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Pharmacology for Nurses: A Pathophysiologic Approach PDF

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Pharmacology for Nurses A01_ADAM8334_06_SE_FM.indd 1 18/01/2019 22:38 This page intentionally left blank A01_THOM6233_05_SE_WALK.indd 9 1/13/17 6:50 PM Sixth Edition Pharmacology for Nurses A Pathophysiologic Approach Michael Patrick Adams Adjunct Professor of Anatomy and Physiology Hillsborough Community College Formerly Dean of Health Professions Pasco-Hernando State College Leland Norman Holland, Jr. Professor Hillsborough Community College Polk State College Carol Quam Urban Associate Dean for Practice and Strategic Initiatives Associate Professor College of Health and Human Services George Mason University A01_ADAM8334_06_SE_FM.indd 3 18/01/2019 22:38 Executive Portfolio Manager: Pamela Fuller Director, Digital Studio: Amy Peltier Development Editor: Teri Zak Digital Producer: Jeff Henn Portfolio Management Assistant: Taylor Scuglik Full-Service Vendor: Pearson CSC Vice President, Content Production and Digital Studio: Full-Service Project Management: Pearson CSC, Dan Knott Paul DeLuca Manufacturing Buyer: Maura Zaldivar-Garcia, LSC Managing Producer Health Science: Melissa Bashe Communications, Inc. 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Copyright © 2020, 2017, 2014, 2011, and 2008 by Pearson Education, Inc., or its affiliates. 221 River Street, Hoboken, NJ 07030. All Rights Reserved. Printed in the United States of America. This publication is protected by copyright, and permission should be obtained from the publisher prior to any prohibited reproduction, storage in a retrieval system, or transmission in any form or by any means, electronic, mechanical, photocopying, record- ing, or otherwise. For information regarding permissions, request forms and the appropriate contacts within the Pearson Education Global Rights & Permissions Department, please visit www.pearsoned.com/permissions/ Unless otherwise indicated herein, any third-party trademarks that may appear in this work are the property of their respective owners and any references to third-party trademarks, logos or other trade dress are for demon- strative or descriptive purposes only. Such references are not intended to imply any sponsorship, endorsement, authorization, or promotion of Pearson’s products by the owners of such marks, or any relationship between the owner and Pearson Education, Inc. or its affiliates, authors, licensees, or distributors. Notice: Care has been taken to confirm the accuracy of information presented in this book. The authors, editors, and the publisher, however, cannot accept any responsibility for errors or omissions or for consequences from application of the information in this book and make no warranty, express or implied, with respect to its contents. The authors and publisher have exerted every effort to ensure that drug selections and dosages set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug ther- apy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Library of Congress Cataloging-in-Publication Data Names: Adams, Michael, 1951- , author. | Holland, Leland Norman, 1957- , author. | Urban, Carol Q. (Carol Quam), author. Title: Pharmacology for nurses : a pathophysiologic approach / Michael Patrick Adams, Leland Norman Holland, Jr., Carol Quam Urban. Description: Sixth edition. | Hoboken, N.J. : Pearson, [2020] | Includes bibliographical references and index. Identifiers: LCCN 2019000512| ISBN 9780135218334 | ISBN 0135218330 Subjects: | MESH: Drug Therapy | Pharmacological Phenomena | Pharmacology | Nurses Instruction Classification: LCC RM301 | NLM WB 330 | DDC 615/.1--dc23 LC record available at https:// lccn.loc.gov/2019000512 ISBN-10: 0-13-521833-0 1 19 ISBN-13: 978-0-13-521833-4 A01_ADAM8334_06_SE_FM.indd 4 28/01/2019 22:23 About the Authors MICHAEL PATRICK ADAMS, PHD, is an accomplished ed- was on the faculty of Lansing Community College and ucator, author, and national speaker. The National Institute St. Petersburg College, and served as Dean of Health Pro- for Staff and Organizational Development in Austin, Texas, fessions at Pasco-Hernando State College for 15 years. He named Dr. Adams a Master Teacher. He has published two is currently Adjunct Professor of Biological Sciences at other textbooks with Pearson Publishing: Core Concepts in Hillsborough Community College. Pharmacology and Pharmacology: Connections to Nursing Practice. Dr. Adams obtained his master’s degree in pharmacol- I dedicate this book to nursing educators, who contribute every ogy from Michigan State University and his doctorate in day to making the world a better and more caring place. education from the University of South Florida. Dr. Adams —MPA LELAND NORMAN HOLLAND, JR., PHD (NORM), over subjects, such as microbiology, biological chemistry, and 25 years ago, started out like many scientists, planning for pharmacology. Dr. Holland’s doctoral degree is in medical a career in basic science research. He was quickly drawn to pharmacology. He is very much dedicated to the success of the field of teaching in higher medical education, where he students and their preparation for careers in health care. has spent most of his career. Among the areas where he has He continues to motivate students in the lifelong pursuit been particularly effective are preparatory programs in of learning. nursing, medicine, dentistry, pharmacy, and allied health. Dr. Holland is both a professor and supporter in nursing To the greatest family in the world: Karen, Alexandria, Caleb, education nationwide. He brings to the profession a depth and Joshua. of knowledge in biology, chemistry, and medically related —LNHII CAROL QUAM URBAN, PHD, RN, Associate Professor, is interdisciplinary teamwork. She has co-authored the the Associate Dean for Practice and Strategic Initiatives in Pearson textbook Pharmacology: Connections to Nursing the College of Health and Human Services at George Mason Practice with Dr. Adams. University in Fairfax, Virginia. Teaching in the School of Nursing for over 25 years, and most recently in the position To my daughter, Joy, an extraordinary pediatric hematology-oncology of Director of the School, she considers pharmacology to be nurse, and in memory of my son, Keith, and husband, Michael. a course that truly integrates nursing knowledge, skills, and —CQU v A01_ADAM8334_06_SE_FM.indd 5 18/01/2019 22:38 Thank You Our heartfelt thanks go out to our colleagues from Approach, sixth edition, has reaped the benefit of your col- schools of nursing across the country who have given lective knowledge and experience as nurses and teachers, their time generously to help create this exciting new edi- and we have improved the materials due to your efforts, tion. These individuals helped us plan and shape our suggestions, objections, endorsements, and inspiration. book and resources by reviewing chapters, art, design, Among those who gave their time generously are the and more. Pharmacology for Nurses: A Pathophysiologic following: Beatrice Adams, PharmD Marcus W. Campbell, PharmD, Adina C. Hirsch, PharmD, BCNSP Critical Care Clinical Pharmacist BC-ADM Assistant Professor of Pharmacy Tampa General Hospital Assistant Professor Pharmacy Practice Practice Department of Pharmacy Director, Center for Drug Information Philadelphia College of Osteopathic Tampa, Florida & Research Medicine LECOM School of Pharmacy Philadelphia, Pennsylvania Shannon Allen, CRNA, MSNA Bradenton, Florida Professor Linda Howe, PhD, RN, CNS, CNE New Mexico Junior College Rachel Choudhury, MSN, MS, RN, CNE Associate Professor Hobbs, New Mexico Associate Dean and Program Director, University of Central Florida Candyce Antley, RN, MN ABSN Orlando, Florida Instructor Musco School of Nursing and Health Anne L. Hume, PharmD, FCCP, Midlands Technical College Professions BCPS Columbia, South Carolina Brandman University Professor of Pharmacy Irvine, California Culeta Armstrong, MSN, RN University of Rhode Island Clinical Assistant Professor Darlene Clark, MS, RN Kingston, Rhode Island University of Memphis Senior Lecturer in Nursing Ragan Johnson, DNP, APRN-BC Memphis, Tennessee Pennsylvania State University University Park, Pennsylvania Assistant Professor Wanda Barlow, MSN, RN, University of Tennessee FNP-BC Janice DiFalco, RN, MSN, CNS, Memphis, Tennessee Instructor CMSRN, FAACVPR Winston-Salem State University Professor Vinh Kieu, PharmD Winston-Salem, North Carolina San Jacinto College Assistant Professor Pasadena, Texas George Mason University Sophia Beydoun, RN, BSN, MSN, Fairfax, Virginia AA-AND Deepali Dixit, PharmD, BCPS Professor Clinical Assistant Professor Dorothy Lee, PhD, RN, ANP-BC Henry Ford Community College Rutgers University Associate Professor of Nursing Dearborn, Michigan Piscataway, New Jersey Saginaw Valley State University University Center, Michigan Staci Boruff, PhD, RN Rachael Durie, PharmD, BCPS Assistant Academic Dean of Health Cardiology Clinical Pharmacist Toby Ann Nishikawa, MSN, RN Programs Assistant Professor of Clinical Assistant Professor Professor of Nursing Pharmacy Weber State University Walters State Community College Rutgers University Ogden, Utah Morristown, Tennessee Neptune, New Jersey Dr. Diana Rangaves, PharmD, RPh Bridget Bradley, PharmD, BCPP Deborah Dye, RN, MSN Director, Pharmacy Technology Assistant Professor Assistant Professor/Nursing Program Pacific University Department Chair Santa Rosa Junior College Hillsboro, Oregon Ivy Tech Community College Santa Rosa, California Lafayette, Indiana Mary M. Bridgeman, PharmD, Timothy Reilly, PharmD, BCPS, BCPS, CGP Jacqueline Frock, RN, MSN CGP, FASCP Clinical Assistant Professor Professor of Nursing Clinical Assistant Professor Rutgers University Oklahoma City Community College Rutgers University Piscataway, New Jersey Oklahoma City, Oklahoma Piscataway, New Jersey Reamer L. Bushardt, PharmD, Jasmine D. Gonzalvo, PharmD, Janet Czermak Russell, MS, MA, P.A.-C BCPS, BC-ADM, CDE APN-BC Professor Clinical Associate Professor Associate Professor Wake Forest Baptist Health Purdue University Essex County College Winston-Salem, North Carolina West Lafayette, Indiana Newark, New Jersey vi A01_ADAM8334_06_SE_FM.indd 6 18/01/2019 22:38 Pooja Shah, PharmD Dustin Spencer, DNP, NP-C, ENP-BC Suzanne Tang, MSN, APRN, FNP-BC Clinical Assistant Professor Assistant Professor of Nursing Instructor Rutgers University Saginaw Valley State University Rio Hondo College Piscataway, New Jersey University Center, Michigan Whittier, California Samantha Smeltzer, RN Dr. Jacqueline Stewart, DNP, CEN, Ryan Wargo, PharmD, BCACP Professor of Nursing CCRN Assistant Professor of Pharmacy Mount Aloysius College Associate Professor of Nursing Practice Cresson, Pennsylvania Wilkes University Director of Admissions Wilkes-Barre, Pennsylvania LECOM School of Pharmacy Rose Marie Smith, RN, MS, CNE Bradenton, Florida Division Dean of Nursing, Liberal Rebecca E. Sutter, DNP, APRN, Arts, Social and Behavioral FNP-BC Timothy Voytilla, MSN, ARNP Sciences Associate Professor Nursing Program Director Redlands Community College George Mason University Keiser University El Reno, Oklahoma Fairfax, Virginia Tampa, Florida vii A01_ADAM8334_06_SE_FM.indd 7 18/01/2019 22:38 Preface When students are asked which subject in their nursing • NEW! Key terms are listed at the beginning of each program is the most challenging, pharmacology always chapter along with corresponding page numbers that appears near the top of the list. The study of pharmacology indicate where their definitions may be found within demands that students apply knowledge from a wide vari- the chapter. ety of the natural and applied sciences. Successfully pre- • UPDATED! Check Your Understanding questions dicting drug action requires a thorough knowledge of appear throughout the drug chapters to reinforce anatomy, physiology, chemistry, and pathology as well as student knowledge. the social sciences of psychology and sociology. Lack of • EXPANDED! Includes more than 40 new drugs, drug adequate pharmacology knowledge can result in immedi- classes, indications, and therapies that have been ap- ate and direct harm to the patient; thus, the stakes in learn- proved since the last edition. ing the subject are high. • UPDATED! Black Box Warnings issued by the FDA are Pharmacology cannot be made easy, but it can be included for all appropriate drug prototypes. made understandable when the proper connections are made to knowledge learned in these other disciplines. The • UPDATED! Pharmacotherapy Illustrated diagrams vast majority of drugs in clinical practice are prescribed for help students visualize the connection between phar- specific diseases, yet many pharmacology textbooks fail to macology and the patient. recognize the complex interrelationships between pharma- • UPDATED! Nursing Practice Application charts have cology and pathophysiology. When drugs are learned in been revised to contain current applications to clinical isolation from their associated diseases or conditions, stu- practice with key lifespan, safety, collaboration, and di- dents have difficulty connecting pharmacotherapy to ther- versity considerations noted. apeutic goals and patient wellness. The pathophysiology focus of this textbook gives the student a clearer picture of Organization and Structure—A Body the importance of pharmacology to disease and, ulti- System and Disease Approach mately, to patient care. The approach and rationale of this textbook focus on a holistic perspective to patient care Pharmacology for Nurses: A Pathophysiologic Approach is orga- which clearly shows the benefits and limitations of phar- nized according to body systems (units) and diseases macotherapy in curing or preventing illness. In addition to (chapters). Each chapter provides the complete information its pathophysiology focus, medication safety and interdis- on the drug classifications used to treat the diseases. Spe- ciplinary teamwork are consistently emphasized through- cially designed numbered headings describe key concepts out the text. Although difficult and challenging, the study and cue students to each drug classification discussion. of pharmacology is truly a fascinating, lifelong journey. The pathophysiologic approach clearly places the drugs in context with how they are used therapeutically. New to This Edition The student is able to locate easily all relevant anatomy, physiology, pathology, and pharmacology in the same The sixth edition of Pharmacology for Nurses: A Pathophysi- chapter in which the drugs are discussed. This approach ologic Approach has been thoroughly updated to reflect provides the student with a clear view of the connection current pharmacotherapeutics and advances in under- among pharmacology, pathophysiology, and the nursing standing disease. care learned in other clinical courses. • NEW! Applying Research to Nursing Practice feature The vast number of drugs available in clinical practice illustrates how current medical research is used to im- is staggering. To facilitate learning, this text uses drug pro- prove patient teaching. Books, journals, or websites totypes in which the most representative drugs in each may be cited, and the complete source information classification are introduced in detail. Students are less in- provided in the References section at the end of timidated when they can focus their learning on one repre- the chapter. sentative drug in each class. viii A01_ADAM8334_06_SE_FM.indd 8 18/01/2019 22:38 Preface ix Chapter 15 Drugs for Seizures 179 This text uses several strategies to Prototype Drug Valproic Acid (Depakene, others) connect pharmacology to nursing practice. Therapeutic Class: Antiseizure drug Pharmacologic Class: Valproate Throughout the text the student will find Actions and Uses PHARMACOKINETICS (PO CAPSULES) interesting features, such as Complemen- Valproic acid has become a preferred drug for treating manyC hapter O1n5s e Dtrugs for SeizPueraeks 175 Duration tary and Alternative Therapies, Treating tfoyprmesu loaft ioepnsile, pwshyi.c Thh cisa nm ceaduicsaet icoonn hfuassi osne vwerhael ntr satdued ynianmg eits. and 2–4 days 1–4 h 6–24 h the Diverse Patient, CoPmrmotuontyitpye-O Drrieungt e d Phenoba•r bVgaiviletpnaro Plic O (aL.ciud m(Deipnakaeln)e) is the standard form of the drug ASiddvee erfsfeec Etsf fienccltusde sedation, drowsiness, GI upset, and pro- Practice, and Lifespan Considerations, • Valproate sodium (Depacon) is the sodium salt of valproic longed bleeding time. Other effects include visual disturbances, Therapeutic Class: Antiseizure drug; sedative Pachida grmivean cPoOl oorg IVi.c Class: Barbiturate; GABAA receptomru sacgleo wneisatkness, tremor, psychomotor agitation, bone that clearly place the drugs in context with • Divalproex sodium (Depakote ER) is a sustained release marrow suppression, weight gain, abdominal cramps, rash, Actions and Uses combination of vaWlpriothic oacvide radnods ites, s podhieumno sbalat rinb ait a l may caualsoepe sceiav, eprruer itruess, ppihraottoosreyn sitivity, erythema multiforme, and their clinical apPphleincoabatriboitanl iss .a Alonpg-pacltyingi nbagrb iRtureat-e used for the m1:a1n maigxteu-re. It is gdiveepn rPeOs sainodn i,s CavNaiSlab dlee inp raens esniotenric, -coma, afantdal hdeepaatthot.oxicity. Black Box Warning: May result in fatal search to Nursinmgen tP orf aa cvatriiectye o ff eseaiztuurers.e Its i si alllsuo sus-ed to produce scoeadtead- form. hepatic failure, especially in children under the age of 2 years. All three formulatioCnos noft rthaei ndrduigc faortmio tnhes :c hAedmmi-inistration ofN ponhsepneocibfica srbymitaptl oism sin oaftdevn ispr-ecede hepatotoxicity: weakness, trate how currenttio nm. Pehdeniocbaalrb riteal ssehoaurldc hno ti bse u usseedd fo r pain reliecf abl veaclparuosatee iat fter absaorbplteio nin o cr aons eesnt eorfin hg ythpee brsraeinn.s Tithiev ity to barfbacitiaul readteems,a ,s aenvoererxeia u, nancdo vno-miting. Liver function tests should may increase a patient’s sensitivity to pain. pharmacokinetics of each form varies, and doses are not be performed prior to treatment and at specific intervals dur- tilol uimstprarotevse ppoatt1ei7en0tnht eit aU GtnPleA ihtBap e3Acni Tohtnhbfeieauan rrNblogilettrasr.avl noaPtsuchmatss iatS tbtieytieors ,c tncwehamthe imncShi ca liasfel leyrae tbsdypy o ennshibanlec finogr sitotnohutt heepdere pcraswhrcceaisrtnsieibogs.eeni naa bgoll l ffeo .r Imn st hoisftro rettrohes elpxpl etrd,i odrrtauhs gpteto ,aan rutaiynincm l,ed ehspi ssvyr eaepslpaepeesrxrocetisirifc oitcw iapaniclthlgyihdy s C .ditsaN ytuesSsdpe dnd eeap roers soibi lsonifpesgni-nt ,ttr ahhup rebeco iafftirirtidpsoeatnhn .6iny, gmrai apnosandn,t h cgssree laoavfut eittcriresoe aa mtnmdae tnetr. aVtaolgperoniicc aecffiedc ctsa,n in pcrloudduincge abnormal neuronal discharges that can cause epilepsy. Valproic acid is administered as monotherapy or in combi- to medication errpoorisso.n Pinhg—aramndF cahcatnsg ecso inn tpaerifnu sion—suncahti oan sw itthh oothseer AEDsi tmo tprelaet mabseennctien sgeiz unreese adnedd co smapfleext y preCcoanutratiinodnicsa.t iIonns c: oHylplaerbseonrsaititviitoy nm ay occur. This caused by hypotension, stroke, shock, and cpaarrtdiail aseciz duryess. -DepakIownteti eEtrhRa icsth taileoso np asapptiroevnedt, f otrh thee hpreeavelnth-care mperdoicvatiiodne srh, opuldh anortm bea acdimstin, isatenredd to patients with liver statistics and facAtrdshm ytithnhiasmttri aaatsi—roenm Araleeyrl tbesev caanuste st.o the tion of migraine headacDnhreuusr gasn–edD maruraengi a:i aPnshssoetrcniuaotmbeda erwbnitihtta abll ipi noitnlaer r aaccthsi ewdviistiehna smge, a pbnleoye sodiitnthgiev drey ds ftruuhngcetsrio.a np, peaunctrieca titis, and congenital chapter. Check Yo• uPra reUntneradl pehresntoabanrbditailn isg a sfoefta-ti-ssue irritantd. iIsnotrrdaemr. 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Er-acll atumbpes diae fies cats s. eVvietrae- ofieasrfc fuieelistscaestt eiionvnfg eta irctaertlmiev afaoottvemrad lp e ocnrfho tpa porhceepornta iodlo.b inHaasrgeb.mnitoaolsd fiiraso lymasn istdh me s abeyol edbcyet. ieTofrfneea cottmifv eethn inte i sm ost ing down comhpypPleehrextne ontbsoairvpbeiit acdl siiss oai rnSdctehore dtehulaaet s IVci oldynrut giun tuhnae-ts m toay wcaou1rss5ee .nd8e apTser nep-aretign-g SesiuzpuporMretisev teh aondds c oonfs cisltass msiafiynilyn ogf eenpdisoluetcrpahsc ayhs e lahamla ionvtterui gbcianhteiao (nnL agamendidc t aol)v aenrd zonisamide (Zonegran), dmeercshtaonoidsm fso srhmnpoaearnwdcictnieeys nant ct. pchae irel.Aeo smC g (sonvroimettriaustmmmasdeloiinsntae .y D sIn.t t;iEdi tfioecos l sl aeacnttfhmfeeesa cpp rtBasos-ic 9baiftn e iy;c srladu i-lnzdsirdkeet due eBdl y1pbrgo2 y)t w ,o sas eoninidcezc suluasrrr,wSye uvnfsricigt,oct aocihmmnos ipimmS naa uirsaddom,ece uafscsi- nn.ia nddrei mmeiddmsthaiiicoeneamanscdvt iehmeo d.an, aFnesfyio otct arbhrai aleel tetv hx nedsaeenu m cltpmaielpapbsortsleieoseasltn,ssr y .t.p s.hETeaeriperz ttauie,ltr emrbepmsee sebnsinyte g so rr faae bnrpazpredlarua a etdtrm yicebyeseaepnc.idl tain Lsac rg abdawn miiylnadiltov yh matpe rnpiseidotgdtaiiigrer tnhtean iemyat etdplhi dasfoeal eifts seioee zcdarpnur lt- sriihuleopeess itb,pri iuen vsresogyenul e afslo liyun n itnrde catootmi nbbgei anebaffsteieocntnci vew es ietiihn- the 20th week of gestation 3unt4il at least 1 weekd aefltaeyrin dge claivlceiurym influx into neurons. By raising the sei- other antiseizure medications. the International Classification of Epileptic Seizures nomen- how drugs act.of the baby. Approximately 25% of women wziuthre ethcrleasmhoplds,i asu ccinimides keep neurons from firing too experience seizures within 72 hours postpartuqmuic.k Flyo, rth yues asursp,p ressincgla atbunroerm. Talh foecsie. T ahreey atreer gmeneedra lplya rtial (focal), generalized, and only effective against asbpseecnicae ls eeipzuilreesp. tTich es syunccdinriommideess (Table 15.1). Types of partial one of the approaches used to prevent or traeraet l iestcelda imn Tpatbilce 15.5.(focal) seizures or generalized seizures may be recognized seizures was magnesium sulfate. The mechanisEmth ofosurx timhiisd e (Zarontin) is the most commonly pre- Check Your Understanding 15.1 based on symptoms observed during a seizure episode. sCuobmstpanlecme’se natnatrisye aiznudr eA altcetirvniatyti vise nTohte wraeplli eussncrdibeerds tdoruogd i.n A th is class. It remains a preferred choice for If an antiseizure drug must be discontinued, how will this be accom- pTHroEt oKtEyTpOeG fEeNaItCu rDeI EfTo rF OmRa EgPnIeLsEiPuSmY sulfate is athpbesrseeen stcyeep nseetsie zoduf rs eeisniz, ualrtehso. uSSnogoemhum ver aeool fpns tryhaoemli cnm paecwitisodefrm ii sra insant lasigsore; eie zof usfteurhcetbe idvtrrlesue fg aoasrr,n ed m rpaoenlifsrslhewee ecdcr.,to atmnhdep w lshepyx ies. cthifisi cm netahotdu nreec oesfs ary? See Appendix A for the Chapter 43. The Skeetiozguerneisc cdaient hisa mveo sat soifgtenni fuicsaedn tw ihmepn asceti zounre sth cea nqnuoatl ibtey has a ketogenic ratio of 3 or 4 g of fat to 1 g of protein and carbohy- ocof nlitfroel.l eTdh tehyro umgah yp hcaarumsaec soethreioraupsy ionrj uwrhye nif tthheerey aorec cuunra cwcehpilte- d1ra5te. 3(A zGeveedno deer Laiml aC eto aln., c20e1p7).t Bse ocafu sAe onf tthies heigihz ruatiroe o f fat aa bplee rasdovner sise defrfeivcitsn gto a t hvee mhiecdleic aotrio npse.r Bfoerfomrei nagn tais edizaunreg edrrouguss iPn thhea driemt, caocmopltichateiornsa psuych as hyperlipidemia and hepatotoxic- awcetriev idtye.v Aelolmpeods,t tahlils sdtaiette sw awsi lal nporitm garrMya1 5n_tArteD, AaoMt8rm3 3w4e_n0i6tl_ lS fEot_aCr 1k5e.einp daidl e w 1p79asyy., ity may occur, and patients on this diet need to be monitored long 08/12/2018 14:27 aR edcreinvte srt’usd lieicse hnasvee aexnadm rineeqdu tihree pao ssesiibziulitrye t-hfarte teh ep keertioogde nbiec fdoireet tTerhme tcoh doeitceec to tfh AesEeD ad ivse hrsieg heflfye citns d(Aivzeidveudaoli dzee Lfoimr ae eatc hal .p, 2a0ti1e7n; t gcoraunldt ipnrogv iad ed brievneerfi’ts f olri cpeantiseen.t sW wiitthh oAulzth esuimcecre’ss,s Pfuarlk pinhsoanrm’s, aacnod- Aarnsdla nd eetp ael.n, 2d0s1 o6,n). the type of seizures, the patient’s previ- tohtheerar pnye,u eropdileegpesnye rcaatinve s edviseeraesleys l i(mRaijta gpoaprtailc, iSpaantigoanm i,n S sincghho,o &l, ous Rmeesdeaicrcahl hsuisgtgoersyt,s EthEaGt t hdea tdaie, ta pnrdod auscseosc iaa hteigdh psuacthceoslos graietes . e Jmogpinlaopyamllye, n20t,1 a6n; dVe syoracti-aDlu arecbtievxi teiet sa la., n2d0 1c8a)n. Tdheef ienxiatcetl ym aefcfheac-t cOonmcpea are md etod isctaatnidoanr dis tsreealetmcteendt,, twhieth p baetitetenrt ciso nptlraocl eodf soeniz au rleosw. sneislmf- ebsetheienmd t.h eC ehfrfeocntiivce ndeesps roef sthseio dnie tm isa uyn kancocwonm apnadn ayp ppeoaorsr tloy Iimnpitrioavle dmoesnet .m Tahye b aem nootuedn tr aips igdlrya adnuda tlhley diniect raepapseeadrs u ton tbiel seeqiuzaullrye cinocnlutdreo lbloetdh dsireeicztu erffeesc.t fIrommp koerttoannet b ocdoyn isnicdreearsaetsi,o annsd mine tnabuorlsic- ecfofencttrivoel foisr eavcehriye sveeizdu,r eo rty upen.t Tilh de rmuogs ts ifrdeeq ueefnfetlcyt rse pporretvede natd vaedrsdei - icnhga ncgaerse t hinatc loucdcuer , iidncernetaisfiynign Gg ApBaAt iaenndt sin ahtib ritiosrky nfeourr osteraiznusmreits-, etfifoenctasl iinncclurdeea sveosm iinti ndgo, sfaet.i gSueer,u cmon dstriupagt iloenv, edlisa rmrhaeya, baen do bhtuanigneer.d dteorsc u(Rmhoe,n 2ti0n1g7 ).the pattern and type of seizure activity, and Ctoo sat sasnisdt ththe ed ihffeicaullttyh coaf rfoel lopwroinvgi dtheer diine t dloentge rtmermin imnagy tahlseo m limoist t The ketogenic diet is a stringently calculated diet that is high its use (Wijnen et al., 2017). Those interested in trying the diet must in fat and low in carbohydrates and protein. It limits water intake to consult with their healthcare provider to optimize the therapy. The avoid ketone dilution and carefully controls caloric intake. Each meal long-term effects are not yet fully known. Treating the Diverse Patient: Sports-Related Concussions There is increased awareness and concern about sports-related Early detection and intervention is a key strategy in the appro- concussions at all ages. Concussions are a form of traumatic priate treatment of a concussion, but not all patients, particularly brain injury (TBI) and can range from mild to severe, with imme- children, seek treatment. Bryan, Rowhani-Rahbar, Comstock, & diate and long-term consequences, including dementia and Rivara (2016) found that as many as 52% of high school sports chronic traumatic encephalopathy (Thomas et al., 2018). Ban, and recreation-related concussions were not reported to a health- Botros, Madden, and Batjer (2016) found a relatively low inci- care provider, and the authors recommend expanding research M15_ADAM8334_06_SdE_eCn1c5.ein dodf s17p5orts-related TBI, but an estimated 13% of pediatric to include recreation-related injuries as a cause of TBI. For c0h8/i1l-2/2018 14:27 and 14% of adult injuries were considered moderate to severe. dren, parents play a key role in identifying and managing these While headaches, dizziness, and visual disturbances were injuries. However, particularly among parents with low income, common after a mild injury, seizures were more common with education is lacking (Lin et al., 2015). Because seizures and long- severe sports-related concussions, and symptoms may persist term complications may occur after a moderate to severe injury, and become chronic (Choe et al., 2016; Merritt, Rabinowitz, & education on prevention and early detection may help to decrease Arnett, 2015). these consequences. M15_ADAM8334_06_SE_C15.indd 170 08/12/2018 14:27 A01_ADAM8334_06_SE_FM.indd 9 18/01/2019 22:38

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