By A. Kan. Woods Hole Oceanographic Institution.

Reduced sympathetic activity commonly used in the management of hypertension buy estrace 2mg with visa. Loop CHAPTER 55 ANTIHYPERTENSIVE DRUGS 803 diuretics (eg cheap estrace 2 mg on line, furosemide) or potassium-sparing diuretics • Oral contraceptives, corticosteroids, appetite sup- (eg, spironolactone) may be useful in some circumstances; pressants, nasal decongestants, non-steroidal anti- see Chapter 56 for discussion of diuretic drugs. Vasodilators (Direct Acting) • Check blood pressure accurately and repeatedly. As a rule, multiple measurements in which systolic pressure Vasodilator antihypertensive drugs directly relax smooth is above 140 mm Hg and/or diastolic pressure is above muscle in blood vessels, resulting in dilation and decreased peripheral vascular resistance. They also reduce afterload and 90 mm Hg, are necessary to establish a diagnosis of may be used in management of heart failure. These drugs have a limited effect surements cannot be overemphasized because there on hypertension when used alone because the vasodilating are many possibilities for errors. Some ways to im- action that lowers blood pressure also stimulates the SNS and prove accuracy and validity include using correct triggers reflexive compensatory mechanisms (vasoconstric- equipment (eg, proper cuff size), having the client tion, tachycardia, and increased cardiac output), which raise rested and in the same position each time blood pres- blood pressure. This effect can be prevented during long-term sure is measured (eg, sitting or supine with arm at therapy by also giving a drug that prevents excessive sym- heart level), and using the same arm for repeated mea- pathetic stimulation (eg, propranolol, an adrenergic blocker). These drugs also cause sodium and water retention, which • In most cases of early hypertension, elevated blood may be minimized by concomitant diuretic therapy. If symptoms do occur, they are usually nonspecific (eg, headache, weakness, fatigue, tachycardia, dizziness, palpitations, INDIVIDUAL DRUGS epistaxis). Antiadrenergic drugs are discussed in Chapter 19 and pectoris, myocardial infarction, or heart failure. Antihypertensive agents are pain, tachycardia, dyspnea, fatigue, and edema may shown in the Drugs at a Glance: Antihypertensive Drugs; occur. Brain damage may be indicated by transient antihypertensive-diuretic combination products are listed ischemic attacks or strokes of varying severity with in Drugs at a Glance: Oral Antihypertensive Combination symptoms ranging from syncope to hemiparesis. Ophthalmoscopic examination may reveal hem- orrhages, sclerosis of arterioles, and inflammation of Nursing Process the optic nerve (papilledema). Because arterioles can be visualized in the retina of the eye, damage to retinal Assessment vessels may indicate damage to arterioles in the heart, brain, and kidneys. These include: • Decreased Cardiac Output related to disease process or • Obesity drug therapy • Elevated serum cholesterol (total and low-density • Ineffective Coping related to long-term lifestyle changes lipoprotein) and triglycerides and drug therapy • Cigarette smoking • Noncompliance related to lack of knowledge about hyper- • Sedentary lifestyle tension and its management, costs and adverse effects of • Family history of hypertension or other cardiovascular disease drug therapy, and psychosocial factors • African-American race • Disturbed Body Image related to the need for long-term • Renal disease (eg, renal artery stenosis) management and medical supervision • Adrenal disease (eg, hypersecretion of aldosterone, • Fatigue related to antihypertensive drug therapy pheochromocytoma) • Deficient Knowledge related to hypertension, anti- • Other cardiovascular disorders (eg, atherosclerosis, left hypertensive drug therapy, and nondrug lifestyle ventricular hypertrophy) changes • Diabetes mellitus • Sexual Dysfunction related to adverse drug effects 804 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM Planning/Goals clothing, too loosely, deflated too rapidly, or reinflated be- The client will: fore completely deflated; a regular-sized cuff used on large arms that need a large cuff; using the stethoscope di- • Receive or take antihypertensive drugs correctly aphragm rather than the bell).

We can choose to cooperate with this complement of opposites by not denying estrace 2mg mastercard, suppressing cheap estrace 2mg on line, or struggling against unwanted discomfort or pain, but rather by accepting all facets of our existence, good and bad, as the natural flow of the Tao. By following the path of acceptance and responsiveness to change we can be- come, in the words of the Taoist philosopher Chuang Tzu, true women and men of Tao. This unceasing flow of change manifests itself as a natural order governed by unalterable, yet perceivable laws. Strangely enough, it is the constancy of these governing principles (like the rising and setting of the sun and moon and the changing of the seasons) that allows people to recognize and utilize them in their own process of transformation. From the Taoist viewpoint this represents the ultimate stage of human existence. The writings of the legendary Taoist sages Lao Tzu and Chuang Tzu furnish us with specific principles as a guide to attaining this state of oneness. At the same time, it is not to be considered inertia, laziness, or mere passivity. Rather, it is the experience of going with the grain or swimming with the current. Our contemporary expression going with the flow is a direct expression of this fundamental Taoist principle, which, in its most basic form, refers to behavior occurring in response to the flow of the Tao. Among these is the need to consciously experience ourselves as part of the unity of life that is the Tao. Lao Tzu writes that we must be quiet and watchful, learning to listen to both our own inner voices and to the voices of our environment in a noninterfering, receptive manner. In this way we also learn to rely on more than just our intellect and logical mind to gather and assess information. All of this allows us to re- spond readily to the needs of the environment, which of course includes ourselves. And just as the Tao functions in this manner to promote harmony and balance, our own actions, performed in the spirit of wu-wei, produce the same result. Wu-wei also implies action that is spontaneous, natural, and effortless.

It is about the craft of putting together words in such a way as to enable you to put messages across to a target audience cheap estrace 2 mg with mastercard. Over the past 100 years or so writers have generally agreed about how to make this kind of writing work purchase estrace 1 mg with mastercard. These include the following elements: logically developing paragraphs, short and simple sentences, active voice, positive statements and sensible word choice. In other words, for simple effective writing, style is not writer-related but reader-related. When it comes to those endless discussions with co-authors or bosses, it gives an easy solution: allow any changes that are likely to improve the chances of putting the message across to the target reader; resist those that will have the opposite effect (see negotiating changes). BOOKLIST: style • The elements of style (3rd edition), by Strunk and White, New York: Macmillan, 1979. A splendid attack on the pomposity of medical writing with some excellent examples and some sensible advice. Trenchant views on writing from a distinguished playwright and journalist. Forget literature; look at how skilled writers describe the games we play. An excellent handbook on how to avoid gobbledegook from one of the original leaders of the Plain English campaign. A new paperback version of a book originally written for the Sunday Times. Style (2) The set of rules set by a publication to lay down policy in some of the many areas where there are genuine ambigu- ities (Mr or Mr. The thinking behind this is that readers care little about which version you use, as long as there is consistency.