fluid is usually pale yellow and serous, and tracheobronchial secretions are usually tan or off-white mucus. Researchers suggest that the appearance of the aspirate may be helpful in distinguishing between gastric and intestinal placement but is of little value in ruling out respiratory placement. This method is less helpful when the patient is receiving continuous Advancing the Nasoenteric Decompression Tube After the tube has passed through the pyloric sphincter, it may be advanced 5 to 7. To enable gravity and peristalsis to assist in the passage of the tube, the patient is generally asked to lie in the following positions in this order: on the right side for 2 hours, on the back for 2 hours, and then on the left side for 2 hours. The tube is irrigated with normal saline solution every 6 to 8 hours to prevent blockage. Purpose Although a wide variety of methods have been used to assess feeding tube location at the bedside, pH testing of aspirate has been found to be the most reliable in differentiating between gastric and respiratory placement of the tube and between gastric and intestinal placement of the tube. However, it is not reliable in distinguishing intestinal from respiratory fluids, because both of these fluids are alkaline. One new method that is being studied to distinguish these fluids is testing the tube aspirate for bilirubin, which is normally found in intestinal fluids but not in respiratory fluids. Results were read by research assistants and staff nurses, who were blinded to (unaware of) the source or type of specimens. A pH reading greater than 5 and a bilirubin reading lower than 5 mg/dL accurately identified 100% of the respiratory specimens. A pH of 5 or less and a bilirubin concentration lower than 5 mg/dL accurately identified 98% of the gastric specimens. Approximately 88% of the specimens with a pH greater than 5 and a bilirubin value of 5 mg/dL or higher were intestinal specimens. Food and Drug Administration for this purpose, further refinements are required to make sure that the most accurate readings can be made. Any question about correct tube placement should be investigated, and placement should be confirmed by x-ray studies whenever indicated. Chapter 36 Gastrointestinal Intubation and Special Nutritional Modalities 991 excessively dry, steam or cool vapor inhalations may be beneficial. Throat lozenges, an ice collar, chewing gum, or sucking on hard candies (if permitted), and frequent movement also assist in relieving patient discomfort. These activities keep the mucous membranes moist and help prevent inflammation of the parotid glands. Symptoms of fluid volume deficit include dry skin and mucous membranes, decreased urinary output, lethargy, and decreased body temperature. Assessment of fluid volume deficit involves maintaining an accurate record of intake and output. Laboratory values, particularly blood urea nitrogen and creatinine, are monitored. Medications (antacids, simethicone, and metoclopramide) are administered to decrease potential problems. Signs and symptoms of complications include coughing during the administration of foods or medications, difficulty clearing the airway, tachypnea, and fever. Assessment includes regular auscultation of lung sounds and routine assessment of vital signs. It is important to encourage the patient to cough and to take deep breaths regularly. The nurse also carefully confirms the proper placement of the tube before instilling any fluids or medications. The nostrils, oral mucosa, esophagus, and trachea are susceptible to irritation and necrosis. Visible areas are inspected frequently, and the adequacy of hydration is assessed. When providing oral hygiene, the nurse carefully inspects the mucous membranes for signs of irritation or excessive dryness. The nurse palpates the area around the parotid glands to detect any tenderness or enlarged nodes, indicating parotitis, and observes for any skin or mucous membrane irritation or necrosis. In addition, it is important to assess the patient for esophagitis and tracheitis; symptoms include sore throat and hoarseness. If it is used for enteral nutrition, the end of the tube is plugged between feedings. The nurse confirms tube placement before any fluids or medications are instilled and once a shift for continuous feedings. Displacement of the tube may be caused by tension on the tube (when the patient moves around in the bed or room), coughing, tracheal or nasotracheal suctioning, or airway intubation. It is important to keep an accurate record of all fluid intake, feedings, and irrigation. To maintain patency, the tube is irrigated every 4 to 6 hours with normal saline to avoid electrolyte loss through gastric drainage. When double- or triple-lumen tubes are used, each lumen is labeled according to its intended use: aspiration, feeding, or balloon inflation. Providing Oral and Nasal Hygiene Regular and conscientious oral and nasal hygiene is a vital part of patient care, because the tube causes discomfort and pressure and may be in place for several days. Moistened cotton-tipped swabs can be used to clean the nose, followed by cleansing with a watersoluble lubricant. The nasal tape is changed every 2 to 3 days, and the nose is inspected for skin irritation. Before the tube is removed, it is flushed with 10 mL of normal saline to ensure that it is free of debris and away from the gastric lining; then the balloon (if present) is deflated. A nasointestinal tube is withdrawn at intervals of 10 minutes until the end reaches the esophagus. If the tube does not come out easily, force should not be used, and the problem should be reported to the physician. As the tube is withdrawn, it is concealed in a towel, because the sight of it may be unpleasant to the patient. Fluid balance is maintained by osmosis, the process by which water moves through membranes from a dilute solution of lower osmolality (ionic concentration) to a more concentrated solution of higher osmolality until both solutions are of nearly equal osmolality. The body attempts to keep the osmolality of the contents of the stomach and intestines at approximately this level. Highly concentrated solutions and certain foods can upset the normal fluid balance in the body. Individual amino acids and carbohydrates are small particles that have great osmotic effect. Fats are not water-soluble and do not enter into a solution in water; thus, they have no osmotic effect. When a concentrated solution of high osmolality is taken in large amounts, water will move to the stomach and intestines from fluid surrounding the organs and the vascular compartment.
When faced with any life-threatening illness symptoms celiac disease clozaril 100mg line, spiritual and existential concerns usually surface treatment tinnitus discount 100 mg clozaril free shipping. Patients with breast cancer often express the need to talk about the uncertainties of their future and their hope and faith that they will be able to manage whatever crisis or challenge comes their way symptoms of strep cheap clozaril 50 mg on line. Purpose While the incidence of cancer is highest in women over 65 years of age symptoms influenza 100mg clozaril with amex, the highest survival rates also occur in this group, with a survival rate of 97% for localized breast cancer. Thus, the purpose of this study was to describe the different meanings of cancer for older women who were long-term survivors of breast cancer. Study Sample and Design A descriptive qualitative study was conducted to explore the experience of long-term survivors of breast cancer. The sample comprised eight women whose survival following treatment for breast cancer ranged from 5. Four of the women had lumpectomy with radiation and chemotherapy, and one had lumpectomy with radiation only as her treatment. Three women had undergone mastectomy and one of them had received oral chemotherapy. Two of the women had positive axillary lymph nodes, and they had lumpectomy combined with radiation and chemotherapy. Interviews lasting 60 to 90 minutes were conducted with the women in their homes; three life history interviews were conducted with each woman and audiotaped. Findings Three meanings of cancer emerged from the data: cancer as sickness and death, cancer as an obstacle, and cancer as transforming. Cancer as sickness and death was the initial perspective of the women at the time of diagnosis and during the early phases of their treatment. They viewed their cancer treatment as past and moved on to renewing their interactions with their surroundings. Nursing Implications Nurses need a better understanding of and sensitivity to the experience of women with breast cancer as they move beyond their disease and its treatment. By asking open-ended questions, the nurse can help women explore their experience so they can begin to shift their view of breast cancer from an experience of sickness and death to a surmountable challenge. The potent hormones released during pregnancy (1,000 times greater than those during a menstrual cycle) stimulate changes in breast tissue (Gemignani & Petrek, 1999). If a mass is found during pregnancy, ultrasound is the preferred diagnostic method because it involves no exposure to radiation, although mammography with appropriate shielding, fine-needle aspiration, and biopsy may also be indicated. Treatment is basically the same as in other women, although radiation is contraindicated in pregnancy. Some oncologists begin chemotherapy as early as the 16th week of pregnancy because fetal organs are already formed at this point. If systemic treatment is necessary, a cesarean section may be performed as soon as maturation of the fetus allows. If aggressive disease is detected early in pregnancy and chemotherapy is advised, termination of the pregnancy is an issue that some patients must face. If a mass is found while a woman is breastfeeding, she is urged to stop breastfeeding to allow the breast to involute (return to its baseline state) before any type of surgery is performed. Chapter 48 Assessment and Management of Patients With Breast Disorders 1469 After a woman has completed treatment for breast cancer, she may consider having children. Although recommendations vary, most women are advised to wait 2 years before becoming pregnant after completing treatment for breast cancer. Most retrospective studies indicate that pregnancy after treatment for breast cancer does not appear to increase the risk of the disease recurring (Gemignani & Petrek, 1999); however, prospective studies are needed to confirm this. Counseling, providing accurate information, and active listening and caring are important nursing interventions when patients are involved in making difficult personal decisions about treatment options, childbearing, or termination of pregnancy. Pertinent questions include the following: How is the patient responding to the diagnosis? Planning and Goals the major goals for the patient may include increased knowledge about the disease and its treatment; reduction of preoperative and postoperative fears, anxiety, and emotional stress; improvement of decision-making ability; pain management; maintenance of skin integrity; improved self-concept; improved sexual function; and the absence of complications. In view of the usually overwhelming emotional reactions to the diagnosis, the patient must be given time to absorb the significance of the diagnosis and any information that will help her to evaluate treatment options. The nurse caring for the woman who has just received a diagnosis of breast cancer needs to be knowledgeable about current treatment options and able to discuss them with the patient. The nurse should be aware of the information that has been given to the patient by the physician. Information about the surgery, the location and extent of the tumor, and postoperative treatments involving radiation therapy and chemotherapy are details that the patient needs to enable her to make informed decisions. As appropriate, the nurse discusses with the patient medications, the extent of treatment, management of side effects, possible reactions after treatment, frequency and duration of treatment, and treatment goals. Methods to compensate for physical changes related to mastectomy (eg, prostheses and plastic surgery) are also discussed and planned. Patients who have lost close relatives to breast cancer (or any cancer) may have difficulty coping with the possible diagnosis of breast cancer because memories of loss and death can emerge during their own crisis. If she will undergo a mastectomy, information about various resources and options is provided. Such services include prostheses, reconstructive surgery, and groups such as Reach to Recovery. The nurse provides anticipatory teaching and counseling at each stage of the process and identifies the sensations that can be expected during additional diagnostic procedures. The patient is introduced to other members of the oncology team (eg, radiation oncologist, medical oncologist, oncology nurse, and social worker) and is acquainted with the role of each in her care. After the treatment plan has been established, the nurse needs to promote preoperative physical, psychological, social, and nutritional well-being. Some women find it helpful and reassuring to talk to a breast cancer survivor, someone who has completed treatment and has been trained as a volunteer to talk with newly diagnosed patients. Careful guidance and supportive counseling are the interventions the nurse can use to help such a patient. Also, encouraging the patient to take one step of the treatment process at a time can be helpful. The advanced practice nurse or oncology social worker can be helpful for patients and family members in discussing some of the personal issues that may arise in relation to treatment. Some patients may need a mental health consultation before surgery to assist them in coping with the diagnosis and impending treatment. Such patients may have had a history of psychiatric problems or demonstrate behavior that leads the surgeon or nurse to initiate a referral to the psychiatrist, psychologist, or psychiatric clinical nurse specialist. Patients should be encouraged to take analgesic agents (opioid or nonopioid analgesic medications such as acetaminophen) before exercises or at bedtime and also to take a warm shower twice daily (usually allowed on the second postoperative day) to alleviate the discomfort that comes from referred muscle pain. A particular concern is preventing fluid from accumulating under the chest wall incision or in the axilla by maintaining the patency of the surgical drains. The dressings and drains should be inspected for bleeding and the extent of drainage monitored regularly. If a hematoma develops, it usually occurs within the first 12 hours after surgery; thus, monitoring the incision is important. A hematoma could cause necrosis of the surgical flaps, although this complication is rare in breast surgery patients. If either of these complications occurs, the surgeon should be notified, and the patient should have an Ace wrap placed around the incision and an ice pack applied. Initially, the fluid in the surgical drain appears bloody, but it gradually changes to a serosanguinous and then a serous fluid during the next several days. The drain is usually left in place for 7 to 10 days and is then removed after the output is less than 30 mL in a 24-hour period. The patient is discharged home with the drains in place; therefore, teaching of the patient and family is important to ensure correct management of the drainage system (Chart 48-6). Dressing changes present an opportunity for the nurse and patient to discuss the incision, particularly how it looks and feels and the progressive changes in its appearance. The nurse explains the care of the incision, sensations to expect, and the possible signs and symptoms of an infection. Generally, the patient may shower on the second postoperative day and wash the incision and drain site with soap and water to prevent infection. The patient needs to know that sensation is decreased in the operative area because the nerves were disrupted during surgery and that gentle care is needed to avoid injury. After the incision is completely healed (usually 4 to 6 weeks), lotions or creams may be applied to the area to increase skin elasticity.
Study Sample and Design Two primary health care clinics located in different regions of the United States were used symptoms of anxiety generic clozaril 50mg with visa. One clinic used a conservative treatment protocol; the other used the active physical rehabilitation protocol symptoms kidney buy clozaril 25 mg with visa. Charts of patients with the appropriate diagnostic code (ie medications covered by medi cal clozaril 100 mg low cost, low-back strain) were reviewed for inclusion criteria (eg medications used to treat schizophrenia buy generic clozaril 100mg, adult age, first-time work-related injury of the back). The convenience sample consisted of two groups of patients (18 patients in each group). The mean number of days off from work was cal- culated for each of the two treatment groups and compared using the t test for independent groups to answer the research question: Do patients with a clinical diagnosis of low back pain differ in their responses to two sets of treatment protocols as measured by number of days absent from work? However, employer costs, including monetary outlay for exercise therapy and loss of productivity due to number of days off from work, were not considered in this study. Nursing Implications the findings suggest that active physical rehabilitation may be more effective than conservative treatment; however, additional studies are needed to replicate the findings and should include a cost-benefit analysis and random assignment of subjects. Additional studies are warranted to determine effectiveness of health promotion programs before back injury occurs. The nurse instructs the patient in the safe and correct way to lift objects-using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles. With feet placed to provide a wide base of support, the patient should bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion, avoiding twisting and jerking. To prevent recurrence of acute low back pain, the nurse may instruct the patient to wear a back support when repeated lifting is required and to avoid lifting more than one third of his or her weight without help. Practicing these protective and defensive postures, positions, and body mechanics results in natural strengthening of the back and diminishes the chance that back pain will recur. Dependency may continue beyond physiologic needs and become a way to fulfill psychosocial needs. Assisting both the patient and support people to recognize continued dependency helps the patient identify and cope with the underlying reason for the dependency. Role-related responsibilities may have been modified with the onset of low back pain. As recovery from acute low back pain and immobility progresses, the patient may resume former rolerelated responsibilities. If these activities contributed to the development of low back pain, however, it may be difficult to resume them without chronic low back pain syndrome, with associated disability and depression resulting. If the patient experiences secondary gains associ- Proper and improper standing postures. This person is using the long and strong muscles of the arms and legs and holding the object so that the line of gravity falls within the base of support. The patient may need help in coping with specific stressors and in learning how to control stressful situations. When people successfully deal with stress, they develop confidence in their abilities to manage other stressful situations. Psychotherapy or counseling may be needed to assist the person in resuming a full, productive life. Back clinics use multidisciplinary approaches to help the patient with pain and with resumption of role-related responsibilities. Exercises are less effective and more difficult to perform when the patient is overweight. Weight reduction is based on a sound nutritional plan that includes a change in eating habits to maintain desirable weight. Monitoring weight reduction, noting achievement, and providing encouragement and positive reinforcement facilitate adherence. Chart 68-3 Health Promotion Activities to Promote a Healthy Back Standing Avoid prolonged standing and walking. Lifting When lifting, keep the back straight and hold the load as close to the body as possible. Obtains relief through use of physical modalities, psychological techniques, and medications d. The patient experiences pain, shoulder tenderness, limited movement, muscle spasm, and atrophy. The syndrome is commonly caused by repetitive hand activities but may be associated with arthritis, hypothyroidism, or pregnancy. The patient experiences pain, numbness, paresthesia, and possibly weakness along the median nerve (thumb and first two fingers). Specific yoga postures, relaxation, and acupuncture may provide nontraditional alternatives to relieve carpal tunnel symptoms. Traditional or endoscopic laser surgical release of the transverse carpal ligament may be necessary. Full recovery of motor and sensory function after nerve release surgery may take several weeks or months. Common Problems of the Upper Extremity the structures in the upper extremity are frequently the sites of painful syndromes. Bursae are fluid-filled sacs that prevent friction between joint structures during joint activity. The inflammation causes proliferation of synovial membrane and pannus formation, which restricts joint movement. Patient education includes the following points: During the acute phase, rest the joint in a position that minimizes stress on the joint structures, to prevent further damage and the development of adhesions. These fragments interfere with joint movement, locking the joint, and cause painful movement. Planning and Goals the goals of the patient may include relief of pain, improved selfcare, and absence of infection. It is caused by an inherited autosomal dominant trait and occurs most frequently in men who are older than 50 years of age and who are of Scandinavian or Celtic origin. The nodule may not change, or it may progress so that the fibrous thickening extends to involve the skin in the distal palm and produces a contracture of the fingers. The patient may experience dull aching discomfort, morning numbness, cramping, and stiffness in the affected fingers. This condition starts in one hand, but eventually both hands are affected symmetrically. With contracture development, palmar and digital fasciectomies are performed to improve function. The nurse compares the affected hand with the unaffected hand and the postoperative status with the documented preoperative status. The nurse asks the patient to describe the sensations in the hands and to demonstrate finger mobility. With tendon repairs and nerve, vascular, or skin grafts, motor function is tested only if prescribed. If the patient is ambulatory, the arm is elevated in a conventional sling with the hand at heart level. Intermittent ice packs to the surgical area during the first 24 to 48 hours may be prescribed to control swelling. Unless contraindicated, active extension and flexion of the fingers to promote circulation are encouraged, even though movement is limited by the bulky dressing. The patient may need to arrange for assistance with feeding, bathing and hygiene, dressing, grooming, and toileting. The nurse encourages use of the involved hand, unless contraindicated, within the limits of discomfort. The nurse teaches the patient to monitor temperature and signs and symptoms that suggest an infection. It also is important to instruct the patient to keep the dressing clean and dry and to report any drainage, foul odor, or increased pain and swelling. Patient education includes aseptic wound care as well as education related to prescribed prophylactic antibiotics. In addition, the nurse teaches the patient to elevate the hand above the elbow and to apply ice (if prescribed) to control swelling.
Of all the agents that have been used to treat chronic type B viral hepatitis medicine quiz order 25 mg clozaril with amex, alpha interferon as the single modality of therapy offers the most promise treatment 7th feb cardiff cheap clozaril 50 mg on line. This regimen of 5 million units daily or 10 million units three times weekly for 4 to 6 months results in remission of disease in approximately one third of patients (Befeler & Di Bisceglie symptoms flu buy 100 mg clozaril fast delivery, 2000) stroke treatment 60 minutes cheap clozaril 50 mg without a prescription. Interferon must be administered by injection and has significant side effects, including fever, chills, anorexia, nausea, myalgias, and fatigue. Late side effects are more serious and may necessitate dosage reduction or discontinuation. These include bone marrow suppression, thyroid dysfunction, alopecia, and bacterial infections. Two antiviral agents (lamivudine [Epvir] and adefovir [Hepsera]) oral nucleoside analogs, have been approved for use in Chapter 39 Assessment and Management of Patients With Hepatic Disorders 1099 chronic hepatitis B in the United States. Viral resistance may be an issue with these agents, and studies of their effectiveness alone and in combination with other therapies are ongoing (Befeler & Di Bisceglie, 2000). Bed rest may be recommended, regardless of other treatment, until the symptoms of hepatitis have subsided. Activities are restricted until the hepatic enlargement and elevated levels of serum bilirubin and liver enzymes have disappeared. Measures to control the dyspeptic symptoms and general malaise include the use of antacids and antiemetics, but all medications should be avoided if vomiting occurs. Nursing Management Convalescence may be prolonged, with complete symptomatic recovery sometimes requiring 3 to 4 months or longer. During this stage, gradual resumption of physical activity is encouraged after the jaundice has resolved. The nurse identifies psychosocial issues and concerns, particularly the effects of separation from family and friends if the patient is hospitalized during the acute and infective stages. Even if not hospitalized, the patient will be unable to work and must avoid sexual contact. Planning that includes the family helps to decrease their fears and anxieties about the spread of the disease. Because of the prolonged period of convalescence, the patient and family must be prepared for home care. The nurse informs family members and friends who have had intimate contact with the patient about the risks of contracting hepatitis B and makes arrangements for them to receive hepatitis B vaccine or hepatitis B immune globulin as prescribed. Those at risk must be aware of the early signs of hepatitis B and of ways to reduce risk to themselves by avoiding all modes of transmission. Because of the risk of transmission through sexual intercourse, strategies to prevent exchange of body fluids are advised, such as abstinence or the use of condoms. The nurse emphasizes the importance of keeping follow-up appointments and participating in other health promotion activities and recommended health screenings. There are approximately 35,000 new cases of hepatitis C in the United States each year. The highest prevalence of hepatitis C is in adults 40 to 59 years of age, and in this age group its prevalance is highest in African Americans. There are 10,000 to 12,000 deaths each year in the United States due to hepatitis C; it has been suggested that these are underestimates. The clinical course of acute hepatitis C is similar to that of hepatitis B; symptoms are usually mild. A chronic carrier state occurs frequently, however, and there is an increased risk of chronic liver disease, including cirrhosis or liver cancer, after hepatitis C. Small amounts of alcohol taken regularly appear to encourage progression of the disease. Therefore, alcohol and medications that may affect the liver should be avoided (Chart 39-9). Recent studies have demonstrated that a combination of interferon (Intron-A) and ribavirin (Rebetol), two antiviral agents, is effective in producing improvement in patients with hepatitis C and in treating relapses. Hemolytic anemia, the most frequent side effect, may be severe enough to require discontinuation of treatment. Pegylated interferon (Pegasys) is now available (Lauer & Walker, 2001; Sheffield et al. Screening of blood has reduced the incidence of hepatitis associated with blood transfusions, and public health programs are helping to reduce the number of cases associated with shared needles in illicit drug use. Because the virus requires hepatitis B surface antigen for its replication, only individuals with hepatitis B are at risk for hepatitis D. Sexual contact with those with hepatitis B is considered to be an important mode of transmission of hepatitis B and D. The incubation period varies between 21 and 140 days (Bacon & Di Bisceglie, 2000). The symptoms of hepatitis D are similar to those of hepatitis B, except that patients are more likely to develop fulminant hepatitis and to progress to chronic active hepatitis and cirrhosis. Treatment is similar to that of other forms of hepatitis; interferon as a specific treatment for hepatitis D is under investigation. Obtaining a history of exposure to hepatotoxic chemicals, medications, or other agents assists in early treatment and removal of the offending agent. Anorexia, nausea, and vomiting are the usual symptoms; jaundice and hepatomegaly are noted on physical assessment. Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure (discussed below) unless he or she receives a liver transplant. Therapy is directed toward restoring and maintaining fluid and electrolyte balance, blood replacement, and comfort and supportive measures. A few patients recover from acute toxic hepatitis only to develop chronic liver disease. Avoiding contact with the virus through good hygiene, including hand washing, is the major method of prevention of hepatitis E. The effectiveness of immune globulin in protecting against hepatitis E virus is uncertain. Manifestations of sensitivity to a medication may occur on the first day of its use or not until several months later, depending on the medication. Usually the onset is abrupt, with chills, fever, rash, pruritus, arthralgia, anorexia, and nausea. However, reactions may be severe and even fatal, even though the medication is stopped. If fever, rash, or pruritus occurs from any medication, its use should be stopped immediately. Although any medication can affect liver function, use of acetaminophen (found in many over-the counter medications used to treat fever and pain) has been identified as the leading cause of acute liver failure (Ostapowicz, Fontana, Schiodt, et al. Others commonly associated with liver injury include but are not limited to anesthetic agents, medications used to treat rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsants, and anti-tuberculosis agents. Inhalational agents of the halothane family (halokanes) are metabolized by the liver and excreted in bile. Halothane hepatitis is a dreaded but rare complication of halothane administration. Because it undergoes little hepatic metabolism, isoflurane is considered the anesthetic agent of choice in patients with liver disease (Bacon & Di Bisceglie, 2000). Although its efficacy is uncertain, a short course of high-dose corticosteroids may be used in patients with severe hypersensitivity. Liver transplantation is an option for drug-induced hepatitis, but outcomes may not be as successful as with other causes of liver failure. The incubation period for post-transfusion hepatitis is 14 to 145 days, too long for hepatitis B or C. In the United States, about 5% of chronic liver disease remains cryptogenic (does not appear to be autoimmune or viral in origin), and half the patients have previously received transfusions. Management of Patients With Nonviral Hepatic Disorders Certain chemicals have toxic effects on the liver and when taken by mouth, inhaled, or injected parenterally produce acute liver cell necrosis, or toxic hepatitis. The chemicals most commonly implicated in this disease are carbon tetrachloride, phosphorus, chloroform, and gold compounds.
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